The mesenteric circulation. Anatomy and physiology

Mesenteric sparing approach for advanced nodal extent in small intestinal neuroendocrine tumors. Is there a limit to the vascular resection in order to avoid creating a short small bowel syndrome? An anatomic research study

PURPOSE

By selectively perfusing the first three jejunal arteries (JA), we aim to assess the individual perfusion length of small bowel (SB) and its impact on nodal resection in stage III-up small-intestinal neuroendocrine tumors (SI-NET).

METHODS

Our anatomical research protocol implies a midline laparotomy and three measures of the SB length. We then perform a classical anterior approach of the superior mesenteric vessels. We carry on with the complete dissection and checking of the superior mesenteric artery (SMA) in order to identify the first three JA. Then we selectively perfuse each artery with colored latex solutions and measure the length of small bowel perfused respectively.

RESULTS

We conducted our protocol on six cadaveric subjects. Mean(SD) SB length was 413(5.7), 535(13.2), 485(15), 353(25.1), 730(17.3) and 525(16° cm respectively from subject one to six. Most JA originated from the left side of the SMA. The first JA originated from its posterior wall in two subjects. Mean(SD) distance of origin of the first three JA was 4.6(1.3)cm, 6(1.1)cm and 7.1(0.9)cm respectively. Mean(SD) diameter of SMA was 10.8(3.3)mm. Mean diameter of the three first JA was 4(1.4)mm, 4(1.5)mm and 5(1.2)mm respectively. Mean(SD) SB length perfused by first and second JA was 224(14.9)cm, 175(8.6)cm, 238.3(7.6)cm, 84.3(5.1)cm, 233.3(5.8)cm and 218.3(10.4)cm respectively from subject one to six.

CONCLUSION

We observed a trend suggesting that the first and second JA may sustain a SB length beyond the viable 1.5 m limit, implying the feasibility of stage III-up SI-NET resection with just two JA.

Evaluating aortomesenteric parameters in a tertiary center of Nepal for superior mesenteric artery syndrome diagnosis and risk factors: cross-sectional study

Background and objectives

This study examines aortomesenteric angle (AMA) and distance (AMD), which are critical in superior mesenteric artery (SMA) syndrome. Addressing the scarcity of SMA cases, the research explores potential links with lower BMI and aims to establish normative data for diagnostic and predictive purposes, using contrast-enhanced computed tomography (CT) scans across various BMI and sex categories.

Methodology

A retrospective quantitative cross-sectional study was conducted on 189 patients undergoing abdominal contrast-enhanced CT scans between December 2019 and December 2020. Ethical clearance was obtained, and participants provided informed consent. Exclusion criteria targeted specific medical histories. Patient demographics, BMI categories, and imaging data were recorded. Helical 128-slice CT scans were employed, with sagittal-oblique multiplanar reconstructions for parameter assessments. Statistical analysis utilized SPSS 26.0, including Pearson correlation coefficients and mean calculations.

Results

The study reveals a mean AMA of 54.07°±8.53° and a mean distance of 16.25±3.44 mm. Elevated BMI is found to positively correlate with AMA and distance, indicating that higher BMI values may augment these parameters, with an additional positive correlation observed between AMA and distance. No significant correlations are found with patient age or sex.

Conclusion

The study concludes that decreased BMI may pose a potential risk for SMA syndrome, as evidenced by the observed correlations with aortomesenteric parameters. Understanding these normal values in the Nepalese population is critical for accurate diagnoses and predictions using CT scans. The research highlights the impact of demographic factors on these parameters and emphasizes their significance in clinical assessments related to SMA syndrome.

Aortic reimplantation of the superior mesenteric artery (SMA) for SMA stenosis in a previously stented patient: New technique and a case report

INTRODUCTION AND IMPORTANCE

Mesenteric artery stenosis leads to inadequate blood flow toward various parts of the gastrointestinal tract. Revascularization is the primary aim of treatment regardless of its approach. During the last decades, open revascularization has been replaced by endovascular-first approach. Mesenteric artery in-stent restenosis occurs in a considerable number of patients that need reintervention in up to half of them using redo endovascular revascularization or open surgery. Here, we reported a case of SMA and celiac artery stenoses treated by aortic reimplantation of the SMA.

