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Tresson P, Tawdi M, Rivoire E, Millon A, Passot G, Rouvière O, Long A. Dissection of the Celiac Trunk Is a Mild Disease. Ann Vasc Surg 2024; 105:362-372. [PMID: 38583764 DOI: 10.1016/j.avsg.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The purpose of this study was to assess whether the presence of an aneurysmal or dissecting arterial disease was a risk factor of poor prognosis in patients presenting a dissection of the celiac trunk (CT). METHODS All patients presenting a CT dissection between January 1, 2014, and June 30, 2022, were included. Patients with a CT dissection due to the extension of an aortic dissection were excluded. Les antécédents familiaux de dissection, de maladie anévrysmale, de maladie athéromateuse ou du tissu conjonctif, la pratique d'une activité physique ou sportive, un effort inhabituel les jours précédant la dissection ainsi qu'un traumatisme étaient recherchés. Family history of dissection, aneurysmal disease, atheromatous or connective tissue disease, physical activity or sport, an unusual effort in the days prior to the dissection and trauma were sought after. Ischemic or aneurysmal complications in the acute phase and the evolution of the dissection were evaluated and compared between patients with an isolated dissection and those presenting an aneurysmal or dissecting arterial disease. RESULTS 45 patients were included in the study. Twenty-three (51.1%) patients presented with symptomatic CT dissection, and 22 (48.9%) with asymptomatic CT dissection. All the patients initially had medical management alone. The mean follow-up was 32 ± 25 months and all patients were asymptomatic at the time last news. 24 (53.3%) presented an isolated CT dissection, and 21 (46.7%) a CT dissection associated with aneurysmal or dissecting arterial disease. There was no significant difference between patients with an isolated CT dissection and those with an associated dissecting or aneurysmal pathology. CONCLUSIONS CT dissection is a stable disease in the midterm, which makes it a mild arterial pathology, with or without aneurysmal or dissecting anomalies in another territory. The mechanical stress exerted on the CT by the arcuate ligament could be responsible for parietal trauma and favor the occurrence of a CT dissection.
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Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France.
| | - Maria Tawdi
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France
| | - Emeraude Rivoire
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France; Université Claude Bernard Lyon 1, LIBM EA7424, Equipe Athérosclérose, Thrombose et Activité Physique, Faculté de Médecine Rockefeller, Lyon, France
| | - Antoine Millon
- Hospices Civils de Lyon, Hôpital Louis Pradel, Service de Chirurgie Vasculaire et Endovasculaire, Bron cedex, France; Université Claude Bernard Lyon 1, LIBM EA7424, Equipe Athérosclérose, Thrombose et Activité Physique, Faculté de Médecine Rockefeller, Lyon, France
| | - Guillaume Passot
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service de Chirurgie Digestive, Lyon cedex, France
| | - Olivier Rouvière
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Radiologie Urinaire et Vasculaire, Lyon cedex, France
| | - Anne Long
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Interne et de Médecine Vasculaire, Lyon cedex, France; Université Claude Bernard Lyon 1, LIBM EA7424, Equipe Athérosclérose, Thrombose et Activité Physique, Faculté de Médecine Rockefeller, Lyon, France
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Jacobs CR, Scali ST, Jacobs BN, Filiberto AC, Anderson EM, Fazzone B, Back MR, Upchurch GR, Giles KA, Huber TS. Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia. J Vasc Surg 2024; 80:413-421.e3. [PMID: 38552885 DOI: 10.1016/j.jvs.2024.03.028] [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] [Received: 01/10/2024] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Clinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI. METHODS All patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death. RESULTS A total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death. CONCLUSIONS The perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.
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Affiliation(s)
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
| | - Benjamin N Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Amanda C Filiberto
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Kristina A Giles
- Division of Vascular Surgery, Maine Medical Center, Portland, PE
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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Zhang B, Shen Y, Jin L, Wang J. Systematic review and meta-analysis of current evidences in endograft therapy vs. medical treatment for Spontaneous Isolated Superior Mesenteric Artery Dissection. Langenbecks Arch Surg 2024; 409:215. [PMID: 39008150 DOI: 10.1007/s00423-024-03406-9] [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] [Received: 06/11/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE Endovascular stent therapy (EST) for spontaneous isolated superior mesenteric artery dissection (SISMAD) is gaining popularity, yet the treatment strategy - BMT or EST - remains debatable. METHODS A meta-analysis examined all randomized trials and observational studies exploring the relative merits and potential risks of EST vs. BMT in treating SISMAD patients. Key outcomes included early and long-term adverse effects, with odds ratios (ORs) and 95% confidence intervals (CI) calculated. A random- or fixed-effects model was selected according to a 50% heterogeneity threshold. RESULTS 9 observational studies involving a total of 672 SISMAD patients (303 EST), met our selection criteria. We discovered no noteworthy distinctions between the EST group and the BMT group in terms of early symptoms' alleviation, reinterventions, or all-cause mortality. However, patients receiving EST management will be hospitalized longer than those receiving BMT (EST: 13.2 ± 5.1 months vs. BMT: 7.0 ± 2.2 months, P < 0.01). In the long run, EST was found to significantly contribute to a higher rate of complete remodeling (OR: 4.53, CI: 3.01 ~ 6.81, P < 0.01; heterogeneity, I2 = 50%) and a lower incidence of aneurysm formation (OR: 0.19, CI: 0.06 ~ 0.6, P < 0.01; heterogeneity, I2 = 0%) than BMT. However, there are no significant differences between ESTand BMTin terms of all-cause mortality, recurrent syndrome, reintervention, and SMA stenosis or occlusion. CONCLUSION EST can effectively prevent the formation of aneurysmal dissection and improve SISMAD remodeling. Both EST and BMT are similar in reducing long-term mortality, recurrent symptoms, severe SMA stenosis or occlusion, and the need for reintervention in patients with SISMAD.
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Affiliation(s)
- Baoyou Zhang
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Yuexin Shen
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Ling Jin
- Department of Cardiac and Thoracic Vascular Surgery, The First People's Hospital of Jiashan County, The Second Affiliated Hospital of Zhejiang University, Jiashan Branch, Jiaxing, Zhejiang, 310051, China
| | - Jian Wang
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang, University's Medical School, Hangzhou, Zhejiang, 310051, China.
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Tamme K, Acosta S, Biloslavo A, Björck M, Casian D, Damaskos D, Forbes A, Kase K, Kisand K, Lakbar I, Mihnovitš V, Murruste M, Mändul M, Nuzzo A, Padar M, Starkopf J, Visconti D, Reintam Blaser A. Biomarkers In Prediction of Acute Mesenteric Ischaemia: a prospective multicentre study (BIPAMI study): a study protocol. BMC Surg 2024; 24:201. [PMID: 38961419 PMCID: PMC11221143 DOI: 10.1186/s12893-024-02491-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/24/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Acute mesenteric ischaemia (AMI) is a life-threatening disease where early diagnosis is critical to avoid morbidity and mortality from extensive irreversible bowel necrosis. Appropriate prediction of presence of bowel necrosis is currently not available but would help to choose the optimal method of treatment. The study aims to identify combinations of biomarkers that can reliably identify AMI and distinguish between potentially reversible and irreversible bowel ischaemia. METHODS This is a prospective multicentre study. Adult patients with clinical suspicion of AMI (n = 250) will be included. Blood will be sampled on admission, at and after interventions, or during the first 48 h of suspicion of AMI if no intervention undertaken. Samples will be collected and the following serum or plasma biomarkers measured at Tartu University Hospital laboratory: intestinal fatty acid-binding protein (I-FABP), alpha-glutathione S-transferase (Alpha- GST), interleukin 6 (IL-6), procalcitonin (PCT), ischaemia-modified albumin (IMA), D-lactate, D-dimer, signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) and lipopolysaccharide-binding protein (LBP). Additionally, more common laboratory markers will be measured in routine clinical practice at study sites. Diagnosis of AMI will be confirmed by computed tomography angiography, surgery, endoscopy or autopsy. Student's t or Wilcoxon rank tests will be used for comparisons between transmural vs. suspected (but not confirmed) AMI (comparison A), confirmed AMI of any stage vs suspected AMI (comparison B) and non-transmural AMI vs transmural AMI (comparison C). Optimal cut-off values for each comparison will be identified based on the AUROC analysis and likelihood ratios calculated. Positive likelihood ratio > 10 (> 5) and negative likelihood ratio < 0.1 (< 0.2) indicate high (moderate) diagnostic accuracy, respectively. All biomarkers with at least moderate accuracy will be entered as binary covariates (using the best cutoffs) into the multivariable stepwise regression analysis to identify the best combination of biomarkers for all comparisons separately. The best models for each comparison will be used to construct a practical score to distinguish between no AMI, non-transmural AMI and transmural AMI. DISCUSSION As a result of this study, we aim to propose a score including set of biomarkers that can be used for diagnosis and decision-making in patients with suspected AMI. TRIAL REGISTRATION NCT06212921 (Registration Date 19-01-2024).
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Affiliation(s)
- Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Tartu University Hospital, Tartu, Estonia.
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Alan Biloslavo
- General Surgery Department, Cattinara University Hospital, Trieste, Italy
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Dumitru Casian
- Department of General Surgery Nr. 3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Moldova
- Vascular Surgery Clinic, Institute of Emergency Medicine, Chisinau, Moldova
| | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Kalle Kisand
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Ines Lakbar
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, Montpellier, France
| | - Vladislav Mihnovitš
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Alexandre Nuzzo
- Department of Gastroenterology, IBD and Intestinal Failure, Intestinal Stroke Center, AP-HP. Nord, Beaujon Hospital, Paris Cité University, Paris, France
| | | | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | | | - Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Knarr J, Augustin AM, Hartung V, Krajinovic K, Kickuth R. Management of isolated dissection of the superior mesenteric artery. ROFO-FORTSCHR RONTG 2024; 196:726-734. [PMID: 38176435 DOI: 10.1055/a-2221-3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Jonas Knarr
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Anne Marie Augustin
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | - Viktor Hartung
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Germany
| | | | - Ralph Kickuth
- Institute of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
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Karanasios E, Ragab Z, Cavenagh H, Stather P, Ali T. Characteristics and Trends in Median Arcuate Ligament Syndrome (MALS) Associated Visceral Artery Aneurysms: A Systematic Descriptive Review of the Literature. Vasc Endovascular Surg 2024; 58:512-522. [PMID: 38271562 DOI: 10.1177/15385744241229842] [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: 01/27/2024]
Abstract
Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P = .84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P = .02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management.
