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Tafur JD, Shah KB, White CJ. Renal and Mesenteric Artery Intervention. Interv Cardiol Clin 2025; 14:205-223. [PMID: 40049848 DOI: 10.1016/j.iccl.2024.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2025]
Abstract
Atherosclerotic disease of the abdominal aorta and its visceral branches poses significant health risks due to its potential to cause severe complications. Atherosclerosis affects renal and mesenteric vessels, contributing to renal artery stenosis and mesenteric ischemia, respectively, both of which can result in organ damage and ischemic bowel disease if left untreated. Therapy with guideline-directed medical therapy is advised in all patients. Chronic mesenteric ischemia (CMI) is infrequent and difficult to diagnose illness. Current evidence suggests that compared with open surgical repair, in anatomically suitable lesions, endovascular therapy is the most cost-effective choice for patients with CMI.
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Affiliation(s)
- Jose D Tafur
- Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, Univ of Queensland, New Orleans, LA, USA
| | - Khanjan B Shah
- Division of Cardiovascular Disease, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, Univ of Queensland, New Orleans, LA, USA; Department of Cardiology, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Value Based Care.
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Lu LY, Eastment JG, Sivakumaran Y. Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm. J Clin Med 2024; 13:2598. [PMID: 38731126 PMCID: PMC11084382 DOI: 10.3390/jcm13092598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?
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Affiliation(s)
- Lawrence Y. Lu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Jacques G. Eastment
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
| | - Yogeesan Sivakumaran
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of Vascular Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
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Ahmed-Khan MA, Moin K, Hanif M, Jiffry M, Vargas J, Khan TZ, Khan S, Nazary A. A Gut-Wrenching Feeling: Overcoming Cognitive Biases in an Atypical Presentation of Chronic Mesenteric Ischemia. Cureus 2023; 15:e36416. [PMID: 37090289 PMCID: PMC10115192 DOI: 10.7759/cureus.36416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 03/22/2023] Open
Abstract
Chronic mesenteric ischemia is a rare but serious condition that can present with a variety of symptoms, including abdominal pain, diarrhea, and weight loss. Our case report presents a 63-year-old male with a past medical history of generalized anxiety disorder, Barrett's esophagus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD) with active smoking who initially presented with severe diffuse abdominal pain, nausea, vomiting, and chronic diarrhea resulting in malnutrition and 40-pound weight loss over a six-month span. The patient underwent extensive diagnostic evaluation and was diagnosed with Yersinia gastroenteritis via gastroenteritis panel (GI Panel), explaining all of the patient's symptoms. The patient underwent treatment for said gastroenteritis but did not experience remission of symptoms, leading to further diagnostic evaluations; a definitive diagnosis was not found, yet the patient's symptoms persisted. The patient then underwent extensive serologic and endoscopic evaluation, after extensive imaging and diagnostic work-up, the patient was finally diagnosed with chronic mesenteric ischemia (CMI) of the superior mesenteric artery (SMA) with severe celiac and inferior mesenteric artery (IMA) stenosis. The patient initially underwent stenting (7 mm by 26 mm Balloon Mounted LifestreamTM Covered Stent; Becton Dickson (BD); Franklin Lakes, NJ, USA), which provided temporary relief to his symptoms, however, the relief did not last long. Upon reimaging, the patient was found to have stenosis of the stent, leading to the eventual placement of a bare-metal stent (ExpressTM LD 7 x 27 mm balloon mounted bare-metal stent; Boston Scientific; Boston, MA, USA) across the celiac artery as well as the placement of an IMA stent (InnovaTM Self-expanding 5 x 20 mm bare-metal stent; Boston Scientific). This eventually resulted in the resolution of the patient's symptoms, eventual weight gain, and improvement in quality of life.
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Shimbara K, Shintakuya R, Honmyo N, Nakagawa N, Kohashi T. Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report. Int J Surg Case Rep 2023; 106:108041. [PMID: 37030161 PMCID: PMC10119882 DOI: 10.1016/j.ijscr.2023.108041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection. CASE PRESENTATION A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms. CLINICAL DISCUSSION MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS. CONCLUSION It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.
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Novitsky R. The Sonographer’s Role in Assessing Celiac Artery Stenosis, to Confirm the Diagnosis: A Case Study. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2023. [DOI: 10.1177/87564793221148984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Celiac artery stenosis may occur in patients with a known history of atherosclerosis and should also be considered in those who present with abdominal pain. Sonography is specific and necessary when the information is correlated with a computed tomogram (CT), as it helps to determine patency and velocity within mesenteric vessels. When stenosis is severe, chronic mesenteric ischemia results, as vascular perfusion is diminished to the intestinal organs. In the case presented with severe atherosclerosis, both CT and sonography were helpful in confirming the diagnosis. Sonography can help in evaluating celiac artery stenosis, caused by atherosclerosis versus median arcuate ligament syndrome, by considering the normal velocities of the vessel.
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Zhou Y, He H, Cui N, Wang X, Long Y, Liu D. Elevated pulsatility index of the superior mesenteric artery indicated prolonged mechanical ventilation in patients after cardiac valve surgery. Front Surg 2023; 9:1049753. [PMID: 36684265 PMCID: PMC9852328 DOI: 10.3389/fsurg.2022.1049753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/11/2022] [Indexed: 01/09/2023] Open
Abstract
Purpose This study examined whether alterations in Doppler parameters of superior mesenteric artery (SMA) are associated with prolonged mechanical ventilation (PMV) in patients who underwent cardiac valve surgery. Methods Hemodynamic and SMA Doppler parameters were collected at intensive care unit(ICU) admission. The duration of mechanical ventilation was monitored. PMV was defined as mechanical ventilation ≥96 h. Results A total of 132 patients admitted to ICU after cardiac valve surgery were evaluated for enrollment, of whom 105 were included. Patients were assigned to the control (n = 63) and PMV (n = 42) groups according to the mechanical ventilation duration. The pulsatility index(SMA-PI) and resistive index of SMA (SMA-RI) were 3.97 ± 0.77 and 0.88 (0.84-0.90) in the PMV group after cardiac valve surgery, which was lower than the SMA-PI (2.95 ± 0.71, p < 0.0001) and SMA-RI of controls (0.8, 0.77-0.88, p < 0.0001). SMA-PI at admission had favorable prognostic significance for PMV (AUC = 0.837, p < 0.0001). Conclusions An elevated SMA-PI is common in patients after cardiac valve surgery with PMV. Increased SMA-PI could help predict PMV after cardiac valve surgery. Using point-of-care ultrasound to measure SMA-PI at ICU admission is an acceptable and reproducible method for identifying patients with PMV.
