Laparoscopic Inferior Mesenteric Artery Ligation: An Alternative for the Treatment of Type II Endoleaks

One of the complications of endovascular repair of abdominal aortic aneurysm is endoleak from a patent inferior mesenteric artery (IMA). Between 1995 and 2002, of 213 patients who had endografts placed for abdominal aortic aneurysm, 4 (1.8%) had enlarging aneurysms from type II endoleaks involving a patent IMA and underwent a secondary procedure. Two patients had endovascular embolizations through the superior mesenteric artery, and two patients underwent laparoscopic inferior mesenteric artery ligation. In the laparoscopic group, operative time was 85 minutes (range, 35-136 minutes). One laparoscopic procedure had to be redone due to a missed IMA branch. Length of stay was 0 and 3 days. At mean followup at 16 months (range, 2-42 months), all patients had had successful resolution of endoleaks. Laparoscopic ligation is a minimally invasive treatment for IMA-mediated type II endoleaks.

Inferior mesenteric artery aneurysm: case report and review of the literature

Aneurysms of the inferior mesenteric artery are very rare. We report a new case associated with aorto-iliac occlusive disease and occlusion of the superior mesenteric artery, as well as review the pertinent literature.

Multiple microaneurysms of the superior hemorrhoidal artery: unusual recurrent massive rectal bleeding: report of a case

A case of massive rectal bleeding in a 38-year-old male patient from a previously unreported source is presented. Multiple microaneurysms affecting the rectum were demonstrated on an inferior mesenteric artery angiogram. The importance of angiography both for diagnosis and potential therapy in patients with continuous active lower gastrointestinal bleeding is emphasized.

Large bowel ischemia following laparoscopic inguinal hernioplasty

The adverse physiological effects of pneumoperitoneum are well understood. However, the clinical implications of compromised mesenteric circulation through several mechanical and physiological mechanisms are not as well recognized. We describe a fatal case of large bowel ischemia following an elective laparoscopic transperitoneal inguinal hernioplasty. The patient was a 78-year-old man who died within 30 h after an uneventful anesthesia and laparoscopic surgery. An autopsy revealed thrombosis of the inferior mesenteric artery and an infrarenal aortic aneurysm with thrombotic plaque on its wall. We reviewed the relevant literature on laparoscopic procedures and mesenteric ischemia. To our knowledge, this is the first reported case of large bowel ischemia following pneumoperitoneum. We conclude that the presence of an aortic aneurysm is an added risk factor in laparoscopy.

Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding

PURPOSE

To demonstrate results in managing lower gastrointestinal (GI) bleeding with the use of superselective catheterization and intentional induction of vasospasm of the bleeding vessel without the use of embolic agents or vasospasm-inducing medications.

MATERIALS AND METHODS

A retrospective review of 15 episodes of lower GI bleeding treated in the past 6 years by intentional catheter-induced vasospasm (CIV) to achieve thrombosis of a bleeding source was conducted. Nine patients had angiographically proven inferior mesenteric artery bleeding and six had angiographically proven superior mesenteric artery bleeding.

RESULTS

Bleeding was stopped initially in all patients after effective treatment of the feeding artery. Only one patient experienced a repeat episode of bleeding 2 days later, which required hemicolectomy. Two other patients who underwent adequate embolization underwent surgery at the discretion of the surgeon involved. The remainder were clinically observed and discharged after return of stable vital signs and hematocrit levels. None of the patients treated had clinically evident intestinal ischemia or infarction. There was one significant repeat incidence of bleeding 2 months after CIV that may have represented recurrent bleeding from the original site.

CONCLUSION

CIV may be a safe and effective first-line method of embolizing known lower GI bleeding. Whether CIV is used as primary therapy or as the result of spasm incurred during superselective catheterization, the patient may be regarded as successfully treated and followed accordingly, thereby possibly avoiding acute surgical therapy.

Inferior mesenteric arteriovenous fistula eight years after sigmoidectomy

We report a 69-year-old woman with liver cirrhosis due to chronic hepatitis C virus (HCV) infection in whom iatrogenic arteriovenous fistula (AVF) developed after sigmoidectomy. A soft mass with bruit led to the diagnosis of inferior mesenteric AVF. Most mesenteric AVF cases have portal hypertension, but this patients showed none of the usual symptoms of portal hypertension; however, she had a splenomegaly that became worse after sigmoidectomy. Clinicians should be aware of the possibility of AVF in patients with a history of abdominal surgery.

Colonic necrosis subsequent to catheter-directed thrombin embolization of the inferior mesenteric artery via the superior mesenteric artery: a complication in the management of a type II endoleak

The optimal management of endoleaks after endovascular repair of abdominal aortic aneurysms remains to be established. In this report, we describe a persistent side-branch, or type II, endoleak 1 year after endograft implantation treated with catheter-directed embolization of the aneurysm sac and the inferior mesenteric artery via the superior mesenteric artery, with embolization agents including thrombin, lipiodol, and gelfoam powder. Shortly after the embolization procedure, colonic necrosis developed in the patient, manifested by peritonitis, which necessitated a partial colectomy. This case underscores the devastating complication of colonic ischemia as a result of catheter-directed embolization of the inferior mesenteric artery in the management of an endoleak.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease

BACKGROUND

Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.