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Affiliation(s)
| | - Zeyad Ragab
- Speciality Registrar- Radiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Harry Cavenagh
- Speciality Registrar- Radiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Philip Stather
- Consultant Vascular Surgeon, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Tariq Ali
- Consultant Interventional Radiologist, Norfolk and Norwich University Hospitals, Norwich, UK
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An TJ, Chen X, Omar OMF, Sutphin PD, Irani Z, Wehrenberg-Klee E, Iqbal S, Kalva SP. The Natural History of Splenic Artery Aneurysms: Factors That Predict Aneurysm Growth. J Vasc Interv Radiol 2024; 35:972-978. [PMID: 38663514 DOI: 10.1016/j.jvir.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 03/12/2024] [Accepted: 04/12/2024] [Indexed: 06/25/2024] Open
Abstract
PURPOSE To examine the natural history of splenic artery aneurysms (SAAs) at a single institution and assess the effect of patient factors and aneurysm characteristics on aneurysm growth. MATERIALS AND METHODS This single-center retrospective study included patients with SAAs who underwent serial imaging over 30 years (1990-2020). Data regarding patient demographics and aneurysm characteristics were collected. The variables contributing to aneurysm growth were assessed using nonparametric tests for continuous variables and chi-square test for categorical variables. Multivariable linear regression was performed using aneurysm growth rate as a continuous dependent variable. RESULTS A total of 132 patients were included in this study. The median maximum diameter of the SAAs was 15.8 mm (range, 4.0-50.0 mm). Growth over time was observed in 39% of the aneurysms, whereas the remaining 61% were stable in size. Of aneurysms that increased in size, the median aneurysm growth rate was 0.60 mm/y (range, 0.03-5.00 mm/y). Maximum aneurysm diameter of >2 cm and the presence of >50% mural thrombus were significant positive predictors for aneurysm growth (P = .020 and P = .022, respectively). Greater than 50% rim calcification was a significant negative predictor for aneurysm growth (P = .009) in multivariate analysis. CONCLUSIONS A larger baseline SAA size, presence of mural thrombus, and lack of rim calcification are associated with increased aneurysm growth rate.
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Affiliation(s)
- Thomas J An
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaomin Chen
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Patrick D Sutphin
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Zubin Irani
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric Wehrenberg-Klee
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shams Iqbal
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts.
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Brandtzäg AA, Eiberg JP, Lönn L, Taudorf M, Resch TA. Copenhagen Mesenteric stent study (COMESS)-a randomized trial of stent versus covered stent treatment for chronic mesenteric ischemia. Trials 2024; 25:426. [PMID: 38943169 PMCID: PMC11212376 DOI: 10.1186/s13063-024-08285-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Current management of mesenteric ischemia is primarily endovascular stent treatment. Typical CMI symptoms are postprandial abdominal pain, food fear, weight loss, and diarrhea. Revascularization is often necessary, as mesenteric ischemia may progress to bowel necrosis and death if left untreated. This study aims to compare the outcome using bare metal stent (BMS) or covered stent (CS) in the endovascular treatment of chronic and acute on chronic mesenteric ischemia. METHODS This is an investigator-driven, prospective, randomized, single-blinded, and single-center, national cohort study at the Copenhagen University Hospital, Denmark. A total of 98 patients with chronic mesenteric ischemia (CMI) and acute-on-chronic mesenteric ischemia (AoCMI) will be randomized to treatment with either BeSmooth BMS (Bentley Innomed GmbH) or BeGraft CS (Bentley Innomed GmbH). Randomization occurs intraoperatively after lesion crossing. DISCUSSION There is currently no published data from prospective controlled trials regarding the preferred type of stent used for the treatment of chronic and acute-on-chronic mesenteric ischemia. This trial will evaluate the short- and long-term outcome of BMS versus CS when treating CMI and AoCMI, as well as the benefit of a more intense postoperative surveillance program. TRIAL REGISTRATION ClinicalTrials.gov NCT05244629. Registered on February 8, 2022.
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Affiliation(s)
- Alexandra A Brandtzäg
- Department of Vascular Surgery, Heart Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jonas P Eiberg
- Department of Vascular Surgery, Heart Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Lönn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Diagnostic Radiology, Center of Diagnostic Investigation, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Taudorf
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Diagnostic Radiology, Center of Diagnostic Investigation, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Timothy A Resch
- Department of Vascular Surgery, Heart Center, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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9
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Reintam Blaser A, Björck M. Authors' Perspective of the Highlights, Limitations, and Future Directions of the Acute MESenteric Ischaemia (AMESI) Study. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00554-9. [PMID: 38914365 DOI: 10.1016/j.ejvs.2024.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/24/2024] [Accepted: 06/20/2024] [Indexed: 06/26/2024]
Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
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10
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Okada I, Hagiwara M, Yoneyama H, Kohara S, Shoji Y. Recanalization of port-superior mesenteric vein thrombosis with long-term anticoagulant therapy after failed early anticoagulant therapy. Surg Case Rep 2024; 10:154. [PMID: 38900377 PMCID: PMC11189877 DOI: 10.1186/s40792-024-01948-0] [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: 12/26/2023] [Accepted: 06/11/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Anticoagulant therapy with heparin is the first-line treatment for acute mesenteric vein thrombosis and is effective in improving outcomes. Conversely, patients with failed early anticoagulant therapy occasionally develop bowel infarction requiring surgery. The efficacy of long-term anticoagulant therapy on recanalizing mesenteric vein thrombosis in patients with failed early anticoagulant therapy remains unclear. Herein, we report a patient who achieved recanalization of port-superior mesenteric vein thrombosis treated with anticoagulant therapy for 10 years after failed early anticoagulant therapy, followed by bowel resection. CASE PRESENTATION A 38-year-old male patient visited an outpatient clinic due to acute exacerbation of abdominal pain that had persisted for a month. He was diagnosed with port-superior mesenteric vein thrombosis on contrast-enhanced computed tomography (CT) scan and was transferred to our institution. Although he presented with abdominal pain, his respiration and circulation were stable upon hospital arrival. Anticoagulant therapy with heparin was started, and the patient was admitted to the intensive care unit. However, the patient's abdominal pain worsened, and he began to develop signs of peritonitis. Repeat CT scan revealed bowel infarction. Thus, the patient underwent bowel resection 6 h after admission. The initial surgery was completed with open abdomen management. Bowel anastomosis was performed on the second-look surgery on the first postoperative day. Finally, the abdomen was closed on the third postoperative day after confirming the absence of bowel ischemia progression. The patient had prolonged impaired bowel function with paralytic ileus, but was discharged on the 60th postoperative day. He was then diagnosed with protein C and S deficiency based on the tests performed. Anticoagulant therapy with warfarin was initiated. He also received anticoagulant therapy in the outpatient setting. The patient's port-superior mesenteric vein thrombosis had improved gradually with warfarin during the follow-up period. At 10 years after surgery, total occlusion of the port-superior mesenteric vein was recanalized with improvement of the portal collateral vessels. In addition, no gastric or esophageal varices were observed. CONCLUSIONS Long-term anticoagulation therapy could affect the recanalization of extensive thrombus in multiple segments in patients with mesenteric venous thrombosis.
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Affiliation(s)
- Ichiro Okada
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Masahiro Hagiwara
- Department of Surgery, Sapporo Higashi Tokushukai Hospital, 3-1, North-33, East-14, Higashi-Ku, Sapporo, Hokkaido, 065-0033, Japan
| | - Hisashi Yoneyama
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256, Midoricho, Tachikawa, Tokyo, 190-0014, Japan
| | - Saeko Kohara
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, 3256, Midoricho, Tachikawa, Tokyo, 190-0014, Japan
| | - Yokobori Shoji
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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11
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Goto D, Yanishi K, Ozawa T, Yoshimura J, Kawamata H, Fujioka A, Seki T, Zen K, Matoba S. Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database. J Am Heart Assoc 2024; 13:e035017. [PMID: 38879458 PMCID: PMC11255773 DOI: 10.1161/jaha.124.035017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/23/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection. METHODS AND RESULTS Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization. CONCLUSIONS EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained. REGISTRATION URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.
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Affiliation(s)
- Daiki Goto
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Takaaki Ozawa
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Jun Yoshimura
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Ayumu Fujioka
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
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12
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Shi Y, Zhou Y, Yuan Y, Kong J, Gong M, Chen L, He X, Su H, Gu J. Establishment of an acute arterial mesenteric ischaemia model in canines with an endovascular approach. Front Vet Sci 2024; 11:1373914. [PMID: 38948676 PMCID: PMC11212455 DOI: 10.3389/fvets.2024.1373914] [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: 01/22/2024] [Accepted: 06/04/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose This study aimed to evaluate the feasibility of establishing an arterial acute mesenteric ischemia (AMI) model in canines using transcatheter autologous thrombus administration. Materials and methods Ten canines were divided into the experimental group (Group A, n = 5) and the sham group (Group B, n = 5). The canines in Group A received thrombus administration to the superior mesenteric artery (SMA) through a guiding catheter, while the canines in Group B received normal saline administration. Blood samples were collected and tested at baseline and 2 h after modelling. Canines in Group A underwent manual thromboaspiration after blood and intestine samples were collected. Ischaemic grades of intestinal mucosa were evaluated under light microscopes. Results The AMI models were successfully conducted in all canines without procedure-related vessel injury or death. At the 2-h follow-up, the high-sensitivity C-reactive protein and D-dimer in Group A were significantly higher than in Group B (5.72 ± 1.8 mg/L vs. 2.82 ± 1.5 mg/L, p = 0.024; 2.25 ± 0.8 μg/mL vs. 0.27 ± 0.10 μg/mL, p = 0.005; respectively). The mean histopathologic intestinal ischaemic grade in Group A was significantly higher than in Group B (2.4 ± 0.5 vs. 0.8 ± 0.4, p < 0.001). After a median of 2 times of thromboaspiration, 80% (4/5) of the canines achieved complete SMA revascularisation. Conclusion This experimental study demonstrated that establishing an arterial model in canines using endovascular approaches was feasible. The present model may play an important role in the investigation of endovascular techniques in the treatment of arterial AMI.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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13
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Ronza FM, Di Gennaro TL, Buzzo G, Piccolo L, Della Noce M, Giordano G, Posillico G, Pietrobono L, Mazzei FG, Ricci P, Masala S, Scaglione M, Tamburrini S. Diagnostic Role of Multi-Detector Computed Tomography in Acute Mesenteric Ischemia. Diagnostics (Basel) 2024; 14:1214. [PMID: 38928630 PMCID: PMC11202795 DOI: 10.3390/diagnostics14121214] [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: 05/10/2024] [Revised: 06/01/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Mesenteric ischemia diagnosis is challenging, with an overall mortality of up to 50% of cases despite advances in treatment. The main problem that affects the outcome is delayed diagnosis because of non-specific clinical presentation. Multi-Detector CT Angiography (MDCTA) is the first-line investigation for the suspected diagnosis of vascular abdominal pathologies and the diagnostic test of choice in suspected mesenteric bowel ischemia. MDCTA can accurately detect the presence of arterial and venous thrombosis, determine the extent and the gastrointestinal tract involved, and provide detailed information determining the subtype and the stage progression of the diseases, helping clinicians and surgeons with appropriate management. CT (Computed Tomography) can differentiate forms that are still susceptible to pharmacological or interventional treatment (NOM = non-operative management) from advanced disease with transmural necrosis in which a surgical approach is required. Knowledge of CT imaging patterns and corresponding vascular pathways is mandatory in emergency settings to reach a prompt and accurate diagnosis. The aims of this paper are 1. to provide technical information about the optimal CTA (CT Angiography) protocol; 2. to explain the CTA arterial and venous supply to the gastrointestinal tract and the relevant ischemic pattern; and 3. to describe vascular, bowel, and extraintestinal CT findings for the diagnosis of acute mesenteric ischemia.