CASE PRESENTATION

A 62-year-old man with history of previous stenting of CA and SMA was referred due to chronic intermittent abdominal. CT angiography of the abdomen showed restenosis of both arteries. A transection distal part of the occlusions SMA and reimplantation of it into the SMA on the anterolateral face of the infrarenal aorta as the end-to-side anastomosis were performed resulting in resolving the patient problem.

CLINICAL DISCUSSION

Chronic mesenteric ischemia can result from various medical conditions. Mesenteric vascular surgical revascularization through open laparotomy had been considered the standard of care. However, minimally invasive surgery such as endovascular therapy has attracted attention in the recent decades. There are some concerns about the difficulties of further surgery in case of re-occlusion. The end-to-side anastomosis and aortic reimplantation can be considered in patients with appropriate runoff in the remaining parts of corresponding vessels.

CONCLUSION

Aortic reimplantation of the superior mesenteric artery in patients with restenosis of stents is a viable option especially in case of inappropriate iliac artery to perform retrograde mesenteric bypass.

The Impact of Biomarkers on the Early Detection of Acute Mesenteric Ischemia

BACKGROUND

acute mesenteric ischemia (AMI) is a life-threatening condition that is caused by inadequate blood flow through the mesenteric vessel and is related to high mortality rates due to systemic complications. This study aims to systematically review the available literature concerning the major findings of possible biomarkers for early detection of acute mesenteric ischemia in the human population.

METHODS

studies that measured the performance of biomarkers during acute mesenteric ischemia were identified with the search of PubMed, Embase, Medline, and Cochrane library.

RESULTS

from a total of 654 articles, 46 articles examining 14 different biomarkers were filtered, falling within our inclusion criteria. Intestinal fatty acid-binding protein (I-FABP) was the most commonly researched biomarker regarding AMI, with sensitivity ranging from 61.5% to 100% and specificity ranging from 40% to 100%. The second most commonly researched biomarker was D-dimer, with a sensitivity of 60-100% and a specificity of 18-85.71%. L-lactate had a sensitivity of 36.6-90.91% and a specificity of 64.29-96%. Several parameters within the blood count were examined as potential markers for AMI, including NLR, PLR, MPV, RDW, DNI, and IG. Citrulline, interleukin 6 (IL-6), and procalcitonin (PCT) were the least-researched biomarkers.

CONCLUSION

different biomarkers showed different accuracies in detecting AMI. I-FABP and D-dimer have been the most researched and shown to be valuable in the diagnosis of AMI, whereas L-lactate could be used as an additional tool. Ischemia-modified albumin (IMA), alpha glutathione S-transferase (αGST), interleukin 6 (IL-6), and citrulline showed potential use in their respective studies. However, further research needs to be done on larger sample sizes and with controls to reduce bias. Several studies showed that neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), red-cell distribution width (RDW), delta neutrophil index (DNI), and immature granulocytes (IGs) might be useful, as well at the same time be widely distributed and affordable in combination with other markers presenting higher specificity and sensitivity.

Coeliac artery avulsion secondary to high velocity blunt abdominal trauma: a case report

Coeliac artery (CA) injuries are an extremely rare subset of blunt abdominal trauma with a reported incidence of only 0.01%. Patterns of CA injury include intimal tear, dissection, thrombosis and pseudoaneurysm, with the most rare being complete CA avulsion. These complex injuries pose a treatment challenge due to rapid blood loss and anatomical difficultly in achieving proximal and multiple points of distal vascular control. To our knowledge, this case of CA avulsion from blunt polytrauma is only the 7th case reported in the literature. To assist in management, we report a case of blunt traumatic CA avulsion managed successfully with open ligation following endovascular balloon occlusion of the juxta-coeliac aorta for haemorrhage control.

Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery

PURPOSE

Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations.

METHODS

A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels.

RESULTS

Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients.