METHODS

One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted.

RESULTS

Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence.

CONCLUSION

Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Inferior mesenteric artery aneurysm associated with occlusion of the superior mesenteric and celiac arteries

We report a case of a large aneurysm of the inferior mesenteric artery that extended from its origin to bifurcation in the left colic and sigmoidal arteries, and was associated with occlusion of the celiac and superior mesenteric arteries in a 64-year-old patient. The diagnosis was made by arteriography. The patient underwent angioplasty and stenting of the superior mesenteric artery before the operation, which consisted of resection of the aneurysm and reimplantation of the left colic and the sigmoidal arteries separately in the aorta. We believe that this is the first reported case managed by angioplasty in combination with surgery, as well as reimplantation of the branches of the inferior mesenteric artery.

Relationship between preoperative patency of the inferior mesenteric artery and subsequent occurrence of type II endoleak in patients undergoing endovascular repair of abdominal aortic aneurysms

OBJECTIVES

The purpose of this study was (1) to find out whether preoperative inferior mesenteric artery (IMA) patency (on radiographic imaging) predicts IMA-related endoleaks after endovascular repair of infrarenal abdominal aortic aneurysms, (2) to determine feasibility of measuring aneurysm sac pressures in patients with endoleaks, and (3) to report early evidence of effective endovascular obliteration of IMA endoleaks.

METHODS

We studied 76 consecutive cases of infrarenal aortic aneurysms that were repaired with an endovascular approach (March 1998-April 1999).

RESULTS

There were 13 (17%) endoleaks persistent 30 days after the procedure. Eleven (85%) of these 13 were IMA-related endoleaks, which were documented with selective superior mesenteric artery angiography. The preoperative finding (on computed tomographic scan) of a patent IMA does not always predict an IMA-related endoleak, but results in a statistically and clinically significant higher ratio of patients with IMA-related endoleaks in the immediate postoperative period (24% versus 3%, P <.035). In eight of the 11 patients with persistent IMA-related endoleaks, measurement of intra-aneurysm sac pressures was possible, and six of these patients had systemic pressures within the excluded aneurysm sac. Nine (82%) of 11 IMA-related endoleaks were successfully obliterated by means of selective IMA embolization.

CONCLUSIONS

Many endoleaks are caused by a patent IMA, and this can result in persistence of systemic pressure within the aneurysm sac. The preoperative finding (on computed tomographic scan) of a patent IMA is a predictor of increased rates of IMA endoleaks, and IMA endoleaks can be successfully obliterated through endovascular procedures, after endovascular abdominal aortic aneurysm repair.

Angiography of leaks after endovascular repair of infrarenal aortic aneurysms

OBJECTIVE

We examined whether leaks that persist after stent grafting are associated with outflow arteries.

SUBJECTS AND METHODS

Selective angiography was performed in 21 patients with persistent leaks after undergoing endovascular repair of infrarenal aneurysms of the abdominal aorta. Late leaks occurred in five patients whose prostheses were originally sealed. Before angiography, the size and position of leaks were determined with CT and color Doppler sonography.

RESULTS

Superselective angiography was successful in 19 of 21 patients. In two patients, angiography was performed over the afferent artery supplying the leak. We found one outflow artery at the site of the leak in 10 patients (47%); two outflow arteries in five (23.8%); and as many as five outflow arteries in three (14%). Angiography overlooked outflow arteries in three patients (14%). The lumbar and inferior mesenteric, urethral, and testicular arteries were identified as outflow arteries.

CONCLUSION

Other than feeder arteries, persistent leaks are associated with outflow vessels that contribute to the patency of leaks.

Polyarthritis nodosa with mesenteric aneurysms demonstrated by angiography: report of a case and successful treatment of the patient with prednisolone and cyclophosphamide

Polyarteritis nodosa is a necrotizing angitis that predominantly affects small and medium-sized arteries. The prognosis of untreated polyarteritis nodosa is very poor. Since symptoms are diverse and no serologic test is specific for polyarteritis nodosa, the diagnosis is difficult and often delayed. We describe a patient with polyarteritis nodosa who had gastrointestinal involvement with multiple aneurysms of the inferior mesenteric artery; only abdominal angiography provided a conclusive diagnosis. Alleviation of symptoms and regression of aneurysms were observed after combination therapy of an immunosuppressive agent, cyclophosphamide, and prednisolone. We emphasize the importance of early diagnosis by angiography and aggressive therapy in patients in whom physical signs indicating definite polyarteritis nodosa are not present.

[High performance liquid chromatography for analysis of reverse transcription polymerase chain reaction (RT-PCR) products]

The polymerase chain reaction is a powerful method for amplifying specific DNA sequences in vitro. Reverse transcribing mRNA into cDNA expands the use of PCR to monitor mRNA expression in biological system. A method for the analysis of RT-PCR products by HPLC was developed. The separation was performed on a nonporous ion exchange resin column with gradient elution of sodium chloride in 20 mmol/L Tris-HCl buffer (pH 9.0) at a flow rate of 1.0 mL/min and the detection wavelength was 260 nm. lambda-DNA-Hind III digest and a series of RT-PCR products were analyzed for studying the mRNA expression of secreted phospholipase A2 after being injured.