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Affiliation(s)
| | | | - Gianfranco Buzzo
- Department of Diagnostic Imaging, AORN “S. Anna e S. Sebastiano”, 81100 Caserta, Italy
| | - Luciana Piccolo
- Department of Diagnostic Imaging, AORN “S. Anna e S. Sebastiano”, 81100 Caserta, Italy
| | - Marina Della Noce
- Department of Diagnostic Imaging, AORN “S. Anna e S. Sebastiano”, 81100 Caserta, Italy
| | - Giovanni Giordano
- Department of Diagnostic Imaging, AORN “S. Anna e S. Sebastiano”, 81100 Caserta, Italy
| | - Giuseppe Posillico
- Department of Diagnostic Imaging, AORN “S. Anna e S. Sebastiano”, 81100 Caserta, Italy
| | - Luigi Pietrobono
- Radiology I, Fondazion e IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesco Giuseppe Mazzei
- Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, University of Siena, 53100 Siena, Italy
| | - Paolo Ricci
- Unit of Emergency Radiology, Department of Radiological, Oncology and Patological Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Salvatore Masala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Mariano Scaglione
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Stefania Tamburrini
- Department of Radiology, Ospedale del Mare-ASL NA1 Centro, 80147 Naples, Italy
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14
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Mei J, Yuan Y, Yan H, Zhao X, Xue T, Su H, Jia Z. Factors associated with false lumen changes in patients with superior mesenteric artery dissection. Vasc Med 2024; 29:274-285. [PMID: 38334057 DOI: 10.1177/1358863x231220624] [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: 02/10/2024]
Abstract
BACKGROUND False lumen changes (FLCs) are the main reference for the prognosis judgment and treatment plan selection for type IIa superior mesenteric artery dissection (SMAD). METHODS For this retrospective study, 55 patients with symptomatic type IIa SMAD were included. Computational fluid dynamics (CFD) analysis was used to explore the hemodynamic basis of FLCs. Correlation and multiple linear regression analyses were performed to identify clinical, morphological and hemodynamic factors associated with FLCs. RESULTS The FLCs of patients with successful conservative treatment (n = 29) are significantly higher than those with failed conservative treatment (n = 26) (58.5 ± 21.1% vs 10.9 ± 17.4%, p < 0.0001). Positive correlations were seen between FLCs and the morphological parameters false lumen length (FLL)/dissection entrance length (DEL) and FLL. In terms of hemodynamic parameters, negative correlations were seen between FLCs and time-averaged wall shear stress (TAWSS), vorticity, and high areas of TAWSS and vorticity, whereas positive correlations were seen between FLCs and oscillatory shear index (OSI), relative residence time (RRT), and high areas of OSI and RRT. Multiple linear regression analysis identified symptom duration (odds ratio [OR], 0.93; 95% CI, 0.91-0.96; p < 0.0001), FLL/DEL (OR, 1.30; 95% CI, 1.01-1.67; p = 0.044), and high RRT area (OR, 2.03; 95% CI, 1.48-2.78; p < 0.0001) as predictors of FLCs. CONCLUSION The clinical predictor symptom duration, morphological factor FLL/DEL, and the hemodynamic factor high RRT area can serve as predictors of FLCs in patients with symptomatic type IIa SMAD.
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Affiliation(s)
- Junhao Mei
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Yuan Yuan
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hui Yan
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xi Zhao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Tongqing Xue
- Department of Interventional Radiology, Huaian Hospital of Huaian's City, Huai'an, China
| | - Haobo Su
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhongzhi Jia
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
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15
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Garzelli L, Dufay R, Tual A, Corcos O, Cazals-Hatem D, Vilgrain V, Nuzzo A, Ben Abdallah I, Ronot M. Predictors of Survival Without Intestinal Resection after First-Line Endovascular Revascularization in Patients with Acute Arterial Mesenteric Ischemia. Radiology 2024; 311:e230830. [PMID: 38860892 DOI: 10.1148/radiol.230830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Background Acute arterial mesenteric ischemia requires emergency treatment and is associated with high mortality rate and poor quality of life. Identifying factors associated with survival without intestinal resection (hereafter, intestinal resection-free [IRF] survival) could help in treatment decision-making after first-line endovascular revascularization. Purpose To identify factors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization. Materials and Methods Patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization because of a low probability of bowel necrosis were included in this single-center retrospective cohort (May 2014 to August 2022). Patient demographics, laboratory values, clinical characteristics at admission, CT scans, angiograms, and endovascular revascularization-related variables were included. The primary end point was 30-day IRF survival, and secondary end points were 3-month, 1-year, and 3-year overall survival. Factors independently associated with 30-day IRF survival were identified with binary logistic regression. Results A total of 117 patients (median age, 70 years [IQR, 60-77]; 53 female, 64 male) were included. Within 30 days after revascularization, 73 of 117 patients (62%) survived without resection, 28 of 117 (24%) survived after resection, 14 of 117 (12%) died without resection, and two of 117 (2%) underwent resection but died. The 30-day IRF survival was 63% (74 of 117). The 3-month, 1-year, and 3-year mortality rate was 18% (21 of 117), 21% (25 of 117), and 27% (32 of 117), respectively. Independent predictors of 30-day IRF survival were persistent bowel enhancement at initial CT (odds ratio [OR], 0.3; 95% CI: 0.2, 0.8; P = .013) and C-reactive protein (CRP) level less than 100 mg/L (OR, 0.3; 95% CI: 0.1, 0.8; P = .002). The 30-day IRF survival was 86%, 61%, 47%, and 23% in patients with both favorable features, persistent bowel enhancement but CRP level greater than 100 mg/L, no bowel enhancement but CRP level less than 100 mg/L, and both unfavorable features, respectively. Conclusion Independent predictors associated with 30-day IRF survival in patients with acute arterial mesenteric ischemia whose first-line treatment was endovascular revascularization were persistent bowel wall enhancement at initial CT and CRP level less than 100 mg/L. © RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Lorenzo Garzelli
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Raphael Dufay
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Arnaud Tual
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Olivier Corcos
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Dominique Cazals-Hatem
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Valérie Vilgrain
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Alexandre Nuzzo
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Iannis Ben Abdallah
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
| | - Maxime Ronot
- From the Departments of Radiology (L.G., R.D., A.T., V.V., M.R.), Pathology (D.C.H.), and Gastroenterology, IBD, and Intestinal Insufficiency (O.C., A.N.), Hôpital Beaujon, AP-HP Nord, 100 Blvd du Général Leclerc, 92110 Clichy, France; Department of Vascular Surgery, Hôpital Bichat, AP-HP Nord, Paris, France (I.B.A.); Université Paris-Cité, Paris, UMR 1149 CRI, Paris, France (V.V., M.R.); Université des Antilles, Cayenne, French West Indies (L.G.)
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Acosta S, Coopersmith CM, Reintam Blaser A. Nomenclature issues: non-occlusive mesenteric ischaemia and colon ischaemia. Intensive Care Med 2024; 50:1013-1014. [PMID: 38656361 DOI: 10.1007/s00134-024-07447-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.
- Intensive Care Unit, Lucerne Cantonal Hospital, Lucerne, Switzerland.
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Farbu BH, Lydersen S, Mohus RM, Ueland T, Mollnes TE, Klepstad P, Langeland H. The detrimental effects of intestinal injury mediated by inflammation are limited in cardiac arrest patients: A prospective cohort study. Resusc Plus 2024; 18:100639. [PMID: 38666252 PMCID: PMC11043872 DOI: 10.1016/j.resplu.2024.100639] [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: 02/12/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background Ischaemic intestines could be a driver of critical illness through an inflammatory response. We have previously published reports on a biomarker for intestinal injury, plasma Intestinal Fatty Acid Binding Protein (IFABP), and inflammatory biomarkers after out-of-hospital cardiac arrest (OHCA). In this post-hoc study we explored the potential indirect effects of intestinal injury mediated through the inflammatory response on organ dysfunction and mortality. Methods We measured IFABP and twenty-one inflammatory biomarkers in 50 patients at admission to intensive care unit after OHCA. First, we stratified patients on median IFABP and compared biomarkers between "low" and "high" IFABP. Second, by causal mediation analysis, we assessed effects of IFABP through the two most important inflammatory biomarkers, interleukin (IL)-6 and terminal complement complex (TCC), on day two circulatory variables, Sequential Organ Failure Assessment (SOFA)-score, and 30-day mortality. Results Cytokines and complement activation were higher in the high IFABP group. In mediation analysis, patients on the 75th percentile of IFABP, compared to the 25th percentile, had 53% (95% CI, 33-74; p < 0.001) higher risk of dying, where 13 (95% CI, 3-23; p = 0.01) percentage points were mediated through an indirect effect of IL-6. Similarly, the indirect effect of IFABP through IL-6 on SOFA-score was significant, but smaller than potential other effects. Effects through IL-6 on circulatory variables, and all effects through TCC, were not statistically significant and/or small. Conclusion Effects of intestinal injury mediated through inflammation on organ dysfunction and mortality were limited. Small, but significant, effects through IL-6 were noted.Trial registration: ClinicalTrials.gov: NCT02648061.
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Affiliation(s)
- Bjørn Hoftun Farbu
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi Marie Mohus
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Thor Ueland
- Thrombosis Research Center (TREC), Division of Internal Medicine, University hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital (Rikshospitalet), Oslo, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital, Bodø, Norway
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Halvor Langeland
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Hofmann A, Schuch P, Berger F, Taher F, Assadian A. Visceral Artery Aneurysms in the Presence of Upstream Stenoses. J Clin Med 2024; 13:3170. [PMID: 38892881 PMCID: PMC11172764 DOI: 10.3390/jcm13113170] [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: 03/31/2024] [Revised: 05/02/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Sutton-Kadir syndrome describes a rare pathology that commonly includes an aneurysm of the inferior pancreaticoduodenal artery in combination with a celiac trunk stenosis or occlusion, often caused by median arcuate ligament compression. Several therapeutic approaches exist including open surgical, endovascular, and hybrid treatments. Other combinations of visceral artery aneurysms and upstream stenoses exist but the cumulative body of evidence on these combinations is weak due to their rarity. Methods: A retrospective analysis of patient data from a single center was carried out. Electronic patient records were filtered for keywords including "visceral aneurysm", "Sutton-Kadir", and "median arcuate ligament". Imaging studies were re-examined by two blinded vascular surgeons with a third vascular surgeon as a referee in case of diverging results. Results: Sixteen patients had a visceral artery aneurysm with an upstream stenosis. All cases had a celiac trunk obstruction while one patient also had a concomitant superior mesenteric artery stenosis. Both median arcuate ligament compression and atherosclerotic lesions were identified. The location of the aneurysms varied even though the inferior pancreaticoduodenal artery was most frequently affected. A classification system based on the different combinations of stenoses and aneurysms is presented and introduced as a new pathologic entity: visceral artery aneurysm in the presence of upstream stenosis (VAPUS). Conclusions: The concomitant presence of visceral artery aneurysms, especially in the pancreaticoduodenal arteries, and blood flow impairment of the celiac axis or superior mesenteric artery is a rare pathology. The proposed VAPUS classification system offers an accessible and transparent route to the precise localization of the affected vessels.
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Affiliation(s)
- Amun Hofmann
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, 1160 Vienna, Austria
| | - Philipp Schuch
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, 1160 Vienna, Austria
| | - Franz Berger
- Department of General Surgery, Klinik Ottakring, 1160 Vienna, Austria
| | - Fadi Taher
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, 1160 Vienna, Austria
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, 1160 Vienna, Austria
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Fan EY, Schanzer A, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Parodi FE, Schneider DB, Sweet MP, Timaran CH, Simons JP. Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)01220-5. [PMID: 38796031 DOI: 10.1016/j.jvs.2024.05.041] [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: 12/27/2023] [Revised: 04/02/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR. METHODS Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention. RESULTS Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency. CONCLUSIONS Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.
