Endovascular treatment of arterial mesenteric ischaemia: a retrospective review

Mesenteric ischaemia is a condition that has traditionally been managed surgically. It poses a challenging diagnostic and therapeutic problem, particularly in the acute setting. We review a small series of eight patients managed with endovascular techniques for either acute or chronic mesenteric ischaemia at The Royal Melbourne Hospital, from 1997 to 2002. We describe our results and relate these to the recent published literature regarding endovascular and surgical management of mesenteric ischaemia. Our experience confirms the valuable contribution of angioplasty and stenting in chronic mesenteric ischaemia, which compares favourably with surgery with regards to complication rates and mortality. We suggest the need for further studies to compare the long-term efficacy of endovascular techniques compared with surgery in the management of chronic mesenteric ischaemia. Furthermore, we demonstrate a role for endovascular management in acute mesenteric ischaemia, in the appropriate clinical setting.

Endocarditis and ulnar artery aneurysm as presenting features of antiphospholipid syndrome and polyarteritis nodosa

Antiphospholipid syndrome in association with vasculitis is highlighted in this report. The combination of thrombotic and inflammatory processes resulted in endocarditis, aneurysm formation and thrombosis. To our knowledge this is the first presentation of a large vessel aneurysm in these conditions. Anticoagulation and immunosuppression are the treatment modalities of choice.

Caveolae and sarcoplasmic reticular coupling in smooth muscle cells of pressurised arteries: the relevance for Ca2+ oscillations and tone

OBJECTIVE

A close association of caveolae and sarcoplasmic reticulum (SR) has been suggested to be important for contractile activation of smooth muscle. Here, we investigate the presence of such arrangements in pressurised resistance arteries and examine the influence of two agents purported to disrupt caveolae and/or SR conformations by different mechanisms of action.

METHODS

Rat mesenteric small arteries (RMSA) were mounted on a pressure myograph and the functional (lumen diameter and Ca(2+) oscillations) and ultrastructural effects of the phosphatase inhibitor calyculin-A (cal-A), or the cholesterol binding agent methyl-beta-cyclodextrin (mbetacd), examined by light and electron microscopy.

RESULTS

Smooth muscle cells of RMSA exhibited a prominent peripheral SR that often encircled individual caveolae. The peripheral SR on occasion was observed to make contact with centrally located SR allowing for a structural association of caveoale-SR-myofilaments. Cal-A maximally constricted RMSA and disrupted the regular SR-caveolae appearance such that concentrated swirls of SR not enveloping caveolae were evident. Mbetacd treatment, in contrast, inhibited agonist contractility and reduced the appearance of caveolae whilst peripheral SR apposition to the plasmalemma could still be observed. Treatment with either agent inhibited agonist-mediated smooth muscle Ca(2+) oscillations.

CONCLUSION

We present data that supports a structural arrangement of caveolae and underlying peripheral SR in smooth muscle cells of pressurised resistance arteries that serves to regulate Ca(2+) oscillations and contractile activation.

[Laparoscopic colon-sigmoid resection with mesenteric artery preservation for diverticular disease]

AIM

About 2/3 of the Western population over the age of 80 years are affected by colic diverticulosis; 25% will develop diverticular disease with or without complications: fistula, obstruction, pericolic abscess, free perforation or hemorrhage. Laparoscopic approach for benign diseases of the colon such as diverticulosis, Chrohn's disease, etc. is unanimously considered as a very effective procedure. We have performed a retrospective analysis of 9 years with laparoscopic approach of the diverticular disease. The purpose of this study was to determine the feasibility, safety and benefits of laparoscopic approach.

METHODS

From May 1994 to November 2002, 69 patients affected by non-complicated diverticular disease, were treated laparoscopically, at the Mininvasive Surgery Department of Spoleto. In the same period other 213 patients suffering from cancer of the colon-rectum were operated through laparoscopic surgery. A colosigmoid resection with mesenteric inferior artery preservation was performed in 46 cases (67%).