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Li SX, Fan YH, Tian GY, Lv GY. Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients. World J Gastrointest Surg 2022; 14:976-985. [PMID: 36185558 PMCID: PMC9521469 DOI: 10.4240/wjgs.v14.i9.976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce.
AIM To evaluate the feasible surgical management of MALS to reduce complications in OLT patients.
METHODS Data for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner.
RESULTS Eight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory.
CONCLUSION The preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.
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Affiliation(s)
- Shu-Xuan Li
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Ye-Hui Fan
- Department of The First Operation Room, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guang-Yao Tian
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Contemporary Management of Median Arcuate Ligament in Liver Transplantation. Transplant Direct 2022; 8:e1348. [PMID: 36569785 PMCID: PMC9771178 DOI: 10.1097/txd.0000000000001348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 12/27/2022] Open
Abstract
Median arcuate ligament (MAL) can impair arterial inflow during orthotopic liver transplantation (OLT). Furthermore, approaches to ensure optimal vascular inflow in the presence of MAL is not standardized. Methods We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL. Results The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention. Conclusions We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.
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Conway AM, Carroccio A, Rosen RJ. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Zhou Y, He H, Wang X, Cui N, Zhou X, Long Y, Liu D. Resistance Index of the Superior Mesenteric Artery: Correlation With Lactate Concentration and Kinetics Prediction After Cardiac Surgery. Front Med (Lausanne) 2021; 8:762376. [PMID: 34901079 PMCID: PMC8651699 DOI: 10.3389/fmed.2021.762376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to measure blood flow changes in the superior mesenteric artery (SMA), using Doppler ultrasound, in post-cardiac surgery patients, to evaluate the correlation between the SMA resistance index (SMA-RI) and lactate concentrations. Methods: The patients' basic hemodynamics, blood gas parameters and lactate concentration were collected at admission. Simultaneously, the SMA blood flow parameters were collected using Doppler ultrasound with the patients in the supine position. The lactate concentrations were measured again at 2, 6, and 12-h time points after the first test. The length of intensive care unit stays and prognoses continued to be monitored. Results: A total of 67 patients were included. The SMA-RI correlated with the admission (r = 0.3117, P = 0.0102), 2-h (r = 0.5091, P < 0.0001), 6-h (r = 0.5061, P < 0.0001), and 12-h (r = 0.2483, P = 0.0428) lactate concentrations. The SMA-RI could predict the 2-h 10% [area under the curve (AUC) = 0.8294, P < 0.0001] and 6-h 40% lactate kinetics (AUC = 0.7708, P = 0.0012). The cut-off value was 0.83. When the SMA-RI was <0.83, the specificity and sensitivity were 86.38 and 75.56%, respectively for the prediction of the 2-h >10% lactate kinetics, and 64.71 and 75.00%, respectively, for the prediction of the 6-h >40% lactate kinetics. The lactate concentrations at admission, 2 and 6-h points were higher in the high-RI group (RI ≥ 0.83) and the intensive care unit stays were significantly longer than in the low-RI group (P = 0.0005). Conclusions: The increase in SMA-RI was associated with higher lactate concentrations and worse lactate kinetics in post-cardiac surgery patients. This may be related to intestinal hypoperfusion. The SMA-RI may be one of the indicators that should be monitored to guide resuscitation in these patients.
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Affiliation(s)
- Yuankai Zhou
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoting Wang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Cui
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiang Zhou
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dawei Liu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Critical Care Medicine, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Sultan SA, Acharya Y, Mustafa M, Hynes N. Two Decades of Experience With Chronic Mesenteric Ischaemia and Median Arcuate Ligament Syndrome in a Tertiary Referral Centre: A Parallel Longitudinal Comparative Study. Cureus 2021; 13:e20726. [PMID: 35047313 PMCID: PMC8759710 DOI: 10.7759/cureus.20726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background Chronic mesenteric ischaemia (CMI) and median arcuate ligament syndrome (MALS) have similar clinical presentations with surgical intervention as the mainstay of treatment. However, surgical response varies and is unpredictable. Therefore, we aim to evaluate the technical and clinical success rates of selective revascularisation in older patients with CMI and younger patients with MALS undergoing arcuate ligament decompression with celiac sympathectomy. Methods We conducted a retrospective single-centre longitudinal comparative study of all the patients who underwent surgery for symptoms of CMI and MALS from December 2002 to 2020 at our tertiary referral vascular centre. Our primary outcome was symptom-free survival post-intervention. The secondary outcomes were perioperative mortality, technical success, and all-cause mortality at 17 years. Results We operated on 28 patients; 17 patients with CMI (revascularisations with bypass) and 11 with MALS (decompression and celiac sympathectomy). All (100%) patients had technical success. There was no perioperative mortality. All the MALS patients had symptom-free survival following the procedure throughout follow-up. In contrast, three patients with CMI complained of recurring abdominal pain even after one year of the surgery. However, there was no further weight loss and none of them required any intervention. Conclusion Stratified management of CMI with revascularisation and open surgical decompression with celiac sympathectomy in MALS are effective treatments with favourable long-term outcomes.
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Affiliation(s)
- Sherif A Sultan
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL.,Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
| | - Yogesh Acharya
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL
| | | | - Niamh Hynes
- Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
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Shintakuya R, Kohashi T, Nakashima A, Oishi K, Honmyo N, Hihara J, Kagawa E, Mukaida H. How to do it: Endovascular stent and ligament resection during pancreaticoduodenectomy for coeliac axis stenosis in median arcuate ligament syndrome. ANZ J Surg 2021; 91:2824-2826. [PMID: 34180573 DOI: 10.1111/ans.17007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.