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Kim YH, Kim HJ, Park S, Hwang D, Kim HK, Huh S, Yun WS. Comparing clinical outcomes of vitamin K antagonists vs non-vitamin K antagonists in anticoagulant therapy for mesenteric venous thrombosis. J Vasc Surg Venous Lymphat Disord 2024:101903. [PMID: 38754777 DOI: 10.1016/j.jvsv.2024.101903] [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: 01/14/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Non-vitamin K antagonist oral anticoagulants have shown similar efficacy and lower bleeding rates than vitamin K antagonists for venous thromboembolism. However, this has not been proven in mesenteric vein thrombosis. This study aimed to compare the clinical outcomes of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. METHODS Between January 2014 and July 2022, mesenteric vein thrombosis was diagnosed on computed tomography in 225 patients in a tertiary hospital. Among them, a total of 44 patients who underwent long-term anticoagulation therapy over 3 months were enrolled in this study. Patients were divided into two groups based on the anticoagulant used: vitamin K antagonists (Group 1, n = 21) and non-vitamin K antagonist oral anticoagulants (Group 2, n = 23). The efficacy outcomes were symptom recurrence and thrombus resolution on follow-up computed tomography, and the safety outcome was bleeding complications. RESULTS The median age of the patients was 56 years (range, 46-68 years), and 52% were men. The most common risk factors were unprovoked intra-abdominal infections (30%). The median duration of anticoagulation therapy was 13 months (20 months in Group 1 vs 6 months in Group 2; P = .076). Of the 44 patients, 17 (39%) received the standard treatment. The median follow-up period was longer in Group 1 than in Group 2 (57 vs 28 months; P = .048). No recurrence of mesenteric vein thrombosis-related symptoms were observed in either group. The median duration of follow-up computed tomography was 31 months (42 months in Group 1 vs 18 months in Group 2; P = .064). Computed tomography revealed complete thrombus resolution, partial resolution, and no changes in 71%, 19%, and 10%, respectively (P = .075). Regarding bleeding complications, varix bleeding and melena developed in two patients in Group 2, and anticoagulation treatment thereafter ceased. CONCLUSIONS Despite the short follow-up duration in the non-vitamin K antagonist oral anticoagulants group, there was no clinically significant difference in the thrombus resolution rate or bleeding complications when compared with the vitamin K antagonists group. Although research on the long-term effects of non-vitamin K antagonist oral anticoagulants in patients is limited, non-vitamin K antagonist oral anticoagulants can be considered an alternative to conventional treatments.
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Affiliation(s)
- Young-Hye Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Hyeon Ju Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Suehyun Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Deokbi Hwang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Hyung-Kee Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Seung Huh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Woo-Sung Yun
- Division of Vascular and Endovascular Surgery, Department of Surgery, Kyungpook National University Hospital, Daegu, South Korea.
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Adili F, Khan S, Setia A. [Indications and technique of open vascular surgical revascularization of visceral arteries in mesenteric ischemia]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:359-366. [PMID: 38329518 DOI: 10.1007/s00104-024-02039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 02/09/2024]
Abstract
Open revascularization for mesenteric ischemia has retained a significant value despite the increasing importance and use of endovascular techniques. Surgical procedures such as retrograde embolectomy, thromboendarterectomy and visceral bypass are indispensable components of the therapeutic armamentarium, particularly in cases of multisegmental vascular involvement, failure of previous endovascular treatment and concomitant presence of peritonitis, shock or multiorgan failure. In this context, preoperative multiphase computed tomography (CT) angiography is essential for the planning and outcome of visceral revascularization. This article summarizes the indications, technique, and results of the most important open surgical procedures.
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Affiliation(s)
- F Adili
- Klinik für Gefäßmedizin, Gefäßchirurgie und Endovaskuläre Chirurgie, Klinikum Darmstadt, Grafenstr. 9, 64283, Darmstadt, Deutschland.
| | - S Khan
- Klinik für Gefäßmedizin, Gefäßchirurgie und Endovaskuläre Chirurgie, Klinikum Darmstadt, Grafenstr. 9, 64283, Darmstadt, Deutschland
| | - A Setia
- Klinik für Gefäßmedizin, Gefäßchirurgie und Endovaskuläre Chirurgie, Klinikum Darmstadt, Grafenstr. 9, 64283, Darmstadt, Deutschland
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22
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Gonzalez-Urquijo M, Vargas JF, Marine L, Mertens N, Valdes F, Bergoeing M, Mertens R. Management of Spontaneous Isolated Celiac Artery Dissection. Ann Vasc Surg 2024; 102:1-8. [PMID: 38307228 DOI: 10.1016/j.avsg.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/13/2023] [Accepted: 11/19/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Spontaneous isolated celiac artery dissection (SICAD) is uncommon, with very few series reported in the literature. The present study aims to describe the clinical characteristics and treatment outcomes of patients with SICAD treated at a single Chilean institution over 20 years. METHODS A retrospective review of all patients from a single academic hospital with SICAD diagnosed between January 2003 and March 2023 was performed. Conservative treatment included antiplatelets, anticoagulation, or both. The normal size of a celiac artery in our population was 7.9 ± 0.79 mm in females and 8.3 ± 1.08 mm in males. We defined a celiac artery with a diameter equal to or more than 12.5 mm as an aneurysmal celiac artery. RESULTS The cohort included 27 patients; 77.8% (n = 21) were males. The median age was 51.0 years (range: 38-84 years). Fourteen (51.8%) patients presented with aneurysmal dilatation. Fourteen (51.8%) patients were treated with antiplatelets, 6 (22.2%) patients with anticoagulation, and 7 (25.9%) with anticoagulation and antiplatelets. One patient was treated with endovascular therapy due to a pseudoaneurysm of the celiac artery detected 10 days after conservative treatment with antiplatelets. The median length of hospital stay was 5 days (range: 2-14 days). Complete remodeling was seen in 6 (22.2%) patients, partial remodeling in 10 (37.0%) patients, and no change was seen in 8 (26.9%) patients. Three (11.5%) patients were lost to follow-up. There were no significant differences between treatments and remodeling outcomes (P = 0.729). The median celiac artery diameter of patients with aneurysmal dilatation was 13.5 mm (range: 12.5-20.5 mm). Systemic arterial hypertension was found more commonly in patients who presented with aneurysmal dilatation than in patients without (87.5% vs. 12.5%, respectively, P = 0.016). Mean follow-up was 41.5 months and median follow-up was 16 months (range: 6-204 months). CONCLUSIONS Most patients with SICAD can be treated conservatively with excellent outcomes. Hypertension was more commonly found in patients with SICAD and aneurysmal dilatation.
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Affiliation(s)
- Mauricio Gonzalez-Urquijo
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Jose Francisco Vargas
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Leopoldo Marine
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Nicolas Mertens
- Departamento de Radiología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Francisco Valdes
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Michel Bergoeing
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Renato Mertens
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile.
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23
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Thurner A, Kickuth R. [Indications and techniques for endovascular revascularization of visceral arteries in mesenteric ischemia]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:353-358. [PMID: 38060014 DOI: 10.1007/s00104-023-02013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
Endovascular revascularization of visceral arteries is an important cornerstone of an interdisciplinary treatment concept for both acute and chronic forms of mesenteric ischemia. The advantages lie in the minimally invasive procedure and the speed of restoration of perfusion. This article provides an overview of the indications, techniques and current state of the clinical literature with respect to endovascular revascularization.
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Affiliation(s)
- Annette Thurner
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - Ralph Kickuth
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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24
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Straarup D, Gotschalck KA, Christensen PA, Rasmussen RW, Krarup H, Lundbye-Christensen S, Handberg A, Thorlacius-Ussing O. Exploring D-Lactate as a Biomarker for Acute Intestinal Necrosis in 2958 Patients: A Prospective Cross-Sectional Study. J Emerg Med 2024; 66:e619-e631. [PMID: 38556374 DOI: 10.1016/j.jemermed.2024.01.001] [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] [Received: 06/23/2023] [Revised: 12/16/2023] [Accepted: 01/06/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Timely diagnosis of acute intestinal necrosis (AIN) is lifesaving, but challenging due to unclear clinical presentation. D-lactate has been proposed as an AIN biomarker. OBJECTIVES We aimed to test the diagnostic performance in a clinical setting. METHODS We performed a cross-sectional prospective study, including all adult patients with acute referral to a single tertiary gastrointestinal surgical department during 2015-2016 and supplemented by enrollment of high-risk in-hospital patients suspected of having AIN during 2016-2019. AIN was verified intraoperatively, and D-lactate was analyzed using an automatic spectrophotometric set-up. A D-lactate cut-off for AIN was estimated using the receiver operating characteristic curve. The performance according to patient subgroups was estimated using the area under the receiver operating characteristic curve (AUC). Given the exploratory nature of this study, a formal power calculation was not feasible. RESULTS Forty-four AIN patients and 2914 controls were enrolled. The D-lactate cut-off was found to be 0.0925 mM. Due to lipemic interference, D-lactate could not be quantified in half of the patients, leaving 23 AIN patients and 1456 controls for analysis. The AUC for the diagnosis of AIN by D-lactate was 0.588 (95% confidence interval 0.475-0.712), with a sensitivity of 0.261 and specificity of 0.892. Analysis of high-risk patients showed similar results (AUC 0.579; 95% confidence interval 0.422-0.736). CONCLUSION D-lactate showed low sensitivity for AIN in both average-risk and high-risk patients. Moreover, lipemic interference precluded valid spectrophotometric assessment of D-lactate in half of the patients, further disqualifying the clinical utility of D-lactate as a diagnostic marker for AIN.
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Affiliation(s)
- David Straarup
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Kåre A Gotschalck
- Department of Gastrointestinal Surgery, Horsens Regional Hospital, Horsens, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Peter A Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Biochemistry
| | | | - Henrik Krarup
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Biochemistry; Department of Molecular Diagnostics
| | | | - Aase Handberg
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Biochemistry
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Kania A, Branchi V, Braun L, Verrel F, Kalff JC, Vilz TO. [Indications and surgical strategy for bowel resection in mesenteric ischemia : Resection margins considering current guidelines and literature as well as the influence of new technical possibilities]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:367-374. [PMID: 38378936 DOI: 10.1007/s00104-024-02041-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/22/2024]
Abstract
Acute mesenteric ischemia (AMI) is still a time-critical and life-threatening clinical picture. If exploration of the abdominal cavity is necessary during treatment, an intraoperative assessment of which segments of the intestines have a sufficient potential for recovery must be made. These decisions are mostly based on purely clinical parameters, which are subject to high level of uncertainty. This review article provides an overview of how this decision-making process and the determination of resection margins can be improved using technical aids, such as laser Doppler flowmetry (LDF), indocyanine green (ICG) fluorescence angiography or hyperspectral imaging (HSI). Furthermore, this article compiles guideline recommendations on the role of laparoscopy and the value of a planned second-look laparotomy. In addition, an overview of strategies for preventing short bowel syndrome is given and other aspects, such as the timing and technical aspects of placement of a preternatural anus and an anastomosis are highlighted.