CONCLUSION

It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

Mesenteric Ischemia and Its Need for Timely Recognition and Management

Mesenteric ischemia is a fatal vascular emergency of the small intestine which, if not diagnosed and treated in time, has a very high mortality rate. Presenting with nonspecific symptoms such as abdominal pain, nausea, constipation, tachycardia, and gastrointestinal bleeds, it can masquerade as other causes of acute abdomen, particularly bowel obstruction. Ideal laboratory tests and markers are still lacking due to complexity in bowel's anatomy, physiology, blood supply, and drainage. We report 10 cases of mesenteric ischemia presented in our center with their demography, laboratory findings, approach to diagnosis, and treatment along with their outcomes at discharge. Out of the ten cases, six cases presented with signs and symptoms of acute bowel obstruction without passage of stool and one with passage of black stool. These seven patients underwent laparotomy, while the remaining three cases who either presented with milder symptoms or refused surgical interventions were managed conservatively. All patients were diagnosed with either acute or chronic mesenteric ischemia based on their operative and/or radiographic findings.

Chronic mesenteric ischemia: causes, methods of diagnosis and treatment

Chronic mesenteric ischemia (CMI) is an urgent public health problem. The long asymptomatic course of the disease, sudden onset and an unfavorable prognosis in the absence of treatment make it necessary to pay closer attention to this pathology. There are currently two competitive treatments for CMI: surgical and endovascular revascularization. Despite numerous studies comparing these methods, the question of which one is more effective and reliable remains open. The review includes current data from clinical trials and meta-analyses demonstrating the advantages and disadvantages of both methods.

Prognostic Factors for Mortality in Acute Mesenteric Ischemia

Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.

Angiographic characteristics of the intermesenteric artery

PURPOSE

The literature reports the presence of the intermesenteric artery (IA), an anastomosis connecting the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA) in 9-18% of human cadaver dissections. This is the first study describing the morphological and demographic characteristics of the IA based on in vivo imaging.

METHODS

A total of 150 consecutive abdominal computed tomography (CT) angiographies of adult patients identified by sex and age were analyzed. The IA was assessed for its presence, point of origin, pathway, point of insertion, and diameter at its origin. The diameters of the SMA, IMA, and other arteries from which the IA originated and into which it inserted were measured by CT angiography using Radiant™ and Osirix MD™ software.

RESULTS

The IA was found in 17 (51.5%) of the females and 60 (51.3%) of the males. The diameters of the SMA and IMA were larger in the males than in the females, but there was no sex difference in the diameter of the IA. The diameter of the SMA was larger than that of the IMA, and the diameter of the IA was smaller than that of the other arteries evaluated. An IA connecting the SMA and IMA trunks was found in 25.9% of the cases, while other connections between the branches of those trunks through an IA occurred less frequently.

CONCLUSIONS

The intermesenteric artery is more frequently found than the literature refers and in most of cases directly connects the upper and lower arterial mesenteric circulations.

Mesenteric ischemia: a radiologic perspective

Mesenteric ischemia is a broad term encompassing several clinical conditions leading to impaired vascularity of bowel loops. Absence of specific clinical presentation and a definitive laboratory marker often lead to delayed diagnosis with high morbidity and mortality in the acute setting. Imaging plays a crucial role in the diagnosis and management. Multi-detector CT (MDCT) is the first line imaging modality for the evaluation of patients with suspected mesenteric ischemia and plays an important role for assessing its severity and complications. This review article highlights the causes, pathophysiology, imaging features and possible endovascular treatment options of mesenteric ischemia.

Celiac Artery Coverage After Thoracic Endovascular Aortic Procedure: A Meta-Analysis of Early and Late Results

BACKGROUND/AIM

Clinical outcomes of celiac artery (CA) coverage during aortic procedures are often contradicting and the fate of this additional maneuver is still unclear. This study summarizes the results of available literature and aims to clarify the impact of CA coverage during thoracic endovascular aneurysm repair (TEVAR) in patients with inadequate distal sealing zone.

METHODS

Prospective and retrospective, observational original articles focused on CA coverage during elective/urgent TEVAR for descending thoracic aortic pathology (DTAP) were included. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials database were examined to identify articles published from January 2007 to December 2020, according to PRISMA guidelines. Early and late visceral (any sign or symptom reported) and neurological (both transient and permanent) complications were considered as primary outcomes. Onset of any endoleak, type IB endoleak, need of reintervention, and TEVAR-related mortality were considered as secondary outcomes.