RESULTS

We have performed only a laparoscopic colectomy technique (no hand-assisted procedures); the convertion rate was of 7.2%, the mean operative time was 145 min, no intraoperative complications were observed and finally the mean hospital stay was of 7.4 days (6-9). The postoperative complications were 1 case of infection of the umbilical scar and 1 case of pleural effusion with bronchopneumonia.

CONCLUSIONS

Elective laparoscopic colectomy for diverticular disease is feasible, safe and gives very good results: minimum postoperative discomfort, rapid recovery, low mobility and postoperative stay, rapid return to normal activities. However, in some cases, this procedure can be extremely difficult because of previous inflammatory complications (adhesions, fistulas or stenosis), therefore, high surgical skills in laparoscopic-colic surgery are required.

[Correlation between dissection of lymph nodes adjacent to mesenteric artery pedicle and prognosis in colorectal cancer patients]

OBJECTIVE

To analyze the impact of radical surgery with different extent of lymph nodes dissection on the prognosis of colorectal carcinoma patients and to see if lymph nodes adjacent to mesenteric artery root should be excised.

METHODS

Data of 1409 cases with colorectal carcinoma treated in Shanghai Cancer Hospital during 1985-2000 were collected. These patients had primary colorectal carcinoma treated by radical surgery with different extent of lymph nodes excision. They were divided into two groups: in group D3 the lymph nodes adjacent to mesenteric artery root were excised (n = 857), while in group D2 (n = 552) were not. The time of follow-up was 6 approximately 289 months (median: 48 months).

RESULTS

The 1-, 3-, 5-, 10-year total survival rates (TS) in group D3 patients were 90.3%, 81.4%, 77.0% and 73.0%, respectively. The 1-, 3-, 5-, 10-year tumor-free survival rates (TFS) in group D3 patients were 89.9%, 79.4%, 74.5% and 70.3%, respectively. In group D2 patients, the 1-, 3-, 5-, 10-year TS were 91.04%, 84.12%, 79.33% and 76.17%, and those of TFS were 90.0%, 82.7%, 76.0% and 71.8%, respectively. The differences in TS and TFS in the two groups of patients were not significant according to Kaplan-Meier analysis (P > 0.05). During the follow-up period, 42 patients in group D3 had local recurrence (4.9%), while in group D2 the rate of local recurrence was 5.4% (P > 0.05). Metastases developed in 79 cases in group D3 and in 60 cases in group D2 (P > 0.05). Multivariate analysis revealed that the excision of lymph nodes adjacent to mesenteric artery pedicle did not statistically correlate with recurrence, metastasis and survival time after radical operation of colorectal cancer.

CONCLUSION

Excision of lymph nodes adjacent to the mesenteric artery root has no significant impact on prognosis and is unnecessary in the radical surgery for colorectal carcinoma.

[Chronic visceral ischemia--diagnostic and therapeutic problem]

Chronic visceral ischemia represents about 1% of cases of the abdominal pain due to which patients are accepted to the medical centres. The diagnose and the treatment are frequently not adequate and the reliable data from the Czech Republic show mortality of subsequent intervention in tens of percent, which is more than the global level. The essential condition for the lowering of the high morbidity and mortality is namely the knowledge of symptoms, diagnose and therapy among the medical doctors of the first and second line. The other step is the centralization of patients with this rare diagnosis in specialized centre.

Up-regulation of CPI-17 phosphorylation in diabetic vasculature and high glucose cultured vascular smooth muscle cells

OBJECTIVE

Contractile responses are significantly increased in vascular smooth muscle tissues isolated from type 2 diabetic db/db mice (hyperreactivity). However, the molecular mechanisms underlying this hyperreactivity are largely unknown. The current study investigates the roles of RhoA, ROCK (rho kinase), PKC (protein kinase C), and CPI-17 (protein kinase C-potentiated phosphatase inhibitor of 17 kDa), molecules shown to play pivotal physiological roles regulating smooth muscle contraction, in diabetes-associated vascular smooth muscle hyperreactivity.