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Affiliation(s)
- Alexander Kania
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland.
| | - Vittorio Branchi
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Lara Braun
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Frauke Verrel
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Jörg C Kalff
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
| | - Tim O Vilz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53127, Bonn, Deutschland
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Mei J, Yu H, Qin L, Zhang J, Xu H, Xue T, Tang L, Jia Z. Multimodal Study of the Superior Mesenteric Artery Wall. Ann Vasc Surg 2024; 102:92-100. [PMID: 38301851 DOI: 10.1016/j.avsg.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND To quantitatively analyze histological and fiber structure of the superior mesenteric artery (SMA) wall and to further explore the possible relationship between the architecture and histology changes of vessel wall and the occurrence of related diseases. METHODS Histological and fiber structure analysis were performed on SMA specimens obtained from 22 cadavers. The SMA specimens were divided into initial, curved, and distal segments, and each segment was separated into the anterior and posterior walls. RESULTS From the initial to the curved to the distal segment, the ratio of elastin decreased (31.4% ± 6.0%, 21.1% ± 5.8%, 18.6% ± 4.7%, respectively; P < 0.001), whereas the ratio of smooth muscle actin (24.5% ± 8.7%, 30.5% ± 6.8%, 36.1% ± 7.3%, respectively; P < 0.001) increased. Elastic fiber longitudinal amplitude of angular undulation was highest in the initial segment [7° (3.25°, 15°)] and lowest in the curved segment [2° (1°, 5°)]. In SMA curved segment, the anterior wall, when compared with the posterior wall, demonstrated a lower ratio of elastin (19.0% ± 5.8% vs. 23.3% ± 5.0%; P = 0.010) and collagen (41.4% ± 12.3% vs. 49.0% ± 10.2%; P = 0.032), a lower elastic fiber longitudinal amplitude of angular undulation [1° (1°, 5°) vs. 3° (2°, 5.25°); P = 0.013], a lower average fiber diameter (8.06 ± 0.36 pixels vs. 8.45 ± 0.50 pixels; P = 0.005), and a lower average segment length (17.96 ± 1.59 pixels vs. 20.05 ± 2.33 pixels; P = 0.001). CONCLUSIONS SMA wall structure varies along the circumferential and axial directions, the presence of dense undulated elastic fiber protects the SMA initial segment of from dissection and aneurysm, but highly cross-linked collagen fiber here increases the likelihood of plaque formation. In the anterior wall of the curved segment, lower elastin and collagen content, lower elastic fiber undulation, and higher degree of collagen fiber cross-linking leads to the occurrence of SMA dissection and aneurysm. In the distal segment, high levels of vascular smooth muscle cells and bundles of long collagen fiber offer protection against the development of SMA-related diseases.
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Affiliation(s)
- Junhao Mei
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Haiyang Yu
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Lihao Qin
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Jiawei Zhang
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Haoran Xu
- Department of Pathology, The Affiliated Changzhou Second People's Hospital with Nanjing Medical University, Changzhou, China
| | - Tongqing Xue
- Department of Interventional Radiology, Huaian Hospital of Huai'an City, Huai'an, China
| | - Liming Tang
- Department of Gastrointestinal Surgery, The Affiliated Changzhou Second People's Hospital with Nanjing Medical University, Changzhou, China
| | - Zhongzhi Jia
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China.
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Duivenvoorden AAM, Metz FM, Wijenbergh R, Verberght HCR, van Bijnen AAJHM, Olde Damink SWM, Geelkerken RH, Lenaerts K, Lubbers T. Intestinal Fatty Acid Binding Protein as a Predictor of Early Mesenteric Injury Preceding Clinical Presentation: A Case Report. EJVES Vasc Forum 2024; 61:136-140. [PMID: 38884076 PMCID: PMC11176664 DOI: 10.1016/j.ejvsvf.2024.04.004] [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: 10/26/2023] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high mortality rate. This case study presents the rare case of a patient who developed mesenteric ischaemia after an emergency thoracic endovascular aneurysm repair (TEVAR) for a type B aortic dissection (TBAD) and peri-operative cardiogenic shock. Study outcomes revealed that intestinal fatty acid binding protein (I-FABP) identified early mucosal damage two days before the clinical presentation. Report A 43 year old male patient was admitted to the emergency department with an acute TBAD and a dissection of the superior mesenteric artery (SMA), for which TEVAR was performed with additional stent placement in the SMA. Peri-operatively, the patient went into cardiogenic shock with a sustained period of hypotension. Post-operatively, the plasma I-FABP levels were measured prospectively, revealing an initial increase on post-operative day five (551.1 pg/mL), which continued beyond day six (610.3 pg/mL). On post-operative day seven, the patient developed a fever and demonstrated signs of peritonitis and bowel perforation. He underwent an emergency laparotomy, followed by an ileocaecal resection (<100 cm) with a transverse ileostomy. Pathological analysis confirmed the diagnosis of mesenteric ischaemia. Discussion The diagnosis of NOMI in critically ill patients is often complicated, and the currently available diagnostic markers lack the specificity and sensitivity to detect early intestinal injury. This case report highlights that elevated I-FABP in plasma levels may indicate the presence of early mesenteric injury. Further research needs to be conducted before I-FABP can be applied in daily practice.
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Affiliation(s)
- Annet A M Duivenvoorden
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Robin Wijenbergh
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hanne C R Verberght
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Annemarie A J H M van Bijnen
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands
| | - Kaatje Lenaerts
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Tim Lubbers
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
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Ratner M, Hartwell CA, Zhang J, Johnson W, Nwachukwu C, Garg K, Kim D, Rockman C. The natural history of celiac artery aneurysms. Vascular 2024:17085381241245142. [PMID: 38623819 DOI: 10.1177/17085381241245142] [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: 04/17/2024]
Abstract
OBJECTIVES The goal of this study was to document the natural history of celiac artery aneurysms (CAAs). BACKGROUND Celiac artery aneurysms are rare. Existing literature is skewed towards outcomes after intervention of large, symptomatic aneurysms but the behavior of untreated CAAs is poorly understood. METHODS This is a single institution, retrospective analysis of patients with CAA diagnosed by CT imaging (2015-2019) identified through an institutional radiology database. Radiologic, demographic, and follow-up data were analyzed. The primary endpoint was the mean growth rate of CAAs. RESULTS Of the 76 patients included, 86.8% were men with a mean age at presentation of 69.8 years. The mean CAA diameter on index imaging was 15.4 +/- 3.8 mm (range, 7-30 mm). All were classified as true aneurysms and 76.3% were saccular. All patients had clinical follow-up with mean follow-up 31.2 months +/- 21.6 months. No patient developed symptoms or rupture. The mean radiological follow-up among 45 patients was 25.2 +/- 16.8 months. Over this period, 16 CAAs (35.6%) enlarged, while 29 (64.4%) remained stable. One patient (1.3%) underwent intervention for increasing size in the setting of a chronic dissection. On multivariate analysis, age <70 was significantly associated with increased risk of aneurysm growth. CONCLUSIONS In this institutional review of patients with CAAs, the majority of aneurysms remained stable in size, with no patients developing symptoms or rupture over clinical follow-up. Given the observed benign behavior of these aneurysms, guidelines that suggest conservative management of CAAs less than 2 cm seems appropriate.
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Affiliation(s)
- Molly Ratner
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - C Austen Hartwell
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA
| | - Jason Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - William Johnson
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Chukwuma Nwachukwu
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Danny Kim
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY, USA
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Mühlberg KS. Diagnosis and Therapy of Visceral Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:135-142. [PMID: 37992729 DOI: 10.1055/a-2178-6670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Abstract
Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome), mesenteric veins, and splenic vein. All VVTs have in common high 30-day mortality up to 20% and it seems to be difficult to diagnose VVT early because of their rarity and their wide spectrum of unspecific symptoms. VVTs are often associated with myeloproliferative neoplasia, thrombophilia, and liver cirrhosis. VVT is primarily diagnosed by sonography and/or computed tomography. In contrast to venous thromboembolism, D-dimer testing is neither established nor helpful. Anticoagulation is the first-line therapy in patients with stable circulation and no evidence of organ complications. Anticoagulation improves significantly recanalization rates and stops the progress of thrombosis. Low-molecular-weight heparin, vitamin K antagonists, as well as direct-acting oral anticoagulants are possible anticoagulants, but it is noteworthy to be aware that all recommendations supporting the off-label use of anticoagulants are based on poor evidence and consist predominantly of case series, observational studies, or studies with small case numbers. When choosing a suitable anticoagulation, the individual risk of bleeding and thrombosis must be weighted very carefully. In cases of bleeding, bowel infarction, or other complications, the optimal therapy should be determined on a case-by-case basis by an experienced multidisciplinary team involving a surgeon. Besides anticoagulation, there are therapeutic options including thrombectomy, balloon angioplasty, stenting, transjugular placement of an intrahepatic portosystemic shunt, liver transplantation, and ischemic bowel resection. This article gives an overview of current diagnostic and therapeutic strategies.
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Affiliation(s)
- Katja S Mühlberg
- Department of Angiology, University of Leipzig, Leipzig, Germany
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Mei J, Yan H, Tang Z, Piao Z, Yuan Y, Dou Y, Su H, Hu C, Meng M, Jia Z. Deep learning algorithm applied to plain CT images to identify superior mesenteric artery abnormalities. Eur J Radiol 2024; 173:111388. [PMID: 38412582 DOI: 10.1016/j.ejrad.2024.111388] [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] [Received: 12/07/2023] [Revised: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVES Atypical presentations, lack of biomarkers, and low sensitivity of plain CT can delay the diagnosis of superior mesenteric artery (SMA) abnormalities, resulting in poor clinical outcomes. Our study aims to develop a deep learning (DL) model for detecting SMA abnormalities in plain CT and evaluate its performance in comparison with a clinical model and radiologist assessment. MATERIALS AND METHODS A total of 1048 patients comprised the internal (474 patients with SMA abnormalities, 474 controls) and external testing (50 patients with SMA abnormalities, 50 controls) cohorts. The internal cohort was divided into the training cohort (n = 776), validation cohort (n = 86), and internal testing cohort (n = 86). A total of 5 You Only Look Once version 8 (YOLOv8)-based DL submodels were developed, and the performance of the optimal submodel was compared with that of a clinical model and of experienced radiologists. RESULTS Of the submodels, YOLOv8x had the best performance. The area under the curve (AUC) of the YOLOv8x submodel was higher than that of the clinical model (internal test set: 0.990 vs 0.878, P =.002; external test set: 0.967 vs 0.912, P =.140) and that of all radiologists (P <.001). The YOLOv8x submodel, when compared with radiologist assessment, demonstrated higher sensitivity (internal test set: 100.0 % vs 70.7 %, P =.002; external test set: 96.0 % vs 68.8 %, P <.001) and specificity (internal test set: 90.7 % vs 66.0 %, P =.025; external test set: = 88.0 % vs 66.0 %, P <.001). CONCLUSION Using plain CT images, YOLOv8x was able to efficiently identify cases of SMA abnormalities. This could potentially improve early diagnosis accuracy and thus improve clinical outcomes.
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Affiliation(s)
- Junhao Mei
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Hui Yan
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zheyu Tang
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Zeyu Piao
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Yuan Yuan
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yang Dou
- Department of Radiology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Haobo Su
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chunfeng Hu
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Mingzhu Meng
- Department of Radiology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China
| | - Zhongzhi Jia
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, China.