RESULTS

A total of 5618 articles were extracted for analysis and 13 studies were finally included in the synthesis. A total of 178 CAs were covered during 2653 TEVAR (7%). Spinal cord ischemia was 8% (95% CI, 5-14%, I² 0%) Any endoleak and type IB endoleak was observed in 12% (95% CI, 6-21%, I² 17%) and 5% (95% CI, 2-11%, I² 0%), respectively. Thoracic endovascular aneurysm repair-related reoperation was necessary in 8% (95% CI, 4-14%, I² 0%), the majority of which (14/18, 78%) performed for distal sealing failure; mortality rate was 9% (95% CI, 5-14%, I² 0%). Out of 178 patients, 168 (94%) were available for follow-up, ranged 12 to 42 months. Visceral complications, any endoleak, and type IB endoleak were identified in 15% (95% CI, 10-23%, I² 45%), 20% (95% CI, 13-29%, I² 8%), and 8% (95% CI, 4-15%, I² 0%), respectively. Thoracic endovascular aneurysm repair-related reintervention was required in 8% (95% CI, 4-14%, I² 0%). Mortality rate was 17% (95% CI, 12-25%, I² 4%).

CONCLUSIONS

Celiac artery coverage in DTAP should be regarded as a "bailout" procedure especially in urgent/emergent settings but requires caution in elective cases. Even if transient visceral ischemia is frequent, life-threatening complications are rare. Early and late mortality rates are similar to standard TEVAR although the risk of type IB endoleak and reintervention may be an issue.

Outcome Comparison of Endovascular and Open Surgery for the Treatment of Acute Superior Mesenteric Artery Embolism: A Retrospective Study

Background

Few centers have adopted endovascular revascularization for the treatment of superior mesenteric artery embolism (SMAE). We sought to evaluate the efficacy of endovascular therapy for the treatment of SMAE and identify post-treatment prognostic factors.

Methods

The clinical data of 41 patients with acute SMA embolism between 2013 and 2021 were retrospectively reviewed. Patients with mesenteric artery thrombosis, mesenteric venous thrombosis, and who had only conservative treatment were excluded.

Results

Forty-one consecutive patients were identified with SMAE (median age, [range] 35–86 years). Endovascular therapy was initiated in 14 patients with no clinical evidence of bowel necrosis, with mainly mechanical thrombectomy, and technical success was achieved in 93%. Endovascular therapy had advantages in duration surgery time, blood loss, bowel rest time, ICU time, and ventilator use. There was no difference in bowel necrosis, length of necrotic bowel resected, or in-hospital mortality between the two groups. An initial white blood cell (WBC) count >15 × 103/dl and neutrophil count >13 × 103/dl were associated with an increased risk of bowel necrosis, and an initial WBC count, renal function, American Society of Anesthesiologists (ASA >3) and necrotic bowel >2 m were associated with increased mortality.

Conclusions

Endovascular treatment has altered the management of SMAE, and it may be adopted in selected patients who are not at risk for bowel necrosis. Avoidance of bowel necrosis patients and close monitoring for bowel necrosis are important.

Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls

Acute small bowel ischemia is a life-threatening condition with a high mortality rate due to its lack of specific symptoms and laboratory profile, which render difficulty in establishing early diagnosis. The etiology of acute small bowel ischemia includes occlusive forms (arterial embolism, arterial thrombosis, and venous thrombosis) and nonocclusive mesenteric ischemia, of which arterial causes are far more common than venous causes. CT, the mainstay of accurate diagnoses, allows the identification of the features of vascular abnormalities and intestinal ischemic injuries, and helps clinicians to restore intestinal blood flow. Without treatment, the prognosis for acute small bowel ischemia is poor. A high index of suspicion and familiarity with the CT spectral findings of bowel ischemia are required to ensure rapid recognition of this condition.

Colonoscopy-related colonic ischemia

Colonoscopy is a risk factor for colon ischemia. The colon is susceptible to ischemia due to its minor blood flow compared to other abdominal organs; the etiology of colon ischemia after colonoscopy is multifactorial. The causative mechanisms include splanchnic circulation impairment, bowel preparation, drugs used for sedation, bowel wall ischemia due to insufflation/barotrauma, and introduction of the endoscope. Gastroenterologists must be aware of this condition and its risk factors for risk minimization, early diagnosis, and proper treatment.