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Affiliation(s)
- Ryuta Shintakuya
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Toshihiko Kohashi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Akira Nakashima
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Koichi Oishi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naruhiko Honmyo
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Jun Hihara
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Eisuke Kagawa
- Department of Cardiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Hidenori Mukaida
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
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Two-way Revascularization to Manage Celiac Artery Stenosis during Pancreaticoduodenectomy: A Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3423. [PMID: 33680671 PMCID: PMC7929557 DOI: 10.1097/gox.0000000000003423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/17/2020] [Indexed: 11/26/2022]
Abstract
Celiac artery (CA) occlusion, or stenosis, is not uncommon, and most cases are asymptomatic. If the CA is occluded, collateral circulation from the superior mesenteric artery (SMA) is maintained through the pancreaticoduodenal arcade. However, the pancreaticoduodenal arcade is removed if pancreaticoduodenectomy (PD) is performed, which results in ischemia of the liver, stomach, and residual pancreas. Thus, these patients require CA revascularization, which can include antegrade endovascular reconstruction and retrograde reconstruction using vascular anastomosis from the SMA system to the CA system. Both methods carry risks of restenosis or anastomotic thrombosis. We report a technique that involves a combination of both revascularization methods in an 89-year-old man who underwent PD for lower bile duct cancer. Preoperative endovascular stent placement in the CA preserved antegrade blood flow to the liver, and intraoperative vascular anastomosis of the jejunal artery and right gastroepiploic artery achieved retrograde blood flow. Although we confirmed both stent and anastomosis patency and blood circulation in our case, obstruction of 1 of these revascularization pathways would not likely lead to ischemia of the liver. Thus, our 2-way revascularization technique for managing celiac artery stenosis during PD may reduce the risk of organ ischemia.
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Pedersoli F, Hitpass L, Isfort P, Zimmermann M, Schulze-Hagen M, Gombert A, Kuhl CK, Bruners P, Keil S. Recanalization and Stenting of the Celiac and the Superior Mesenteric Artery Supported by Use of a Steerable Introducer Sheath: Report on 2 Years' Experience. Vasc Endovascular Surg 2020; 55:158-163. [PMID: 33213286 DOI: 10.1177/1538574420975264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare technical parameters and success of recanalization of celiac (CA) or superior mesenteric artery (SMA) with usage of steerable vs not steerable introducer sheaths. METHODS A retrospective analysis was performed on all consecutive patients who underwent recanalization with stent implantation of CA or SMA between 2015 and 2019. Data regarding technical success (successful stent placement with restoration of sufficient blood flow by the first attempt without changing kind of introducer sheath or access site), indication for treatment, vascular access, kind of introducer sheath, fluoroscopy time and radiation dose were collected. Preinterventional CT were analyzed to classify the difficulty of catheterization of target vessels. Technical parameters were compared with independent t-test (p ≤ 0.05). RESULTS 66 patients underwent recanalization of CA or SMA. Usage of steerable introducer sheaths was associated with higher technical success compared to not steerable introducer sheaths with transfemoral approach respectively of 8/8 vs 15/19 for the CA and 11/11 vs 17/20 for the SMA. Steerable introducer sheaths were used in recanalization considered more technically difficult compared to not steerable introducer sheaths (58% vs 33%). Usage of steerable introducer sheath showed a statistically significant reduction of radiation dose in the recanalization of the SMA (respectively 32035 ± 15716 cGy cm2 vs 60102 ± 28432 cGy cm2; p = 0.005). CONCLUSION Even if used in more difficult interventions, steerable introducer sheaths showed a higher technical success compared to not steerable introducer sheaths with transfemoral access.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Lea Hitpass
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, 39058RWTH University Hospital Aachen, Aachen, Germany
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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Barnes JA, Columbo JA, Ponukumati AS, Zwolak RM, Olive FT, Goodney PP, Powell RJ, Zacharias N. Long-Term Outcomes of Mesenteric Stenting and Analysis of In-Stent Restenosis Duplex Velocity Criteria. Ann Vasc Surg 2020; 68:226-233. [DOI: 10.1016/j.avsg.2020.04.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 12/01/2022]
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Pedersoli F, Zimmermann M, Schulze-Hagen M, Sieben P, Barzakova E, Goerg F, Keil S, Gombert A, Kuhl CK, Isfort P, Bruners P. Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access. Vasc Endovascular Surg 2020; 54:477-481. [PMID: 32419653 DOI: 10.1177/1538574420927132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. METHODS We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. RESULTS Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. CONCLUSIONS The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Paul Sieben
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Emona Barzakova
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Fabian Goerg
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Alexander Gombert
- Clinic for Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
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Abstract
Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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19
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Robins JE, Young Z, Glocker RJ, Stoner MC, Doyle AJ. Recurrent Superior Mesenteric Artery Stent Fracture. Ann Vasc Surg 2019; 59:306.e11-306.e15. [DOI: 10.1016/j.avsg.2019.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 02/08/2019] [Accepted: 02/13/2019] [Indexed: 11/30/2022]
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Czigany Z, Boecker J, Morales Santana DA, Bednarsch J, Meister FA, Amygdalos I, Isfort P, Liebl M, Neumann UP, Lurje G. Median Arcuate Ligament Compression in Orthotopic Liver Transplantation: Results from a Single-Center Analysis and a European Survey Study. J Clin Med 2019; 8:jcm8040550. [PMID: 31018577 PMCID: PMC6518097 DOI: 10.3390/jcm8040550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/15/2019] [Accepted: 04/22/2019] [Indexed: 12/17/2022] Open
Abstract
Median arcuate ligament compression (MALC) potentially causes arterial complications in orthotopic liver transplantation (OLT). Here we aimed to investigate the incidence of MALC and its impact on clinical outcome after OLT. In addition, we performed an international survey among 52 European liver transplant centers to explore local protocols on the management of these patients. Data of 286 consecutive OLT recipients from a prospective database were analyzed retrospectively (05/2010-07/2017). Preoperative computed-tomography images were evaluated. Celiac axis stenosis due to MALC was found in 34 patients (12%). Intrinsic stenosis was present in 16 (6%) patients. Twenty-six patients (77%) with MALC underwent standard arterial revascularization with median arcuate ligament (MAL)-division. Patients treated for MALC had comparable baseline data and no difference was found in early- and long-term outcome compared to the rest of our cohort. Our survey found heterogeneous strategies regarding diagnosis and treatment of MALC. Only 29% of the centers reported the division of MAL in these patients as routine procedure. Even though there is no consensus on diagnosis and management of MALC among European centers, a surgical division of MAL is feasible and safe and should be considered in OLT recipients with MALC.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | | | - Iakovos Amygdalos
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Peter Isfort
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Martin Liebl
- Institute of Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
- Department of Surgery, Maastricht University Medical Centers (MUMC), 6202 AZ Maastricht, The Netherlands.