METHODS

Experiments utilized db/db mouse mesenteric arteries and aortas and primary rat aortic smooth muscle cells (VSMCs) cultured in high or normal glucose. RhoA, ROCK, and CPI-17 protein expression and activity were determined by immunoblotting for total or phosphorylated proteins. RhoA activity was determined by subcellular fractionation and pull-down assays. Isometric contractions were determined using isolated mesenteric artery strips.

RESULTS

Active phosphorylated CPI-17 and total and active membrane-bound RhoA were significantly increased in db/db mouse mesenteric arteries and aortas. High glucose time-dependently activated RhoA, ROCK, and CPI-17 in VSMCs. Moreover, inhibiting either RhoA with C3 exoenzyme or ROCK with Y-27632 or H-1152 for 30 min diminished high glucose-induced CPI-17 phosphorylation. Inhibiting protein kinase C (PKC) with GF109203X for 30 min did not inhibit high glucose-induced CPI-17 phosphorylation. Interestingly, when added at the same time as high glucose for a total of 48 h, GF109203X diminished high glucose-induced RhoA and ROCK activation as well as CPI-17 phosphorylation, suggesting PKC is required for high glucose-induced RhoA/ROCK activation and consequently CPI-17 phosphorylation. Importantly, in isolated db/db mouse mesenteric arteries, inhibiting ROCK with Y-27632 or H-1152 significantly alleviated the contractile hyperreactivity in response to phenylephrine or high potassium.

CONCLUSIONS

Diabetes and high glucose activate RhoA, ROCK, and CPI-17, which in turn contribute to diabetic vascular smooth muscle hyperreactivity.

Hypomagnesemia and chondrocalcinosis in short bowel syndrome

Chondrocalcinosis is a result of deposition of calcium pyrophosphate dihydrate (CPPD) crystals in cartilage and fibrocartilage. Chondrocalcinosis is usually sporadic but has also been associated with a variety of metabolic diseases including hypomagnesemia. Reported cases of hypomagnesemia associated chondrocalcinosis were mostly due to renal genetic disorders such as Bartter's or Gitelman's syndrome. We describe 3 patients with chronic hypomagnesemia induced by short bowel syndrome who developed symptomatic chondrocalcinosis. CPPD crystals were identified by polarizing light microscopy in one patient. The underlying intestinal pathology was radiation enteritis in 2 patients and mesenteric arterial thrombosis in the third. Our observations strengthen the hypothesis of a role for magnesium in CPPD crystal deposition disease.

Direct stimulation of K(ATP) channels by exogenous and endogenous hydrogen sulfide in vascular smooth muscle cells

ATP-sensitive K+ (K(ATP)) channels in vascular smooth muscle cells (VSMC) are important targets for endogenous metabolic regulation and exogenous drug therapy. H2S, as a novel gasotransmitter, has been shown to relax rat aortic tissues via opening of K(ATP) channels. However, interaction of H2S, exogenous-applied or endogenous-produced, with K(ATP) channels in resistance artery VSMC has not been delineated. In the present study, using the whole-cell and single-channel patch-clamp technique, we demonstrated that exogenous H2S activated K(ATP) channels and hyperpolarized cell membrane in rat mesenteric artery VSMC. H2S enhanced the amplitude of whole-cell K(ATP) currents with an EC50 value of 116 +/- 8.3 microM and increased the open probability of single K(ATP) channels. H2S hyperpolarized membrane potentials by -12 mV in nystatin-perforated VSMC. Furthermore, inhibition of endogenous H2S production with D,L-propargylglycine (PPG) reduced whole-cell K(ATP) currents. PPG alone had no effect on unitary K(ATP) channel currents in cell-free membrane patches. In addition, effects of H2S on K(ATP) channels and membrane potentials were independent of cGMP-mediated phosphorylation. This study demonstrated modulation of K(ATP) channel activity by exogenous and endogenous H2S in resistance artery VSMC, thus helping elucidate cardiovascular functions of this endogenous gas.