A Shifting Trend Towards Endovascular Intervention in the Treatment of Acute Mesenteric Ischemia

Background

Acute mesenteric ischemia (AMI) is a vascular emergency with a quite low incidence, but it is associated with disproportionately more severe morbidity and mortality. The aim of this study was to assess the current trend in the treatment of AMI and to see if endovascular intervention is an effective treatment modality in the selected group of patients.

Methods

A retrospective review of patients admitted with AMI between 2007 and 2018 was performed. Outcome measures were length of stay (LOS) at hospital and intensive care unit (ICU), and post-treatment mortality.

Results

A total of 98 patients with AMI were admitted during the study period. Patients undergoing endovascular treatment compared with surgery were younger (62.9 ± 13.7 years vs. 69.5 ± 12.8 years; p = 0.01). Shorter LOS in hospital and ICU was observed for those treated with endovascular approach (6.8 ± 3.4 and 3.25 ± 0.5 days) compared to the surgical group (25 ± 8.6 and 12.8 ± 26.8 days; p < 0.001). Out of 39 patients requiring ICU admission, 48.7% were surgically treated and 10.2% underwent endovascular intervention (p < 0.001). Mortality associated with surgery was 30.6% compared to only 6.6% with endovascular intervention (p < 0.001). Between 2007 and 2012, only one patient underwent endovascular intervention and 20 underwent surgery compared to 14 patients treated with endovascular approach and 16 with surgery between 2013 and 2018.

Conclusion

In this non-randomized, retrospective case series, patients with endovascular treatment fared clinically better and the intervention was found to be safe and feasible in the selected group of patients. We suggest a preference for this modality where possible. At our hospital, a trend favoring this approach is apparent during the last six years.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Maintaining oxygen delivery is crucial to prevent intestinal ischemia in critical ill patients

Background

Intestinal ischemia is a common complication with obscure pathophysiology in critically ill patients. Since insufficient delivery of oxygen is discussed, we investigated the influence of oxygen delivery, hemoglobin, arterial oxygen saturation, cardiac index and the systemic vascular resistance index on the development of intestinal ischemia. Furthermore, we evaluated the predictive power of elevated lactate levels for the diagnosis of intestinal ischemia.

Methods

In a retrospective case-control study data (mean oxygen delivery, minimum oxygen delivery, systemic vascular resistance index) of critical ill patients from 02/2009–07/2017 were analyzed using a proportional hazard model. General model fit and linearity were tested by likelihood ratio tests. The components of oxygen delivery (hemoglobin, arterial oxygen saturation and cardiac index) were individually tested in models.

Results

59 out of 874 patients developed intestinal ischemia. A mean oxygen delivery less than 250ml/min/m² (LRT vs. null model: p = 0.018; LRT for non-linearity: p = 0.012) as well as a minimum oxygen delivery less than 400ml/min/m² (LRT vs null model: p = 0.016; LRT for linearity: p = 0.019) were associated with increased risk of the development of intestinal ischemia. We found no significant influence of hemoglobin, arterial oxygen saturation, cardiac index or systemic vascular resistance index. Receiver operating characteristics analysis for elevated lactate levels, pH, CO₂ and central venous saturation was poor with an area under the receiver operating characteristic of 0.5324, 0.52, 0.6017 and 0.6786.

Conclusion

There was a significant correlation for mean and minimum oxygen delivery with the incidence of intestinal ischemia for values below 250ml/min/m² respectively 400ml/min/m². Neither hemoglobin, arterial oxygen saturation, cardiac index, systemic vascular resistance index nor elevated lactate levels could be identified as individual risk factors.

Many faces of acute bowel ischemia: overview of radiologic staging

Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient’s management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.

Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery Status

OBJECTIVE

The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis.

METHODS

This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI).

RESULTS

Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups.

CONCLUSION

Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.

Ultrasound imaging for assessing functions of the GI tract

OBJECTIVE

In the following review we outline how ultrasound can be used to measure physiological processes in the gastrointestinal tract.

APPROACH

We have investigated the potential of ultrasound in assessing gastrointestinal physiology including original research regarding both basic methodology and clinical applications.