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Blauw JTM, Metz FM, Nuzzo A, van Etten-Jamaludin FS, Brusse-Keiser M, Boermeester MA, Peppelenbosch M, Geelkerken RH. The Diagnostic Value of Biomarkers in Acute Mesenteric Ischaemia Is Insufficiently Substantiated: A Systematic Review. Eur J Vasc Endovasc Surg 2024; 67:554-569. [PMID: 37640253 DOI: 10.1016/j.ejvs.2023.08.059] [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] [Received: 03/02/2023] [Revised: 07/30/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE There is an urgent need for accurate biomarkers to support timely diagnosis of acute mesenteric ischaemia (AMI) and thereby improve clinical outcomes. With this systematic review, the aim was to substantiate the potential diagnostic value of biomarkers for arterial occlusive AMI. DATA SOURCES The Pubmed, Embase, and the Cochrane Library electronic databases were searched. REVIEW METHODS A systematic review of the literature has been conducted to define the potential diagnostic value of biomarkers for arterial occlusive AMI. All studies including ≥ 10 patients describing biomarkers for macrovascular occlusive AMI between 1950 and 17 February 2023 were identified within the Pubmed, Embase, and the Cochrane Library electronic databases. There were no restrictions to any particular study design, but letters and editorials were excluded. The QUADAS-2 tool was used for the critical appraisal of quality. The study protocol was registered on Prospero (CRD42021254970). RESULTS Fifty of 4334 studies were eligible for inclusion in this review. Ninety per cent of studies were of low quality. A total of 60 biomarkers were identified, with 24 in two or more studies and 15 in five or more studies. There was variation in reported units, normal range, and cut off values. Meta-analysis was not possible due to study heterogeneity. Biomarkers currently recommended by the European Journal of Vascular and Endovascular Surgery, European Society for Trauma and Emergency Surgery 2016, and World Society of Emergency Surgery 2017 guidelines also had heterogeneous low quality data for use in the diagnosis of AMI. CONCLUSION This systematic review demonstrates high heterogeneity and low quality of the available evidence on biomarkers for arterial occlusive AMI. No clinical conclusions can be drawn on a biomarker or combination of biomarkers for patients suspected of arterial occlusive AMI. Restraint is advised when rejecting or determining AMI solely based on biomarkers.
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Affiliation(s)
- Juliëtte T M Blauw
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Alexandre Nuzzo
- Structure d'Urgences Vasculaires Intestinales Gastroentérologie, MICI et Assistance Nutritive, Hôpital Beaujon APHP, Université de Paris, France
| | | | - Marjolein Brusse-Keiser
- Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands; Health Technology and Services Research (HTSR), BMS Faculty, University of Twente, Enschede, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Maikel Peppelenbosch
- Department of Gastroenterology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands.
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Tanda E, Zappadu S, De Donno G, Dettori S, Ciccarello S, Piredda F, Fadda GF. Hybrid Clampless Anastomosis in Antegrade Aorto-Superior Mesenteric Artery Bypass. Vasc Endovascular Surg 2024; 58:419-425. [PMID: 37975249 DOI: 10.1177/15385744231215566] [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: 11/19/2023]
Abstract
BACKGROUND Bypass surgery in severe aorto-iliac calcifications is a complex procedure. Aortic clamping can be highly risky and endovascular approach can be unsuccessful. We report our experience describing three cases of chronic mesenteric ischemia. In all three cases the preoperative computed tomography angiography revealed an ostial occlusion of the celiac trunk and of the superior mesenteric artery (SMA), a coral reef abdominal aorta, and severe calcification of the iliac arteries. An antegrade aorto-mesenteric bypass using a hybrid clampless anastomosis on the supraceliac aorta was performed. RESULTS The procedures were performed via laparotomy. We carried out the exposure of the anterior supraceliac aorta limited to the zone without major calcifications; then we performed a side-to-end media-adventitial anastomosis between the supraceliac aorta and a Dacron graft 7 mm without any arteriotomy or clamping. The proximal graft and the aortic anastomosis site were punctured using a 18 G needle. An introducer was then positioned over a wire through the prosthetic graft and pushed into the aorta. Balloon expandable covered stenting to open and stabilize the anastomosis site was performed. Finally, the graft was tunneled to the SMA, and an end-to-side anastomosis was performed. The postoperative courses were uneventful, and the patients were promptly discharged. The follow-up, which in the first case is 4 years, showed the complete patency of the graft in each of the cases treated. CONCLUSIONS The hybrid clampless anastomosis appears to be safe and useful in cases of severe aortic calcification.
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Affiliation(s)
- Elisabetta Tanda
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Sara Zappadu
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Gabriele De Donno
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Salvatora Dettori
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Sandro Ciccarello
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Franco Piredda
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
| | - Gian Franco Fadda
- Unit of Vascular Surgery, "Cliniche San Pietro" Hospital, AOU Sassari, Sassari, Italy
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Mei J, Yan H, Zhao X, Yuan Y, Su H, Xue T, Jia Z. In-stent Restenosis After Stenting for Superior Mesenteric Artery Dissection Is Associated With Stent Landing Zone: From Clinical Prediction to Hemodynamic Mechanisms. J Endovasc Ther 2024:15266028241241494. [PMID: 38561992 DOI: 10.1177/15266028241241494] [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: 04/04/2024]
Abstract
OBJECTIVE To identify risk factors for in-stent restenosis (ISR) in patients undergoing stent placement for superior mesenteric artery dissection (SMAD) and to determine the hemodynamic mechanism underlying ISR. METHODS For this retrospective study, patients with SMAD who had ISR after stent placement were included in the ISR group, and age- and sex-matched patients with SMAD who did not experience ISR after stent placement were included in the control group. Clinical, imaging, and hemodynamic data were assessed. Multivariable regression was used to identify independent ISR risk factors. Structural and fluid dynamics simulations were applied to determine the hemodynamic mechanism underlying the occurrence of ISR. RESULTS The study population included 26 patients with ISR and 26 control patients. Multivariate analysis demonstrated that stent-to-vascular (S/V) ratio (odds ratio [OR], 1.14; 95% confidence interval [CI]: 1.00-1.29; p=0.045), stent proximal position >10 mm away from the SMA root (OR, 108.67; 95% CI: 3.09-3816.42; p=0.010), and high oscillatory shear index (OSI) area (OR, 1.25; 95% CI: 1.02-1.52; p=0.029) were predictors of ISR. In structural and fluid dynamics simulations, a stent proximal position near the abdominal aorta (AA) or entering into the AA reduced the contact area between the proximal struts of the stent and the vascular wall, and alleviated the distal lumen overdilation. CONCLUSION The S/V ratio, stent proximal position away from the SMA root (>10 mm), and high OSI area are independent risk factors for ISR in patients with SMAD undergoing stent placement. Deploying the proximal end of the stent near the AA or entering into the AA appears to improve the hemodynamic environment in the SMA lumen and ultimately reduce the risk of ISR. CLINICAL IMPACT In-stent restenosis is an uncommon but potentially catastrophic complication after stent placement for the management of superior mesenteric artery dissection. This study identified risk factors for in-stent restenosis and demonstrated that, as long as the stent can fully cover the dissection range, deploying the proximal end of the stent near the abdominal aorta or less entering into the abdominal aorta may reduce the risk of in-stent restenosis in this patient population.
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Affiliation(s)
- Junhao Mei
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital, Nanjing Medical University, Changzhou, China
| | - Hui Yan
- Department of Radiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xi Zhao
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Yuan Yuan
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Haobo Su
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Tongqing Xue
- Department of Interventional Radiology, Huaian Hospital of Huai'an City, Huai'an, China
| | - Zhongzhi Jia
- Department of Interventional and Vascular Surgery, The Affiliated Changzhou Second People's Hospital, Nanjing Medical University, Changzhou, China
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Kamboj M, Das A, Idris H, Singh A, Chaudhary SM, Mallipeddi MC. A Case Study of Abdominal Aortic Aneurysm Detection and Critical Vascular Surgery. Cureus 2024; 16:e58894. [PMID: 38800210 PMCID: PMC11116928 DOI: 10.7759/cureus.58894] [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] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Abdominal aortic aneurysm, characterized by a persistent dilation exceeding 3 cm or 50% of the aortic diameter, poses a substantial risk, particularly in males over 65. Despite its potentially asymptomatic nature, early detection is imperative due to the elevated mortality rates, reaching 90% following rupture. The presented case involves a 60-year-old male with progressively worsening abdominal pain, a history of cardiovascular disease, hypertension, and smoking. Initial examinations were inconclusive, requiring advanced imaging that revealed a large aneurysmal dilation. Therapeutic measures included endovascular aneurysm repair (EVAR), highlighting the significance of timely intervention. Despite elective surgery risks, mortality rates decrease significantly when the aneurysm diameter surpasses 43 mm. This report stresses the need for primary care physicians to conduct thorough screenings, recognize risk factors, and facilitate prompt referrals for advanced imaging. The case's pivotal lesson lies in the comprehensive management of abdominal aortic aneurysm, showcasing the potential for life-saving interventions and the critical role of early detection in mitigating the severe consequences associated with its rupture.
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Affiliation(s)
- Mamta Kamboj
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Arghadip Das
- Internal Medicine, Nil Ratan Sircar Medical College and Hospital, Kolkata, IND
| | - Hadeeqa Idris
- Internal Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Ajay Singh
- Internal Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Sachin M Chaudhary
- Internal Medicine, Gujarat Cancer Society (GCS) Medical College, Hospital and Research Centre, Ahmedabad, IND
| | - Mohitha C Mallipeddi
- Internal Medicine, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, IND
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Terlouw LG, van Dijk LJD, van Noord D, Bakker OJ, Bijdevaate DC, Erler NS, Fioole B, Harki J, van den Heuvel DAF, Hinnen JW, Kolkman JJ, Nikkessen S, van Petersen AS, Smits HFM, Verhagen HJM, de Vries AC, de Vries JPPM, Vroegindeweij D, Geelkerken RH, Bruno MJ, Moelker A. Covered versus bare-metal stenting of the mesenteric arteries in patients with chronic mesenteric ischaemia (CoBaGI): a multicentre, patient-blinded and investigator-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:299-309. [PMID: 38301673 DOI: 10.1016/s2468-1253(23)00402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mesenteric artery stenting with a bare-metal stent is the current treatment for atherosclerotic chronic mesenteric ischaemia. Long-term patency of bare-metal stents is unsatisfactory due to in-stent intimal hyperplasia. Use of covered stents might improve long-term patency. We aimed to compare the patency of covered stents and bare-metal stents in patients with chronic mesenteric ischaemia. METHODS We conducted a multicentre, patient-blinded and investigator-blinded, randomised controlled trial including patients with chronic mesenteric ischaemia undergoing mesenteric artery stenting. Six centres in the Netherlands participated in this study, including two national chronic mesenteric ischaemia expert centres. Patients aged 18 years or older were eligible for inclusion when an endovascular mesenteric artery revascularisation was scheduled and a consensus diagnosis of chronic mesenteric ischaemia was made by a multidisciplinary team of gastroenterologists, interventional radiologists, and vascular surgeons. Exclusion criteria were stenosis length of 25 mm or greater, stenosis caused by median arcuate ligament syndrome or vasculitis, contraindication for CT angiography, or previous target vessel revascularisation. Digital 1:1 block randomisation with block sizes of four or six and stratification by inclusion centre was used to allocate patients to undergo stenting with bare-metal stents or covered stents at the start of the procedure. Patients, physicians performing follow-up, investigators, and radiologists were masked to treatment allocation. Interventionalists performing the procedure were not masked. The primary study outcome was the primary patency of covered stents and bare-metal stents at 24 months of follow-up, evaluated in the modified intention-to-treat population, in which stents with missing data for the outcome were excluded. Loss of primary patency was defined as the performance of a re-intervention to preserve patency, or 75% or greater luminal surface area reduction of the target vessel. CT angiography was performed at 6 months, 12 months, and 24 months post intervention to assess patency. The study is registered with ClinicalTrials.gov (NCT02428582) and is complete. FINDINGS Between April 6, 2015, and March 11, 2019, 158 eligible patients underwent mesenteric artery stenting procedures, of whom 94 patients (with 128 stents) provided consent and were included in the study. 47 patients (62 stents) were assigned to the covered stents group (median age 69·0 years [IQR 63·0-76·5], 28 [60%] female) and 47 patients (66 stents) were assigned to the bare-metal stents group (median age 70·0 years [63·5-76·5], 33 [70%] female). At 24 months, the primary patency of covered stents (42 [81%] of 52 stents) was superior to that of bare-metal stents (26 [49%] of 53; odds ratio [OR] 4·4 [95% CI 1·8-10·5]; p<0·0001). A procedure-related adverse event occurred in 17 (36%) of 47 patients in the covered stents group versus nine (19%) of 47 in the bare-metal stent group (OR 2·4 [95% CI 0·9-6·3]; p=0·065). Most adverse events were related to the access site, including haematoma (five [11%] in the covered stents group vs six [13%] in the bare-metal stents group), pseudoaneurysm (five [11%] vs two [4%]), radial artery thrombosis (one [2%] vs none), and intravascular closure device (none vs one [2%]). Six (13%) patients in the covered stent group versus one (2%) in the bare-metal stent group had procedure-related adverse events not related to the access site, including stent luxation (three [6%] vs none), major bleeding (two (4%) vs none), mesenteric artery perforation (one [2%] vs one [2%]), mesenteric artery dissection (one [2%] vs one [2%]), and death (one [2%] vs none). INTERPRETATION The findings of this trial support the use of covered stents for mesenteric artery stenting in patients with chronic mesenteric ischaemia. FUNDING Atrium Maquet Getinge Group.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
| | - Louisa J D van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | - Olaf J Bakker
- Department of Vascular Surgery, St Antonius Ziekenhuis, Nieuwegein, Netherlands; Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Diederik C Bijdevaate
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Ziekenhuis, Rotterdam, Netherlands
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | | | - Jan Willem Hinnen
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands; Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, Netherlands
| | - Suzan Nikkessen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | | | - Henk F M Smits
- Department of Radiology, Bernhoven Hospital, Uden, Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Jean-Paul P M de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, Groningen, Netherlands
| | - Dammis Vroegindeweij
- Department of Radiology and Nuclear Imaging, Maasstad Ziekenhuis, Rotterdam, Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, Netherlands; Multi-modality Medical Imaging (M3I) group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
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Berczeli M, Chinnadurai P, Veress DS, Diaz O, Bavare CS, Lumsden AB. Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms. J Endovasc Ther 2024; 31:214-222. [PMID: 35983655 DOI: 10.1177/15266028221118510] [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: 11/15/2022]
Abstract
PURPOSE The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. MATERIALS AND METHODS Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. RESULTS A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0-4 vs 2,1-3 vessels). CONCLUSION Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. CLINICAL IMPACT Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.