[Splanchnic aneurysms: 10 treated cases and review of the literature]

The splanchnic aneurysms, which are complicated by rupture in 25% of cases with a mortality of 25-70%, are usually a surprise during diagnostic tests for other abdominal pathologies or emergency laparotomies. 10 cases treated (8 in elective and 2 in emergency surgery) are presented here: the aneurysm was in celiac trunk (1 patient), common hepatic artery (1 pt.), hepatic artery (2 pts.), gastroduodenal artery (1 pt.), superior mesenteric artery (1 pt.), inferior pancreaticoduodenal artery (1 pt.), right colic artery (1 pt.) and inferior mesenteric artery (1 pt.). There were 1 case of Marfan syndrome and 9 cases of atherosclerosis, 4 of which arteries presenting hyperdynamic flow consequent to occlusions of the superior mesenteric artery and/or the celiac trunk. The 2 cases operated on for hemoperitoneum underwent aneurysmectomy and ligation of the inflow vessels (1 death from pulmonary embolism on 5th postoperative day), whereas the 8 cases electively treated (with no deaths and I case of transient diarrhoeal syndrome) underwent 4 aneurysmal resections with end-to-end arterial reconstruction, 3 PTFE-graft substitutions and 1 autologous saphenous vein substitution. At follow-up (12-74 months; mean 30.6) all the reconstructions resulted successful. These data confirm the consistent indications of the recent Literature suggesting the indication to the surgical treatment of the incidental aneurysms in the splanchnic area.

A rare case of bloody diarrhea: thrombosis of the V. mesenterica inferior following laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholecystolithiasis. The most common complications, as current experiences show, are bleeding, bile duct injury and non-technical complications like pneumonia. In some individual cases ischemic lesions of bowel by injury or thrombosis of intestinal vessels are described. Here we report the rare case of intestinal venous thrombosis following laparoscopic cholecystectomy. The complication clinically appeared within 24 h after operation starting with bloody diarrhea and mimicking inflammatory bowel disease. The patient, a 41-year old man, was treated with high-dose heparin and could be discharged after 44 days without complaints. Coloscopy six months after the event showed a restitution ad integrum.

Thrombosis resulting in rectal perforation in a horse

A 12-year-old Quarter Horse gelding was admitted to the veterinary medical teaching hospital with a 2-day history of signs of abdominal pain. Initial findings on physical examination included signs of lethargy, dehydration, diarrhea, and gastric reflux. Results of laboratory testing indicated that the horse had panleukopenia with neutrophilic toxic changes, was dehydrated, and was hypocalcemic. During the first 48 hours of hospitalization, 1 abdominal palpation per rectum and 3 analyses of peritoneal fluid were performed; abnormalities were not detected. A preliminary diagnosis of enterocolitis was made. Salmonella anatum was isolated from the feces. The horse's condition improved during a 5-day period, although left jugular thrombosis did develop. On day 8 of hospitalization, the gelding was found dead. Necropsy revealed acute severe fibrinous peritonitis as the result of vasculitis and thrombosis of the caudal mesenteric artery and its cranial rectal branch with rectal infarction and perforation. Immediate classification of rectal tears and perforation as iatrogenic should be avoided. Ischemic vascular disease is a consideration, and horses with thromboembolic disorders may be at risk for rectal perforations.

Angioplasty for the treatment of visceral ischemia

PURPOSE

To evaluate percutaneous transluminal angioplasty (PTA) in the treatment of visceral ischemia.

PATIENTS AND METHODS

Over a 14-year period, 25 focal visceral artery stenoses were treated with PTA in 16 patients with acute or chronic visceral ischemia. Thirteen patients were women and three were men, with a mean age of 64.7 years (range, 54-79 years). PTA was performed in seven celiac arteries, 17 superior mesenteric arteries, and one inferior mesenteric artery.

RESULTS

PTA was technically successful in 14 of 16 patients (88%). Two patients were lost to follow-up. Nine of 12 patients (75%) demonstrated primary patency with relief of clinical symptoms at a mean follow-up of 2.3 years (range, 0.3-5 years). The remaining three patients underwent successful repeat PTA for recurrent symptoms. There was one postprocedural death, and one patient subsequently underwent successful surgical bypass for recurrent visceral ischemia.

CONCLUSIONS

Angioplasty of the visceral arteries may provide relief for select patients with intestinal ischemia, but redilation may be required in some patients.

[Juvenile vascular pathology due to homocystinuria. A clinical case report]

The authors report a case of juvenile vasculopathy in a homocystinuria patient. They point out that thromboembolism may be the only symptomatic expression of this genetically determined metabolic disease. Diagnostic approach and surgical therapy of the vascular lesions as well as medical therapy to prevent further complications are analysed. The opportunity to perform clinical tests for the diagnosis of homocystinuria in all those young patients presenting vascular lesions without other risk factors is finally stressed.