Successful Nonoperative Management of Acute Intraperitoneal Hemorrhage Due to Undiagnosed Polyarteritis Nodosa

We present a rare case of polyarteritis nodosa (PAN), where the initial presentation was intraperitoneal hemorrhage. The diagnosis was confirmed on angiography, and the patient was managed medically without laparotomy. PAN is an extremely rare cause of spontaneous intraperitoneal bleeding but must be carefully considered in the differential diagnosis in order to insure appropriate management of this group of patients.

Sarcoma of the Abdominal Aorta Involving Marginal Arteries of the Small Intestine: A Case Report

Primary sarcoma of the aorta is extremely rare. In the past, the disease was commonly diagnosed on autopsy. However, now it is possible to make a diagnosis preoperatively using various imaging studies such as computed tomographic scanning and magnetic resonance imaging. The authors have experienced one case of abdominal aortic sarcoma in a patient who complained of the symptoms of typical intestinal angina. We diagnosed an aortic sarcoma preoperatively but failed to resect the tumor on thoracolaparotomy because of the tumor extension to marginal arteries of the whole small intestine. We recommend preoperative laparoscopy for evaluation of tumor extension to marginal arteries of the small intestine in a patient having aortic sarcoma and intestinal angina if the patient is considered to be a surgical candidate.

ANCA-negative pauci-immune crescentic glomerulonephritis complicated with recurrent massive gastrointestinal hemorrhage

On April 25, 2003, a 62-year-old Japanese man had been admitted to a hospital because of heavy proteinuria and elevated serum creatinine level, and purpura on the lower extremities. On May 15, 2003, he was referred to our hospital for evaluation and treatment. Serum immunoglobulin and complements were within normal ranges. Immune serology was negative for antinuclear antibody, antiglomerular basement membrane antibody, and antineutrophil cytoplasmic antibodies. Histological examination of a percutaneous renal biopsy specimen revealed that all of the glomeruli had severe crescent formation without deposits of immunoreactants. A diagnosis of antineutrophil cytoplasmic antibody-negative pauci-immune crescentic glomerulonephritis was made. The patient was treated with one cycle of steroid pulse therapy (1000 mg methylprednisolone daily, given on 3 consecutive days), and subsequently with prednisolone (60 mg/day). Despite this treatment, renal failure progressed rapidly and hemodialysis was started 1 month after the acute presentation. On May 30, 2003, he suddenly developed massive hematochezia. A technetium-targeted red-blood-cell scan suggested bleeding in the small intestine. On June 11, he presented with massive melena. A bleeding ulcer was found in the third part of the duodenum, and was treated successfully with endoscopy, using a heater probe. On June 19, he presented with massive hematochezia again. Mesenteric angiography revealed active bleeding from the iliac branch of the superior mesenteric artery. He was treated with continuous intraarterial vasopressin infusion by a catheter seated in the branch artery. The majority of patients with pauci-immune crescentic glomerulonephritis, one of the most common causes of rapidly progressive glomerulonephritis, have glomerular disease as part of a systemic vasculitis. Massive gastrointestinal bleeding, although rare, should be considered one of the serious complications in these patients.

[Initial analysis of the use of the L-D-Hydro (Eato L-D-Hydro) organic tubular graft for performing the modified Blalock-Taussig procedure in congenital heart diseases with decreased pulmonary blood flow]

OBJECTIVE

To analyze the initial results of the use of an organic tubular graft for systemic-pulmonary anastomoses.

METHODS

From March 2002 to April 2003, 10 patients underwent systemic-pulmonary shunt of the modified Blalock-Taussig type, using a new type of biological graft originating from the bovine mesenteric artery treated with polyglycol, the so-called L-D-Hydro. The patients' ages ranged from 3 days to 7 years, and 60% of them were of the male sex. The diagnoses of heart disease were determined on echocardiography. All patients had clinical signs of severe hypoxia (cyanosis). The heart diseases were as follows: tetralogy of Fallot (40%), tricuspid atresia (50%), and atrioventricular septal defect (10%).