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany.
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Robles-Martín ML, Reyes-Ortega JP, Rodríguez-Morata A. A Rare Case of Ischemia–Reperfusion Injury After Mesenteric Revascularization. Vasc Endovascular Surg 2019; 53:424-428. [DOI: 10.1177/1538574419839547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- María L. Robles-Martín
- Department of Angiology and Vascular Surgery, Quirónsalud Málaga Hospital, Málaga, Spain
| | - Juan P. Reyes-Ortega
- Department of Angiology and Vascular Surgery, Quirónsalud Málaga Hospital, Málaga, Spain
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Imai D, Maeda T, Wang H, Ohmine T, Edahiro K, Edagawa M, Takenaka T, Yamaguchi S, Konishi K, Tsutsui S, Matsuda H. Acute median arcuate ligament syndrome after pancreaticoduodenectomy. Surg Case Rep 2018; 4:137. [PMID: 30478805 PMCID: PMC6261092 DOI: 10.1186/s40792-018-0545-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/18/2018] [Indexed: 12/18/2022] Open
Abstract
Background Median arcuate ligament syndrome (MALS) can cause severe complications after pancreaticoduodenectomy (PD). Most of the reported cases of MALS have been diagnosed perioperatively and can be treated efficiently by interventional radiology or division of the median acute ligament (MAL) fibers. Case report A 69-year-old woman underwent PD with resection of the SMV for pancreatic head cancer. Intraoperative exploration showed normal anatomy of the celiac trunk. Intraoperative digital palpation revealed normal pulsation of the common hepatic artery after resection of the gastroduodenal artery. On postoperative day (POD) 3, her liver function tests were abnormal, and bloody fluids were found in the drain. Abdominal CT showed necrosis of the pancreatic body and ischemia in the liver secondary to MALS which was not detected in the preoperative CT. Interventional radiology was tried first but failed. Division of the MAL fibers markedly increased the blood flow in the hepatic artery. Resection of the remnant pancreas and spleen was also performed simultaneously. Abdominal CT on POD 20 showed re-occlusion of the celiac artery. She experienced rupture of the gastrojejunostomy site, severe hepatic cytolysis, and choledochojejunostomy stricture thereafter. Conclusions This is the third case of MALS that has developed acutely after PD. MALS can cause refractory complications even after MAL release.
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Affiliation(s)
- Daisuke Imai
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan.
| | - Takashi Maeda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Huanlin Wang
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Takahiro Ohmine
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Keitaro Edahiro
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Makoto Edagawa
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Tomoyoshi Takenaka
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Shohei Yamaguchi
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Kozo Konishi
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Shinichi Tsutsui
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
| | - Hiroyuki Matsuda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, 1-9-6, Sendamachi, Naka-ku, Hiroshima City, Hiroshima, 730-0052, Japan
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Sun X, Fan Z, Qiu W, Chen Y, Jiang C, Lv G. Median arcuate ligament syndrome and arterial anastomotic bleeding inducing hepatic artery thrombosis after liver transplantation: A case report. Medicine (Baltimore) 2018; 97:e10947. [PMID: 29923979 PMCID: PMC6023679 DOI: 10.1097/md.0000000000010947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
RATIONALE Median arcuate ligament (MAL) may compress the coeliac trunk inducing median arcuate ligament syndrome (MALS). MALS is a risk factor for hepatic artery thrombosis (HAT) in liver transplant recipients. PATIENT CONCERNS A thin female complained about upper abdominal pain for two months. DIAGNOSES The patient was diagnosed as primary biliary cirrhosis. INTERVENTIONS The patient received two liver transplantations. During the first liver transplantation, the hepatic artery (HA) pulsations were normal. Doppler B ultrasonography showed normal blood flow in the HA in the first week. A 4 cm hematoma was detected in the first porta hepatis. On the ninth day, the hematoma had increased to 9 cm along with development of HAT. Exploratory laparotomy was performed. Bleeding at the site of arterial anastomosis was considered to be the reason for the hematoma. Doppler imaging revealed no blood flow in the liver. Computed tomography angiography demonstrated MALS. Salvage liver transplantation combined with dissection of MAL was performed. The maximum velocity of HA increased to 87 cm/s. OUTCOMES The patient was discharged from the hospital 17 days after the second transplantation. At discharge, the liver function was normal and Doppler showed good blood flow in the HA. LESSONS MALS can cause HAT after liver transplantation. Before the liver transplantation, we should use Doppler B ultrasonography and sagittal CT imaging to judge whether the patient is with MALS. Also, before arterial anastomosis in liver transplantation is conducted, we should observe the impacts on the HA caused by pre-blocking gastroduodenal artery, which determines if we are supposed to do MAL dissection or bridge HA with aorta.