MAIN RESULTS

Our main findings show the use of ultrasound to study esophageal motility, measure volume and contractility of the stomach, assess motility, wall thickness, and perfusion of the small bowel, and evaluate wall vascularization and diameters of the large bowel.

SIGNIFICANCE

Ultrasound is a widely accessible technology that can be used for both scientific and clinical purposes. Being radiation-free and user friendly, the examination can be frequently repeated enabling longitudinal studies. Furthermore, it does not influence normal GI physiology, thus being useful to estimate motility and subtle changes in physiology. Accordingly, ultrasound scanning and physiological measurements may make a big difference for the scientist and the doctor; and for the patients who receive an efficient work-up.

Bowel ischemia and gangrene-primary true enterolith

Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field. Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made. The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.

Survival rates and prognostic factors in right- and left-sided colon cancer stage I-IV: an unselected retrospective single-center trial

PURPOSE

Colorectal cancer revealed over the last decades a remarkable shift with an increasing proportion of a right- compared to a left-sided tumor location. In the current study, we aimed to disclose clinicopathological differences between right- and left-sided colon cancer (rCC and lCC) with respect to mortality and outcome predictors.

METHODS

In total, 417 patients with colon cancer stage I-IV were analyzed in the present retrospective single-center study. Survival rates were assessed using the Kaplan-Meier method and uni/multivariate analyses were performed with a Cox proportional hazards regression model.

RESULTS

Our study showed no significant difference of the overall survival between rCC and lCC stage I-IV (p = 0.354). Multivariate analysis revealed in the rCC cohort the worst outcome for ASA (American Society of Anesthesiologists) score IV patients (hazard ratio [HR]: 16.0; CI 95%: 2.1-123.5), CEA (carcinoembryonic antigen) blood level > 100 µg/l (HR: 3.3; CI 95%: 1.2-9.0), increased lymph node ratio of 0.6-1.0 (HR: 5.3; CI 95%: 1.7-16.1), and grade 4 tumors (G4) (HR: 120.6; CI 95%: 6.7-2179.6) whereas in the lCC population, ASA score IV (HR: 8.9; CI 95%: 0.9-91.9), CEA blood level 20.1-100 µg/l (HR: 5.4; CI 95%: 2.4-12.4), conversion to laparotomy (HR: 14.1; CI 95%: 4.0-49.0), and severe surgical complications (Clavien-Dindo III-IV) (HR: 2.9; CI 95%: 1.5-5.5) were identified as predictors of a diminished overall survival.

CONCLUSION

Laterality disclosed no significant effect on the overall prognosis of colon cancer patients. However, group differences and distinct survival predictors could be identified in rCC and lCC patients.

Acute celiac artery occlusion secondary to blunt trauma: Two case reports

BACKGROUND

Acute celiac artery (CA) injuries are extremely rare but potentially life-threatening and are more often caused by a penetrating injury rather than a blunt injury. The clinical manifestation of CA injuries is usually atypical, which easily causes missed diagnosis and misdiagnosis. Currently, there are only a few reports of acute traumatic occlusion of CA. The CA artery gives off branches to dominate the liver, stomach. and spleen; however, occluded CA did not cause significant organ ischemia, and the compensatory blood flow from the superior mesenteric artery (SMA) played a pivotal role.

CASE SUMMARY

Herein, we report two cases of acute CA occlusion secondary to severe blunt trauma. Case one was a 19-year-old male, suffered from a motorcycle crash. He complained of dyspnea, and the closed drainage was performed soon after the hemopneumothorax was confirmed by ultrasound. Computed tomography (CT) scan revealed hemopneumothorax, multiple rib fractures, right scapular fracture, and liver rupture. Reexamination with contrast-enhanced CT suggested perihepatic fluid was significantly increased, and CA was occluded. Because the hepatic hemorrhage is associated with hepatic artery injury, the CA was retrogradely opened through the SMA, and then, the right hepatic artery was embolized with coils successfully through the conventional pathway. Stent implantation was not performed, and the CA occlusion was managed by conservative treatment. A follow-up CT scan 3 mo after discharge showed the origin of CA remained occluded. Case two was a 37-year-old man, suffered injury from fall from height. He complained of lower back and bilateral heel pain. Contrast-enhanced CT examination revealed multiple rib fractures, bilateral pneumothorax, fourth lumbar (L4) vertebral burst fracture, and pelvic fractures. Furthermore, a small high-density mass in a lesser peritoneal sac and in front of the abdominal aorta was detected. The reexamination 14 h after admission showed the CA was occluded. The patient was conservatively treated. The symptoms of nausea after meals disappeared about 4 wk later, and abdominal distension was significantly relieved after 6 wk. The abdominal CT angiography at 60 d showed that the CA thrombus was not recanalized.