RESULTS

One patient died due to sepsis and 9 had an immediate improvement in O2 saturation on pulse oximetry and in the partial oxygen pressure on arterial blood gas analysis. The intensive care unit length of stay ranged from 2 to 6 days. No patient had obstruction of the shunt on the immediate postoperative period or any other complication. All patients had a patent shunt on the echocardiographic studies performed in the immediate postoperative period and later, in the third postoperative month. No bleeding occurred during surgery or in the postoperative period.

CONCLUSION

The tubular L-D-Hydro graft proved to be promising for performing systemic-pulmonary shunt as an alternative for the inorganic products available in the market, however, we need a greater number of implantations and late follow-up for definitive assessment.

Safety and efficacy of superselective angioembolization in control of lower gastrointestinal hemorrhage

BACKGROUND

We evaluated the safety and efficacy of angioembolization to control lower gastrointestinal hemorrhage.

METHODS

Retrospective chart review of patients undergoing angiography for lower gastrointestinal hemorrhage from January 2000 to December 2002.

RESULTS

Seventy-seven patients with lower gastrointestinal hemorrhage underwent mesenteric angiography. Angioembolization was performed in 11 patients. Sixty-six patients were not embolized; 47 of these were treated medically and 19 surgically. Mortality rate was not significantly different in patients treated surgically (3 of 19, 16%) versus those managed medically (6 of 47, 13%; P = 0.746). Of the 11 patients who were embolized, 10 had immediate cessation of hemorrhage, 7 had gastrointestinal ischemia, and 6 died (55%). Overall mortality in non-embolized patients was 9 of 66 (14%; P = 0.002 versus mortality in embolized patients).

CONCLUSIONS

Angioembolization, though effective at controlling hemorrhage, is associated with ischemic complications and a high mortality rate. Our data support surgical or medical management for lower gastrointestinal hemorrhage.

Protection from angiotensin II-mediated vasculotoxic and hypertensive response in mice lacking PI3Kgamma

Hypertension affects nearly 20% of the population in Western countries and strongly increases the risk for cardiovascular diseases. In the pathogenesis of hypertension, the vasoactive peptide of the renin-angiotensin system, angiotensin II and its G protein–coupled receptors (GPCRs), play a crucial role by eliciting reactive oxygen species (ROS) and mediating vessel contractility. Here we show that mice lacking the GPCR-activated phosphoinositide 3-kinase (PI3K)γ are protected from hypertension that is induced by administration of angiotensin II in vivo. PI3Kγ was found to play a role in angiotensin II–evoked smooth muscle contraction in two crucial, distinct signaling pathways. In response to angiotensin II, PI3Kγ was required for the activation of Rac and the subsequent triggering of ROS production. Conversely, PI3Kγ was necessary to activate protein kinase B/Akt, which, in turn, enhanced L-type Ca²⁺ channel–mediated extracellular Ca²⁺ entry. These data indicate that PI3Kγ is a key transducer of the intracellular signals that are evoked by angiotensin II and suggest that blocking PI3Kγ function might be exploited to improve therapeutic intervention on hypertension.

[Nononcologic abdominal surgery in the elderly]

Due to rising life expectancy of the population, the proportion of elderly patients requiring surgery is rising as well. Present aspects of selected, typical, nononcologic diseases of elderly people are discussed. The key to success in their treatment is not to consider primarily the patient's calendrical age but to assess the individual profile of risk factors on the basis of comorbidities. The kind, extent, and timing of an operation has to be based on this assessment. For the treatment of acute diseases (e.g., complicated ulcera, cholecystitis, appendicitis, mesenteric ischemia, and diverticulitis), a rapid and efficacious diagnostic algorithm is essential that takes into account the reduced functional reserve of old people. Constructive interdisciplinary cooperation and minimally invasive techniques play dominant roles in both diagnosis and therapy. Given these prerequisites, there is no reason to withhold surgical intervention from elderly patients.