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Pillai AK, Kalva SP, Hsu SL, Walker TG, Silberzweig JE, Annamalai G, Baerlocher MO, Mitchell JW, Midia M, Nikolic B, Dariushnia SR. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol 2018; 29:642-647. [PMID: 29574024 DOI: 10.1016/j.jvir.2017.11.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 11/19/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anil K Pillai
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Texas
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven L Hsu
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - T Gregory Walker
- Division of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ganesan Annamalai
- Department of Medical Imaging, University of Toronto, Mt. Sinai Hospital & University Health Network, Toronto, Ontario, Canada
| | - Mark O Baerlocher
- Department of Radiology, Royal Victoria Hospital, Barrie, Ontario, Canada
| | - Jason W Mitchell
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Mehran Midia
- Department of Diagnostic Imaging, McMaster University, Hamilton, Ontario, Canada
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, New York
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia.
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Miyata T, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uemura S, Kato Y, Ohgi K, Kohga A, Uchida T, Sano S, Nakagawa M, Uesaka K. Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report. J Surg Case Rep 2018; 2018:rjy002. [PMID: 29383246 PMCID: PMC5786235 DOI: 10.1093/jscr/rjy002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/24/2017] [Accepted: 01/14/2018] [Indexed: 12/17/2022] Open
Abstract
A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.
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Affiliation(s)
- Takashi Miyata
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sunao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshiyasu Kato
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Atsushi Kohga
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tsuneyuki Uchida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shusei Sano
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masahiro Nakagawa
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Wang XM, Hua XP, Zheng GL. Celiac Artery Compression Syndrome Evaluated with 3-D Contrast-Enhanced Ultrasonography: a New Approach. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:243-250. [PMID: 29079396 DOI: 10.1016/j.ultrasmedbio.2017.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/22/2017] [Accepted: 09/11/2017] [Indexed: 06/07/2023]
Abstract
This study was performed to estimate the value of 3-D contrast-enhanced ultrasonography (3-D-CEUS) in the diagnosis of celiac artery compression syndrome (CACS). Patients suspected of having CACS were assessed with 3-D-CEUS and contrasted with computed tomography angiography. Diagnostic accuracy was evaluated with a receiver operating characteristic curve. Three-dimensional CEUS revealed 19 positive and 9 negative cases. In the negative group, the contrast agent did not change with respiration. In the positive group, the contrast agent exhibited a hook-shaped stenosis on expiration and returned to normal on inspiration. Computed tomography angiography indicated 1 false-positive case and 1 false-negative case. The sensitivity and specificity of 3-D-CEUS were 95% and 89%, respectively. The area under the receiver operating characteristic curve was 0.982 (p <0.01). In conclusion, 3-D-CEUS can accurately reveal the characteristic hooked appearance and dynamic nature of CACS with respiration, and thus, it represents a new, non-invasive approach to CACS diagnosis.
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Affiliation(s)
- Xian-Ming Wang
- Department of Ultrasound, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China
| | - Xian-Ping Hua
- Department of Cardiovascular Medicine, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China.
| | - Guo-Liang Zheng
- Department of Radiology, Affiliated Xiaolan Hospital of Southern Medical University, Zhongshan, Guangdong, China
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Takeuchi Y, Morikage N, Samura M, Harada T, Yamashita O, Suehiro K, Okada M, Hamano K. Treatment Options for Celiac Stenosis and Pancreaticoduodenal Artery Aneurysms. Ann Vasc Surg 2017; 41:281.e21-281.e23. [DOI: 10.1016/j.avsg.2016.10.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
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28
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Bulut T, Oosterhof-Berktas R, Geelkerken RH, Brusse-Keizer M, Stassen EJ, Kolkman JJ. Long-Term Results of Endovascular Treatment of Atherosclerotic Stenoses or Occlusions of the Coeliac and Superior Mesenteric Artery in Patients With Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2017; 53:583-590. [PMID: 28254161 DOI: 10.1016/j.ejvs.2016.12.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/25/2016] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Over the past decade, primary percutaneous mesenteric artery stenting (PMAS) has become an alternative to open revascularisation for treatment of mesenteric ischaemia. Institutes have presented favourable short-term outcomes after PMAS, but there is a lack of data on long-term stent patency. METHODS One hundred and forty-one patients treated by PMAS for acute and chronic mesenteric ischaemia over an 8 year period were studied. Anatomical success was assessed by duplex ultrasound and/or CT angiography. A stenosis ≥70% was considered to be a failure. RESULTS Eighty-six coeliac arteries (CA) and 99 superior mesenteric arteries (SMA) were treated with PMAS in 141 patients. Nine CAs (10%) and 30 SMAs (30%) were occluded at the time of treatment. Median follow-up was 32 months (IQR 20-46). The overall primary patency rate at 12 and 60 months was 77.0% and 45.0%. The overall primary assisted patency rate was 90.3% and 69.8%. Overall secondary patency was 98.3% and 93.6%. CONCLUSION This study shows excellent long-term secondary patencies after PMAS, comparable with published data on long-term patencies after open surgical revascularisation.
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Affiliation(s)
- T Bulut
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - R Oosterhof-Berktas
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Radiology Martini Ziekenhuis, Groningen, The Netherlands
| | - R H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Faculty Science and Technology, Experimental Centre of Technical Medicine, University of Twente, Enschede, The Netherlands
| | - M Brusse-Keizer
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - E J Stassen
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J J Kolkman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Gastroenterology University Medical Centre, Groningen, The Netherlands
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Columbo JA, Kang R, Goodney PP. Endovascular-First for Chronic Mesenteric Ischemia and the Importance of Long-Term Surveillance. Angiology 2016; 68:841-842. [PMID: 27856668 DOI: 10.1177/0003319716679342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ravinder Kang
- 2 Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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30
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Celiac artery compression of patients undergoing pancreatic surgery – a case series. Eur Surg 2016. [DOI: 10.1007/s10353-016-0443-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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31
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Park HM, Lee SD, Lee EC, Lee IJ, Han SS, Kim HB, Kim SH, Lee SA, Park SJ. Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases. Ann Surg Treat Res 2016; 91:149-53. [PMID: 27617257 PMCID: PMC5016606 DOI: 10.4174/astr.2016.91.3.149] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/13/2016] [Accepted: 04/18/2016] [Indexed: 12/18/2022] Open
Abstract
We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.