CONCLUSION

Patients with CA occlusion will have different clinical manifestations, and the dominant organ will not have obvious ischemia. Conservative treatment is safe, and the patient’s symptoms will be improved with the establishment of collateral circulation.

How to ensure immediate and long-term good blood supply by the careful dissection of the marginal artery and supercharge with neck vessels in esophageal reconstruction with the colon segment interposition: 35 years of experience

BACKGROUND

Colon interposition for total esophageal replacement cases represents one of the most challenging procedures in surgery. A retrospective study has been conducted and suggestions are proposed according to the analysis of 268 patients who underwent colon interposition for esophageal replacement. Complication rates and the duration of hospital stay were retrospectively analyzed.

METHODS

A total of 268 patients were operated between 1984 and 2018. In group 1, 164 patients underwent colon interposition without supercharging with neck vessels and in group 2, 104 patients underwent colon interposition with supercharging. Data regarding flap loss, anastomotic leakage, the duration of hospital stay, and stricture formation in the long-term were statistically analyzed and compared between two groups.

RESULTS

The success rate of reconstruction was 98,1% (161 of 164 patients) and 99% (103 of 104 patients) for group 1 and 2, respectively. Early complication (anastomotic leakage) rate was 4,9% in group 1 and 1% in group 2. The differences between two groups regarding flap loss and anastomotic leakage rates were not statistically significant (p = 0,495 and p = 0,077, respectively). The hospital stay was 26,3 days for patients without supercharging (group1) and 20,5 days for patients with supercharging (group 2). In group 1, 6,7% (11/164) of patients had narrowing at the junction of the pharynx and colon; however, in group 2, proximal anastomotic stricture formation was observed in only 1% (1/104) of the patients. The stricture rate was significantly lower in group 2 when compared to group 1 (p = 0,021).

CONCLUSION

The careful dissection of the marginal artery and supercharging with neck vessels provide lower complication rates in colon interposition for esophageal reconstruction.

A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy-6-year Follow-up

OBJECTIVE

To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature.

MATERIALS AND METHODS

The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump.

RESULTS

At the 6-year follow-up, the patient had no intestine-related sequelae.

CONCLUSION

Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

High-Value Multidetector CT Angiography of the Superior Mesenteric Artery: What Emergency Medicine Physicians and Interventional Radiologists Need to Know

The superior mesenteric artery (SMA) provides vital blood supply to the midgut, and an acute abnormality can rapidly precipitate bowel ischemia and infarction and lead to morbidity and mortality. Vascular diseases that acutely compromise the SMA threaten its tributaries and include occlusion, dissection, aneurysm rupture, pseudoaneurysm, vasculitis, and SMA branch hemorrhage into the bowel. Emergency medicine physicians rely on the radiologist to identify SMA abnormalities, to characterize them, and to detail findings that guide the appropriate triage of these patients. As such, radiologists must be cognizant of the features that influence patient treatment to assist vascular surgeons and interventional radiologists in decision making. Some patients can be treated medically, while clinical and radiographic findings may suggest the need for interventional or surgical repair of the artery. In the latter case, multidetector CT findings aid in determining which of the various surgical and endovascular treatment options is optimal, and both vascular and gastrointestinal sequelae of acute SMA abnormalities contribute to these determinations. The authors review acute life-threatening conditions involving the SMA including acute occlusion, dissection, aneurysm, pseudoaneurysm, and hemorrhage and discuss the vascular and gastrointestinal multidetector CT findings in each of these conditions that help to guide surgical and interventional management. ^©RSNA, 2019.