Analysis of factors influencing hepatocellular carcinoma detection: efficient use of computed tomography during arterial portography and during hepatic arteriography

BACKGROUND

This study was performed to investigate the situations in which computed tomography (CT) combined with arterial portography and hepatic arteriography surpassed dynamic CT in the detection of hepatocellular carcinoma.

METHODS

Computed tomography combined with arterial portography and hepatic arteriography was performed on 137 patients with chronic hepatitis (92 men and 45 women; mean age, 66.5 years) with hepatocellular carcinoma (HCC) as revealed or suspected by dynamic CT. We analyzed the clinical factors leading to the discovery of additional HCC lesions on CT combined with arterial portography and hepatic arteriography that were undetected by dynamic CT.

RESULTS

Computed tomography combined with arterial portography and hepatic arteriography detected additional HCC lesions that had not been revealed by dynamic CT in 33 of 137 patients. Univariate analysis revealed that in the event of HCC recurrence (vs. primary), multiple HCC lesions detected by dynamic CT (vs. single) and decreased liver function (Child's classification B/C vs. A) significantly favored the additional detection of HCC lesions. Multivariate logistic regression indicated that recurrence was the strongest predicting factor for finding additional lesions on computed tomography combined with arterial portography and hepatic arteriography.

CONCLUSIONS

Computed tomography combined with arterial portography and hepatic arteriography is capable of finding additional HCC lesions undetectable by dynamic CT, especially in advanced cases such as HCC recurrence, which may affect the choice of treatment.

Embolization for major lower gastrointestinal haemorrhage: five-year experience

The management of major lower gastrointestinal haemorrhage has changed dramatically in the last 15 years. Innovations in coaxial catheter technology have allowed the interventional radiologist to reach the small peripheral mesenteric arteries and perform superselective embolization with a variety of agents. The present large series represents the 5-year experience of this technique at the Alfred Hospital, Melbourne, in a patient cohort with a high number of comorbidities. Technical success was achieved in 96% of cases. The clinical symptoms of mesenteric ischaemia developed in four patients after embolization and were managed conservatively in two. The procedure-related mortality was low when compared with the published complication rates for emergency surgery, in this clinical setting.

Endovascular Recanalisation in Occlusive Mesenteric Ischemia—Feasibility and Early Results

OBJECTIVE

To evaluate a single centre experience of endovascular treatment of mesenteric ischemia caused by vascular occlusion.

DESIGN

Retrospective study.

MATERIAL AND METHODS

Between 1995 and 2002 17 patients (12 females; mean age 61 years) with symptoms of bowel ischemia were treated endovascularly for arterial occlusion. Vessels were evaluated with angiography and pressure gradient measured. A mean gradient of > 20 mmHg or a stenosis of > 50% was considered significant. Patient data were recorded prospectively and follow-up was supplemented with retrospective chart review. Fifteen patients had follow up imaging, median 10 months (3-29 months) postoperatively. Median clinical follow up was 14 months (5-42 months).

RESULTS

Recanalisation was successful in 16 patients (94%). The average number of stents used was 1.6 per patient. For one patient recanalisation failed with subsequent SMA dissection. A celiac artery stenosis was stented but symptoms remained postoperatively. Perioperative mortality was 5.8% (n = 1). 14/17 patients (82%) displayed symptom relief/improvement. Six patients required secondary endovascular intervention; PTA (n = 3); stent/stentgraft (n = 3). Two of these patients required a third procedure. 4/6 patients that underwent secondary intervention were asymptomatic and of recurrent stenosis > 75% and a gradient > 15 mmHg mean pressure gradient on imaging. Two patients were treated because of a combination of angiographic findings and/or significant pressure gradient combined with clinical symptoms.

CONCLUSIONS

Endovascular treatment of mesenteric ischemia due to vessel occlusion is feasible with acceptable short-term results and limited complications. Most patients experience relief/improvement of symptoms. A significant number of patients might need endovascular re-intervention because of restenosis.