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Affiliation(s)
- Hyeong Min Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Eung Chang Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - In Joon Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Hyun Boem Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seoung Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Soon-Ae Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
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Jeican II, Ichim G, Gheban D. Intestinal ischemia in neonates and children. ACTA ACUST UNITED AC 2016; 89:347-51. [PMID: 27547054 PMCID: PMC4990429 DOI: 10.15386/cjmed-600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/22/2015] [Accepted: 01/12/2016] [Indexed: 12/15/2022]
Abstract
The article reviews the intestinal ischemia theme on newborn and children. The intestinal ischemia may be either acute - intestinal infarction (by vascular obstruction or by reduced mesenteric blood flow besides the occlusive mechanism), either chronic. In neonates, acute intestinal ischemia may be caused by aortic thrombosis, volvulus or hypoplastic left heart syndrome. In children, acute intestinal ischemia may be caused by fibromuscular dysplasia, volvulus, abdominal compartment syndrome, Burkitt lymphoma, dermatomyositis (by vascular obstruction) or familial dysautonomia, Addison’s disease, situs inversus abdominus (intraoperative), burns, chemotherapy administration (by nonocclusive mesenteric ischemia). Chronic intestinal ischemia is a rare condition in pediatrics and can be seen in abdominal aortic coarctation or hypoplasia, idiopathic infantile arterial calcinosis.
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Affiliation(s)
- Ionuţ Isaia Jeican
- 1st Department of Surgery, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriela Ichim
- 3rd Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Emergency Hospital for Children Cluj-Napoca, Romania
| | - Dan Gheban
- Department of Pathology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Emergency Hospital for Children Cluj-Napoca, Romania
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Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure. J Vasc Surg 2016; 63:1582-7. [DOI: 10.1016/j.jvs.2016.02.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/10/2016] [Indexed: 11/17/2022]
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Geiger MA, Universidade Estadual de Campinas, Brazil, Callaert J, Deloose K, Bosiers M, Hospital da Pontifícia Universidade Católica de Campinas, Brazil, Hospital Sint Blasius, Belgium. Percutaneous retrograde crossing of a near-occluded celiac trunk via the superior mesenteric artery as an adjuvant maneuver for antegrade stenting. J Vasc Bras 2016. [DOI: 10.1590/1677-5449.002415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract We describe the case of a 63-year-old woman with chronic mesenteric ischemia, persistent postprandial upper abdominal pain and progressive weight loss. Retrograde recanalization was performed via the superior mesenteric artery in order to achieve the goal of crossing the near-occlusion, showing that retrograde catheterization of the celiac trunk can be a feasible approach in challenging cases in which an antegrade approach fails as a single maneuver.
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Moghadamyeghaneh Z, Carmichael JC, Mills SD, Dolich MO, Pigazzi A, Fujitani RM, Stamos MJ. Early Outcome of Treatment of Chronic Mesenteric Ischemia. Am Surg 2015. [DOI: 10.1177/000313481508101128] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.
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Affiliation(s)
- Zhobin Moghadamyeghaneh
- Divisions of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Joseph C. Carmichael
- Divisions of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Steven D. Mills
- Divisions of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Matthew O. Dolich
- Divisions of Trauma and Critical Care Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Alessio Pigazzi
- Divisions of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Roy M. Fujitani
- Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
| | - Michael J. Stamos
- Divisions of Colorectal Surgery, Department of Surgery, University of California, Irvine, School of Medicine, Orange, California
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Shah AS, Schwartz LB, Moawad J, Gewertz BL. Technique profile: mesenteric reconstructions for occlusive disease. Expert Rev Cardiovasc Ther 2015; 13:1445-58. [DOI: 10.1586/14779072.2015.1094376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Christofi G, Donas KP, Pitoulias GA, Torsello G, Schwindt AG, Stavroulakis K. Endovascular treatment of occluded and stenotic visceral vessels in patients with chronic mesenteric ischemia. Vascular 2015; 25:3-9. [PMID: 26438613 DOI: 10.1177/1708538115608579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Current evidence in the literature about endovascular treatment (ET) of visceral vessels in patients with chronic mesenterial ischemia (CMI) based on morphological characteristics is limited. The aim of this study was the evaluation of ET in occluded and stenotic visceral vessels. Methods Patients undergoing ET for CMI between November 2000 and November 2012 were included in this retrospective study. Primary measure outcome was the symptom-free survival (SFS). Secondary outcomes were primary (PPR), secondary patency (SPR) rates and technical success rate (TSR). A Cox-regression analysis identified risk factors for the primary and secondary measure outcomes. Results Forty patients were included in the present study (men: 21, mean age: 68). The overall number of vessels with intention-to-treat was 62. Fifty-two visceral arteries (18 occlusions and 34 stenoses) were successfully treated by endovascular means. The overall TSR was 84%. Visceral vessel occlusions and atherosclerotic disease of the superior mesenteric artery (SMA) were identified as independent risk factors for poorer TSR ( p < 0.05). The 12-month SFS was 60%. The overall 12-month PPR and SPR were 71% and 94%, respectively. No significant differences were observed between occluded and stenotic vessels ( p > 0.05) concerning the PPR. On the other hand, the subgroup analysis revealed higher SPR among occluded visceral vessels ( p < 0.001) and coeliac axis lesions ( p < 0.001). Conclusions ET was associated with high incidence of symptoms recurrence despite the satisfying patency rates in both occluded and stenotic vessels. Additionally, visceral vessel occlusion and presence of atherosclerotic lesions in the SMA were associated with poorer TSR.