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Affiliation(s)
- Marton Berczeli
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
- Siemens Medical Solutions USA Inc., Malvern, PA, USA
| | - Daniel S Veress
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Orlando Diaz
- Department of Interventional Neurology, Houston Methodist Hospital, Houston, TX, USA
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
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Bass GA, Kaplan LJ, Gaarder C, Coimbra R, Klingensmith NJ, Kurihara H, Zago M, Cioffi SPB, Mohseni S, Sugrue M, Tolonen M, Valcarcel CR, Tilsed J, Hildebrand F, Marzi I. European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities. Eur J Trauma Emerg Surg 2024; 50:367-382. [PMID: 38411700 PMCID: PMC11035411 DOI: 10.1007/s00068-023-02441-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/28/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature. METHODS Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society. RESULTS Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training. CONCLUSIONS This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA.
- Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA, USA.
| | - Lewis Jay Kaplan
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
- Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA
| | - Christine Gaarder
- Department of Traumatology at Oslo University Hospital Ullevål (OUH U), Olso, Norway
| | - Raul Coimbra
- Riverside University Health System Medical Center, Moreno Valley, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
- Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA
| | - Nathan John Klingensmith
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA
| | - Hayato Kurihara
- State University of Milan, Milan, Italy
- Emergency Surgery Unit, Ospedale Policlinico di Milano, Milan, Italy
| | - Mauro Zago
- General & Emergency Surgery Division, A. Manzoni Hospital, ASST, Lecco, Lombardy, Italy
| | | | - Shahin Mohseni
- Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
- Faculty of School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Michael Sugrue
- Letterkenny Hospital and Galway University, Letterkenny, Ireland
| | - Matti Tolonen
- Emergency Surgery, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, HUS, Finland
| | | | - Jonathan Tilsed
- Hull Royal Infirmary, Anlaby Road, Hu3 2Jz, Hull, England, UK
| | - Frank Hildebrand
- Department of Orthopaedics Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
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Sorour AA, Dehaini H, Alnahhal KI, Khalifeh A, Rowse JW, Quatromoni JG, Caputo FJ, Lyden SP, Kirksey L. Natural history of superior mesenteric artery in-stent restenosis. J Vasc Surg 2024; 79:818-825.e2. [PMID: 38128845 DOI: 10.1016/j.jvs.2023.11.035] [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] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence. METHODS Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350. RESULTS The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups. CONCLUSIONS The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.
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Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
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Chidambaram R, Soares J, Hicks R, Samuelson S, Tibballs J, Ferguson J, Jansen S. Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone. J Med Imaging Radiat Oncol 2024; 68:289-296. [PMID: 38437188 DOI: 10.1111/1754-9485.13631] [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] [Received: 10/18/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. METHODS A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. RESULTS Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. CONCLUSION Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.
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Affiliation(s)
- Rama Chidambaram
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Julian Soares
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rhiannon Hicks
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
- Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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40
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Cai W, Zhao Y, Mallappa S. Scoping Review of Clinical Presentations and Outcomes in Patients with Concomitant COVID-19 Infection and Acute Mesenteric Ischaemia. Viruses 2024; 16:506. [PMID: 38675849 PMCID: PMC11054494 DOI: 10.3390/v16040506] [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] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES COVID-19 infection confers an increased risk of coagulation dysfunction (1) predisposing to thromboembolism in many anatomical sites including the gastrointestinal tract (GIT) (2). This study investigates the clinical presentation and outcome in patients presenting with concurrent COVID-19 infection and gastrointestinal tract ischaemia. Furthermore, differentiation and comparisons are drawn between those with arterial and venous aetiology for mesenteric ischaemia. METHODS A systematic search was undertaken on EMBASE, PubMed, and MEDLINE. Two independent reviewers screened titles, abstracts, and full-text articles according to the inclusion criteria and extracted relevant data. Data analyses were conducted using Excel®. RESULTS Forty-one studies were included in the data analyses, yielding 44 patients. Twenty-six patients had mesenteric arterial occlusion, sixteen patients had mesenteric venous occlusion, and two patients had both arterial and venous mesenteric occlusion. All patients had concurrent COVID-19 infection. The survival rate in patients with arterial aetiology was 38.5% in contrast to 68.8% in patients with venous aetiology. Twelve patients (29.3%) experienced respiratory symptoms in the community before the onset of gastrointestinal symptoms, and five (12.2%) developed gastrointestinal symptoms during their inpatient stay for COVID-19 pneumonitis. CONCLUSIONS Acute mesenteric ischaemia presents a clinical challenge to diagnose due to its non-specific symptoms. Concurrent COVID-19 infection with its predominant respiratory symptoms adds a further challenge in recognising the non-specific symptoms of mesenteric ischaemia. Our study draws attention to the increased thromboembolic risk posed by COVID-19 infection and the need for a high index of suspicion to aid prompt diagnosis and management of acute mesenteric ischaemia, even in the post-pandemic era.
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Affiliation(s)
- Wenyi Cai
- East Suffolk and North Essex Foundation Trust, Colchester CO4 5JL, UK
- Colchester General Hospital, Turner Road, Colchester CO4 5JL, UK
| | - Yi Zhao
- Imperial College London School of Medicine, London SW7 2DD, UK;
| | - Sreelakshmi Mallappa
- West Hertfordshire Teaching Hospitals NHS Trust, Hertfordshire WD18 0HB, UK;
- The Hillingdon Hospitals NHS Foundation Trust, Uxbridge UB8 3NN, UK
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Reintam Blaser A, Tamme K, Starkopf J, Forbes A, Murruste M, Talving P, Acosta S, Björck M. The incidences of acute mesenteric ischaemia vary greatly depending on the population and diagnostic activity. Crit Care 2024; 28:85. [PMID: 38500182 PMCID: PMC10946189 DOI: 10.1186/s13054-024-04870-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Tartu University Hospital, Tartu, Estonia
| | - Peep Talving
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- North Estonia Medical Centre, Tallinn, Estonia
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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Takagi T, Morita Y, Matsumoto A, Ida S, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report. Surg Case Rep 2024; 10:41. [PMID: 38358535 PMCID: PMC10869672 DOI: 10.1186/s40792-024-01817-w] [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: 11/06/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Median arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region. Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically. CASE PRESENTATION A 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved. CONCLUSIONS Reports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.
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Affiliation(s)
- Toru Takagi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
- Division of Surgical Care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, 1-20-1 Handayama, Chuo-ku, 431-3192, Japan.
| | - Akio Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Shinya Ida
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryuta Muraki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Ryo Kitajima
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Satoru Furuhashi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Makoto Takeda
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Department of Perioperative Functioning Care & Support, Hamamatsu University School of Medicine, Hamamatsu, 1-20-1 Handayama, Chuo-ku, 431-3192, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Schmid BP, Gonçalves VA, Freire LMD, Nasser F, Menezes FH. Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm. J Vasc Bras 2024; 23:e20230148. [PMID: 38433982 PMCID: PMC10903786 DOI: 10.1590/1677-5449.202301482] [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: 10/16/2023] [Accepted: 12/16/2023] [Indexed: 03/05/2024] Open
Abstract
Background Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR). Objectives To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition. Methods Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature. Results All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years. Conclusions Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.
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Affiliation(s)
- Bruno Pagnin Schmid
- Universidade Estadual de Campinas - UNICAMP, Campinas, SP, Brasil.
- Hospital Israelita Albert Einstein - HIAE, São Paulo, SP, Brasil.
| | | | | | - Felipe Nasser
- Hospital Israelita Albert Einstein - HIAE, São Paulo, SP, Brasil.
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Bagley K, Schuller JG. Mesenteric ischemia in the acute care setting. Nursing 2024; 54:48-55. [PMID: 38271132 DOI: 10.1097/01.nurse.0000998028.77929.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
ABSTRACT Mesenteric ischemia is a group of disorders requiring prompt identification, supportive care, and treatment. Chronic mesenteric ischemia can develop into acute mesenteric ischemia, which has high mortality. Acute mesenteric ischemia can be occlusive (caused by arterial embolism, arterial thrombosis, or mesenteric venous thrombosis) or nonocclusive, with treatment depending on the underlying cause.
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Woestemeier A, Semaan A, Kalff JC, Lingohr P. [Diagnosis and treatment of Dunbar syndrome]. Schmerz 2024; 38:6-11. [PMID: 37989790 DOI: 10.1007/s00482-023-00766-x] [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] [Accepted: 10/09/2023] [Indexed: 11/23/2023]
Abstract
The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.