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Affiliation(s)
- Georgia Christofi
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Konstantinos P Donas
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Georgios A Pitoulias
- 2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany.,3 Division of Vascular Surgery, G. Gennimatas General Hospital, Aristotle University, Thessaloniki, Greece
| | - Giovanni Torsello
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Arne G Schwindt
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Konstantinos Stavroulakis
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
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Sundermeyer A, Zapenko A, Moysidis T, Luther B, Kröger K. Endovascular treatment of chronic mesenteric ischemia. Interv Med Appl Sci 2014; 6:118-24. [PMID: 25243077 DOI: 10.1556/imas.6.2014.3.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/15/2014] [Accepted: 05/20/2014] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Data regarding endovascular treatment of chronic mesenteric ischemia (CMI) are sparse. Angioplasty is often accompanied by early restenosis and the need of further interventions. Thus we present our own patients' data and review the recent literature. METHODS We retrospectively reviewed all endovascular CMI treatments performed from 2008 to 2012 (27 patients, 14 females, mean age 70 ± 9 years). Patients' data were retrieved from electronic health records. Patients' follow-up included routinely performed color-coded ultrasonography, and, if performed for other clinical reasons, computed tomography or angiography. In addition, data extracted from 11 studies focusing on endovascular CMI treatment were analyzed. RESULTS Procedures were performed without clinical complications in all patients. Seven patients received pure angioplasty and 20 patients stent-assisted angioplasties using bare metal stents, respectively. Three patients died 3, 5 and 32 months after the intervention. Five patients underwent re-intervention (one early restenosis at day 4 after pure angioplasty with stent placement and four because of in-stent restenosis, 5 to 23 months after placement). Another patient was treated surgically because of stent occlusion and reoccurring abdominal angina 15 months after the intervention. The 11 studies found in the literature included 429 cases with 196 treatments of the coeliac trunk (truncus coeliacus = TC), 319 of the superior mesenteric artery (SMA) and 42 of the inferior mesenteric artery (IMA). Patency rates in the more recent studies were high with up to 80% within 1 year. Data of earlier studies report longer follow-up periods and indicate low patency rates after three years. Our 2-year patency rate of 50% is within the range of reported patency data. CONCLUSIONS The presented data show that endovascular SMA treatment is a suitable and safe procedure in patients suffering from CMI, but long-term results are limited.
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Oderich GS, Bower TC, Sullivan TM, Bjarnason H, Cha S, Gloviczki P. Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg 2014; 49:1472-9.e3. [PMID: 19497510 DOI: 10.1016/j.jvs.2009.02.006] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 02/06/2007] [Accepted: 02/03/2009] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Outcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification. METHODS The data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting. RESULTS The ER patients were significantly older (71 +/- 15 vs 65 +/- 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 +/- 0.5 vs 1.8 +/- 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group (P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 +/- 8 vs 3 +/- 5 days; P < .001). At 5 years, OR had improved (P < .05) recurrence-free survival (89% +/- 4% vs 51% +/- 9%), and primary (88% +/- 3% vs 41% +/- 9%) and secondary patency rates (97% +/- 2% vs 88% +/- 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved (P < .05) recurrence-free survival (91% +/- 3% vs 56% +/- 8% at 5 years) and better primary and secondary patency rates (93% +/- 2% and 98% +/- 1% vs 52% +/- 8% and 93% +/- 4% at 3 years). CONCLUSION OR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.
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Affiliation(s)
- Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Joyce DD, Antiel RM, Oderich G, Gloviczki P, Tung J, Grothe R, Absah I, Zarroug AE. Pediatric Median Arcuate Ligament Syndrome: Surgical Outcomes and Quality of Life. J Laparoendosc Adv Surg Tech A 2014; 24:104-10. [DOI: 10.1089/lap.2013.0438] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Ryan M. Antiel
- Divisions of General Surgery, Mayo Clinic, Rochester, Minnesota
| | - Gustavo Oderich
- Divisions of Vascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter Gloviczki
- Divisions of Vascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jeanne Tung
- Divisions of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Rayna Grothe
- Divisions of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Imad Absah
- Divisions of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota
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Ikeda O, Nakasone Y, Yokoyama K, Inoue S, Tamura Y, Yamashita Y. Simultaneous coil embolization and angioplasty using a self-expanding nitinol stent to treat pancreaticoduodenal artery aneurysms associated with celiac artery stenosis. Acta Radiol 2013; 54:949-53. [PMID: 23761555 DOI: 10.1177/0284185113488577] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The degeneration of pancreaticoduodenal arcade vessels due to pancreaticoduodenal artery aneurysms is associated with celiac artery stenosis or occlusion. While technical advances have made it possible to treat pancreaticoduodenal arcade aneurysms (PDAA) and celiac artery stenosis by endovascular techniques, there is no consensus regarding their optimal treatment. PURPOSE To treat pancreaticoduodenal arcade aneurysms (PDAA) by simultaneous coil embolization and celiac artery stenting, and propose indications for treating PDAA with celiac artery stenosis by this method. MATERIAL AND METHODS We reviewed 11 patients who underwent transcatheter coil embolization (TCE) to treat PDAA. When the aneurysmal neck size was less than half of the short axis of the aneurysm we used packing only, when it was more than half of the short axis we undertook isolation. In the latter situation, when there was evidence of celiac artery stenosis, we performed celiac artery stenting using self-expandable stents. RESULTS Ten of the 11 patients (91%) presented with celiac axis stenosis due to median arcuate ligament compression. Coil-packing of the aneurysmal sac only, thus preserving the native arterial circulation, was done in five patients, another five underwent isolation by embolization of vessels distal and proximal to the PDAA with simultaneous stenting of the stenotic celiac axis, and one patient was treated by isolation only. One patient developed acute pancreatitis. There were no other complications and all aneurysms were successfully excluded. In one patient the celiac stent thrombosed after stopping the antiplatelet regimen. CONCLUSION TCE can be effective in patients with PDAA. In the presence of celiac artery stenosis, we recommend isolation of the aneurysms with simultaneous stenting of the stenotic celiac trunk using self-expandable stents.
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Affiliation(s)
- Osamu Ikeda
- Department of Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Honjo Kumamoto, Japan
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Sultan S, Hynes N, Elsafty N, Tawfick W. Eight years experience in the management of median arcuate ligament syndrome by decompression, celiac ganglion sympathectomy, and selective revascularization. Vasc Endovascular Surg 2013; 47:614-9. [PMID: 23942948 DOI: 10.1177/1538574413500536] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.