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Affiliation(s)
- Anna Woestemeier
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Alexander Semaan
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Jörg C Kalff
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Philipp Lingohr
- Klinik- und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
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Sghaier A, Jelassi MA, Fradi K, Mraidha MH, Hamila F, Youssef S. Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated. Radiol Case Rep 2024; 19:636-641. [PMID: 38111544 PMCID: PMC10726322 DOI: 10.1016/j.radcr.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 12/20/2023] Open
Abstract
Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.
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Affiliation(s)
- Asma Sghaier
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Department of Surgery at Hospital of Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
| | - Mohamed Amine Jelassi
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
| | - Khalil Fradi
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Department of Surgery at Hospital of Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
| | - Mohamed Hédi Mraidha
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Department of Surgery at Hospital of Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
| | - Fehmi Hamila
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Department of Surgery at Hospital of Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
| | - Sabri Youssef
- Hospital Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Department of Surgery at Hospital of Farhat Hached of Sousse, Rue Ibn El Jazzar, 4002 Sousse, Tunisia
- Faculty of Medicine of Sousse, Rue Mohamed Karoui, 4002 Sousse, Tunisia
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Pratesi C, Esposito D, Martini R, Novali C, Zaninelli A, Annese AL, Baggi P, Bellosta R, Bianchini Massoni C, Bonardelli S, Carriero S, Cervelli R, Chisci E, Cioni R, Corvino F, DE Cobelli F, Fanelli F, Fargion AT, Femia M, Freyrie A, Gaggiano A, Gallitto E, Gennai S, Giampalma E, Giurazza F, Grego F, Guazzarotti G, Ierardi AM, Kahlberg AL, Mascia D, Mezzetto L, Michelagnoli S, Nardelli F, Niola R, Lenti M, Perrone O, Piacentino F, Piffaretti G, Pulli R, Puntel G, Puppini G, Rossato D, Rossi M, Silingardi R, Sirignano P, Squizzato F, Tipaldi MA, Venturini M, Veraldi GF, Vizzuso A, Allievi S, Attisani L, Fino G, Ghirardini F, Manzo P, Migliari M, Steidler S, Miele V, Taurino M, Orso M, Cariati M. Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM). THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:49-63. [PMID: 38037721 DOI: 10.23736/s0021-9509.23.12809-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.
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Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy -
| | - Romeo Martini
- Department of Angiology, San Martino Hospital, Belluno, Italy
| | - Claudio Novali
- Department of Vascular Surgery, GVM Maria Pia Hospital, Turin, Italy
| | | | - Antonio L Annese
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Paolo Baggi
- Department of Vascular Surgery, ASST Spedali Civili, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | | | | | - Serena Carriero
- Department of Diagnostic and Interventional Radiology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosa Cervelli
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Emiliano Chisci
- Department of Vascular Surgery, S. Giovanni di Dio Hospital, Florence, Italy
| | - Roberto Cioni
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Fabio Corvino
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Francesco DE Cobelli
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Fabrizio Fanelli
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Marco Femia
- Department of Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, Milan, Italy
| | - Antonio Freyrie
- Department of Vascular Surgery, University Hospital of Parma, Parma, Italy
| | - Andrea Gaggiano
- Department of Vascular Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Stefano Gennai
- Department of Vascular Surgery, Baggiovara Hospital, Modena, Italy
| | - Emanuela Giampalma
- Department of Diagnostic and Interventional Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Francesco Giurazza
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Franco Grego
- Department of Vascular Surgery, University Hospital of Padua, Padua, Italy
| | - Giorgia Guazzarotti
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Anna M Ierardi
- Department of Diagnostic and Interventional Radiology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Daniele Mascia
- Department of Vascular Surgery, San Raffaele Hospital, Milan, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, Verona, Italy
| | | | - Floriana Nardelli
- Department of Diagnostic and Interventional Radiology, Città della Salute e della Scienza, Turin, Italy
| | - Raffaella Niola
- Department of Diagnostic and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Massimo Lenti
- Department of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | - Orsola Perrone
- Department of Diagnostic and Interventional Radiology, A.O.U. Pisana, Pisa, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | | | - Raffaele Pulli
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Gino Puntel
- Department of Diagnostic and Interventional Radiology, University Hospital of Verona, Verona, Italy
| | - Giovanni Puppini
- Department of Diagnostic and Interventional Radiology, University Hospital of Verona, Verona, Italy
| | - Denis Rossato
- Department of Diagnostic and Interventional Radiology, Città della Salute e della Scienza, Turin, Italy
| | - Michele Rossi
- Department of Diagnostic and Interventional Radiology, Sant'Andrea University Hospital, Rome, Italy
| | | | | | | | - Marcello A Tipaldi
- Department of Diagnostic and Interventional Radiology, Sant'Andrea University Hospital, Rome, Italy
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Circolo Hospital, Varese, Italy
| | - Gian F Veraldi
- Department of Vascular Surgery, University Hospital of Verona, Verona, Italy
| | - Antonio Vizzuso
- Department of Diagnostic and Interventional Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Sara Allievi
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Luca Attisani
- Department of Vascular Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Gianluigi Fino
- Department of Vascular Surgery, S. Maria della Misericordia Hospital, Perugia, Italy
| | | | - Paola Manzo
- Department of Vascular Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Baggiovara Hospital, Modena, Italy
| | - Stephanie Steidler
- Department of Diagnostic and Interventional Radiology, San Raffaele Hospital, Milan, Italy
| | - Vittorio Miele
- Department of Diagnostic and Interventional Radiology, Careggi University Hospital, Florence, Italy
| | - Maurizio Taurino
- Department of Vascular Surgery, Sant'Andrea University Hospital, Rome, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche, Perugia, Italy
| | - Maurizio Cariati
- Department of Diagnostic and Interventional Radiology, ASST Santi Paolo e Carlo, Milan, Italy
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Shang T, Zhou HJ, Wang YS, Qiu C, Chen TC, Sun J, Lu T, Wu Z, Zhang H, Li Z, Li DL. Mid-term Results of the Treatment of Isolated Dissection of the Celiac Artery: A Comparative Analysis of Endovascular Versus Conservative Therapy. J Endovasc Ther 2024; 31:80-88. [PMID: 35852451 DOI: 10.1177/15266028221112254] [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: 11/16/2022]
Abstract
OBJECTIVES Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA. METHODS Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed. RESULTS A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10-85 months) and 44.0 (range, 9-80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001). CONCLUSIONS EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required. CLINICAL IMPACT Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery.
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Affiliation(s)
- Tao Shang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hua-Ji Zhou
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Vascular Surgery, Ping Hu People's Hospital, Jiaxing, China
| | - Yi-Shu Wang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tian-Chi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Sun
- Department of Vascular Surgery, Hwa Mei Hospital, University of Chinese Academy of Sciences (Ningbo No.2 Hospital), Ningbo, China
| | - Tian Lu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dong-Lin Li
- Department of Vascular Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Reintam Blaser A, Mändul M, Björck M, Acosta S, Bala M, Bodnar Z, Casian D, Demetrashvili Z, D'Oria M, Durán Muñoz-Cruzado V, Forbes A, Fuglseth H, Hellerman Itzhaki M, Hess B, Kase K, Kirov M, Lein K, Lindner M, Loudet CI, Mole DJ, Murruste M, Nuzzo A, Saar S, Scheiterle M, Starkopf J, Talving P, Voomets AL, Voon KKT, Yunus MA, Tamme K. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study). Crit Care 2024; 28:32. [PMID: 38263058 PMCID: PMC10807222 DOI: 10.1186/s13054-024-04807-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). METHODS All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. RESULTS AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. CONCLUSIONS The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. TRIAL REGISTRATION NCT05218863 (registered 19.01.2022).
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Martin Björck
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zsolt Bodnar
- Letterkenny University Hospital, Letterkenny, Ireland
| | - Dumitru Casian
- University Clinic of Vascular Surgery, "Nicolae Testemitanu" State University of Medicine and Pharmacy of the Republic of Moldova, Chişinău, Moldova
| | | | - Mario D'Oria
- University Hospital of Trieste ASUGI, Trieste, Italy
| | | | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
| | - Hanne Fuglseth
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Moran Hellerman Itzhaki
- Intensive Care Unit and Institute for Nutrition Research, Rabin Medical Center, University of Tel Aviv, Petah Tikva, Israel
| | - Benjamin Hess
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Karri Kase
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University and City Hospital #1, Arkhangelsk, Russia
| | - Kristoffer Lein
- University Hospital North Norway and UiT The Arctic University of Norway, Tromsö, Norway
| | - Matthias Lindner
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Damian J Mole
- Chair of Surgery, University of Edinburgh Centre for Inflammation Research, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marko Murruste
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, AP-HP. Nord, Beaujon Hospital, Paris Cité University, Paris, France
| | - Sten Saar
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | | | - Joel Starkopf
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
| | - Peep Talving
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | | | | | - Mohammad Alif Yunus
- General Surgeon of General Surgery Department, Hospital Melaka, Malacca, Malaysia
| | - Kadri Tamme
- Institute of Clinical Medicine, University of Tartu, Puusepa 8, 50406, Tartu, Estonia
- Tartu University Hospital, Puusepa 8, Tartu, Estonia
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50
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Fang G, Lu Y, Zou L, Wang Y, Fu W, Dong Z. Endovascular Strategies and Outcomes for Aberrant Splenic Artery Aneurysms. J Endovasc Ther 2024:15266028231224165. [PMID: 38197227 DOI: 10.1177/15266028231224165] [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: 01/11/2024]
Abstract
OBJECTIVES Aberrant splenic artery aneurysms (ASAAs) located at the splenomesenteric trunk (SMT) and the celiacomesenteric trunk have a close anatomical relationship with the superior mesenteric artery (SMA). The aim of this study was to review our institutional experience of endovascular treatment for ASAAs and evaluate the long-term outcomes. METHODS A retrospective review of patients with ASAAs who underwent endovascular treatment between December 2006 and December 2022 was performed. The demographics of the patients, aneurysm characteristics, treatment strategies, perioperative and long-term outcomes, and complications were analyzed. RESULTS A total of 29 patients with ASAAs were endovascularly treated at our institution. The SMT variant occurred in the majority of the patients. All ASAAs were characterized by eccentric growth and extremely short inflow arteries. Only 1 patient's inflow artery of the aneurysm exceeded 1 cm in length. Thirteen patients were treated by coil embolization alone. Four patients received bare stent-assisted coil embolization. A combination of coil embolization and covered stent placement across the orifice of the aberrant splenic artery was performed in the remaining 12 cases. Coil migration into the SMA occurred in 2 patients during the operation. Technical success was achieved in all patients. With a median duration of 63 (34-101) months of follow-up, no intestinal ischemia, aneurysm-related death, aneurysm rupture, or sac enlargement occurred. Three cases of aneurysm sac reperfusion were observed, and 1 patient underwent reintervention with secondary embolization. Asymptomatic occlusion of the covered stent was detected in 1 patient at 2 years. CONCLUSIONS Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and poses a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications. CLINICAL IMPACT Aberrant splenic artery aneurysm (ASAA) is an extremely rare entity. This study reported a large sample size of ASAAs treated by endovascular techniques with long-term follow-up. The ASAA was characterized by an extremely short inflow artery and a close anatomical relationship with the superior mesenteric artery (SMA). Endovascular treatment is a safe, effective, and durable option for ASAAs. Inflow embolization might be difficult to achieve in ASAAs and pose a high risk of coil migration into the SMA. Long-term observation indicates that reasonable use of the covered stent could achieve reliable inflow artery exclusion in ASAAs without intestinal complications.
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Affiliation(s)
- Gang Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yige Lu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Lingwei Zou
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yuning Wang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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