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Affiliation(s)
- Sherif Sultan
- 1Department of Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, Galway, Ireland
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Ahanchi SS, Stout CL, Dahl TJ, Carty RL, Messerschmidt CA, Panneton JM. Comparative analysis of celiac versus mesenteric artery outcomes after angioplasty and stenting. J Vasc Surg 2013; 57:1062-6. [DOI: 10.1016/j.jvs.2012.10.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/04/2012] [Accepted: 10/11/2012] [Indexed: 11/27/2022]
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AbuRahma AF, Campbell JE, Stone PA, Hass SM, Mousa AY, Srivastava M, Nanjundappa A, Dean LS, Keiffer T. Perioperative and late clinical outcomes of percutaneous transluminal stentings of the celiac and superior mesenteric arteries over the past decade. J Vasc Surg 2013; 57:1052-61. [DOI: 10.1016/j.jvs.2012.10.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 11/15/2022]
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Al-Hammash SM, Al-Ethawi AESD, Ismail KA. Endovascular treatment of chronic mesenteric ischemia in an adolescent male: case report. F1000Res 2013; 2:277. [PMID: 25075283 PMCID: PMC4103498 DOI: 10.12688/f1000research.2-277.v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2013] [Indexed: 11/20/2022] Open
Abstract
Chronic mesenteric ischemia (CMI) is a condition characterized by inadequate blood flow to the bowel resulting from stenosis of one or more of the three mesenteric arteries. Fibromuscular dysplasia is the most common cause in children and young adults; whereas atherosclerosis is the most common cause in the elderly. Treatment is mandatory in symptomatic patients, because it may lead to malnutrition, bowel infarction or even death.Herein, we present the case of a 14-year old male, diagnosed with CMI who underwent percutaneous balloon angioplasty (PTA) followed by stent placement with immediate positive results.
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Affiliation(s)
- Sadiq Muhammed Al-Hammash
- Ibn Al-Bittar Center for Cardiac Surgery, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq
| | | | - Kasim Abbas Ismail
- Ibn Al-Bittar Center for Cardiac Surgery, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq
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Abstract
Atherosclerotic vascular disease involving the mesenteric arteries occurs frequently in the elderly population. Although the prevalence of ischemic bowel disease is difficult to determine, acute mesenteric ischemia (AMI) has been reported to cause in 1 in 1000 hospital admissions, whereas chronic mesenteric ischemia (CMI) is estimated to affect 1 in 100,000 individuals. Mesenteric ischemia generally manifests in its chronic form as postprandial abdominal pain resulting in significant weight loss, and in its acute form as an abrupt development of abdominal pain, lower gastrointestinal bleeding, and subsequent intestinal necrosis. This article discusses the cause, clinical manifestations, diagnosis, and management of AMI and CMI.
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Baker AC, Chew V, Li CS, Lin TC, Dawson DL, Pevec WC, Hedayati N. Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization. J Vasc Surg 2012; 56:1364-71; discussion 1371. [DOI: 10.1016/j.jvs.2012.03.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 02/16/2012] [Accepted: 03/19/2012] [Indexed: 10/27/2022]
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Pecoraro F, Rancic Z, Lachat M, Mayer D, Amann-Vesti B, Pfammatter T, Bajardi G, Veith FJ. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg 2012; 27:113-22. [PMID: 23088809 DOI: 10.1016/j.avsg.2012.05.012] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 07/06/2011] [Accepted: 05/06/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist. METHODS A systematic literature review of the last 25-years was conducted through MEDLINE, Embase, and Cochrane Review/Trials register to identify studies reporting on CMI treatment with more than 10 patients. Primary outcomes were perioperative mortality and morbidity rates. Secondary outcomes were survival rates, primary and secondary patency rates, vessels treated, CMI recurrence, follow-up (FU), technical success (TS), and in-hospital length of stay (InH-LOS). Patients were divided into endovascular treatment (ET) or open treatment (OT) groups. Subsequently, primary and secondary outcomes were analyzed by study publication year for the interval periods 1986-2000 ("A") and 2001-2010 ("B"). Differences were assessed using the t-test and the χ(2) test. RESULTS Forty-three articles with 1,795 patients were included. Perioperative mortality and morbidity rates were lower in the ET group. No difference in survival rate was observed. Primary and secondary patencies were superior in the OT group. A greater number of vessels were revascularized in the OT group. CMI recurrence was more frequent in the ET group. FU was longer in the OT group. TS was superior in the OT group and InH-LOS was shorter in the ET group. A higher number of patients were treated by ET in the period "A." No differences in mortality and morbidity were observed between period "A" and "B" in ET and OT groups. CONCLUSIONS Considering the lower periprocedural mortality and morbidity after ET, this approach should be considered as the first treatment option in most CMI patients, especially in those with severe malnutrition. Primary OT should be restricted to cases that do not qualify for ET or good surgical risk patients with long life expectancy. Considering better long-term results of OT, ET treatment should be considered as a bridge therapy to OT in some patients requiring retreatment if ET does not preclude subsequent OT.
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Affiliation(s)
- Felice Pecoraro
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; Vascluar Surgery Unit, University Hospital P. Giaccone, Via L.Giuffrè 5, Palermo, Italy.
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Meyer M, Gharagozloo F, Nguyen D, Tempesta B, Strother E, Margolis M. Robotic-assisted treatment of celiac artery compression syndrome: report of a case and review of the literature. Int J Med Robot 2012; 8:379-83. [DOI: 10.1002/rcs.1448] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2012] [Indexed: 01/07/2023]
Affiliation(s)
- Mark Meyer
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
| | - Farid Gharagozloo
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
| | - Duy Nguyen
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
| | - Barbara Tempesta
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
| | - Eric Strother
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
| | - Marc Margolis
- Washington Institute of Thoracic and Cardiovascular Surgery; The George Washington University Medical Center; Washington; DC; USA
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Sharafuddin MJ, Nicholson RM, Kresowik TF, Amin PB, Hoballah JJ, Sharp WJ. Endovascular recanalization of total occlusions of the mesenteric and celiac arteries. J Vasc Surg 2012; 55:1674-81. [DOI: 10.1016/j.jvs.2011.12.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 12/02/2011] [Accepted: 12/08/2011] [Indexed: 01/04/2023]
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