Isquemia intestinal por trombosis mesentérica en paciente geriátrico, resuelta por intervencionismo. Reporte de caso

Mesenteric thrombosis represents a vascular urgency caused by the abrupt interruption of blood flow, whether arterial or venous; clinical presentation can be nonspecific, which can represent a diagnostic challenge. According to its vascular etiology, a different therapeutic approach is required. If there is clinical suspicion or signs of peritonitis, the imaging diagnosis can support to identify the presented pathology. On this occasion, there is a clinical case of an 84-year-old http://doi.org/10.22201/fm.24484865e.2020.63.2.04 | Vol. 63, n.o 2, Marzo-Abril 2020 25 patient who goes to the emergency department for generalized abdominal pain, which led to a diagnostic imaging study, to confirm this finding. Key words: Intestinal ischemia; atherosclerosis; Mesenteric thrombosis; catheterization

Review Article: Mesenteric Ischemia

PURPOSE OF REVIEW

Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders.

RECENT FINDINGS

There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.

How to manage chronic mesenteric ischemia? A deliberated strategy

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.

Ischemic Gut in Critically Ill (Mesenteric Ischemia and Nonocclusive Mesenteric Ischemia)

Ischemic gut or splanchnic hypoperfusion is a life-threatening emergency and it is associated with high mortality. It requires prompt diagnosis and intervention to establish the mesenteric blood flow, hence an attempt to avoid gut necrosis. Despite the understanding of pathogenesis of acute mesenteric ischemia and advanced treatment and revascularization techniques, it still remains a big diagnostic dilemma for the clinicians. Any delay in diagnosis and appropriate treatment affects the overall outcome of the patient. The high incidence of sepsis and multiorgan failure requires high-quality intensive care management.

How to cite this article: Gupta S, Tomar DS. Ischemic Gut in Critically Ill (Mesenteric Ischemia and Nonocclusive Mesenteric Ischemia). Indian J Crit Care Med 2020;24(Suppl 4):S157–S161.

Mesenteric ischemia: what the radiologist needs to know

Acute mesenteric ischemia (AMI) is a life-threatening condition that often presents with abdominal pain. Early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI. This article reviews practical etiological classification, pathophysiology of imaging manifestations and common pitfalls in intestinal ischemia.

"Fatal Gastrointestinal and Peritoneal Ischemic Disease" of Unknown Cause at Arba Minch Hospital, Southern Ethiopia

Gastrointestinal and peritoneal ischemic disease due to unknown etiology present with intestinal obstruction and/or peritonitis otherwise in healthy patient emerged as fatal disease at Arba Minch General Hospital. This disorder was diagnosed based on intraoperative finding. Clinical presentation and natural history of disease progression were similar. It is estimated that about 6-10 lives are being claimed each year at Arba Minch Hospital with this disease of unidentified cause accounting for the largest figure of surgical department. Here we report case analysis and literature review illustrating clinical presentation, workup, preoperative diagnosis, intraoperative diagnosis, and final outcome of fatal gastrointestinal and peritoneal ischemic disease.

Acute mesenteric ischaemia: a pictorial review

Abstract

Acute mesenteric ischaemia (AMI) is an uncommon cause of acute hospital admission with high mortality rates (50–90%) that requires early diagnosis and treatment. With the increase in average life expectancy, AMI represents one of the most threatening abdominal conditions in elderly patients. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can reverse this process leading to a full recovery, but the diagnosis of AMI is difficult. The failure to recognise AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Unfortunately, common CT findings in bowel ischaemia are not specific. Therefore, it is often a combination of nonspecific clinical, laboratory and radiological findings that helps most in the correct interpretation of CT findings. The purpose of this article is to provide an overview of the anatomy, physiology of mesenteric perfusion and discussions of causes, pathogenesis and CT findings in various types of acute bowel ischaemia. Familiarity with various imaging features of mesenteric injury is essential to make a timely diagnosis that will lead to improved patient outcomes.

Teaching Points

• AMI is a potentially life-threatening disorder whose prognosis depends on early recognition, accurate diagnosis and timely intervention.

• Arterial inflow occlusion due to thrombosis or embolisation is the most common cause of AMI.

• Four aetiological types of AMI have been associated with different characteristics and risk factors (EAMI, TAMI, VAMI and NOMI).

• Physical examination and laboratory findings are not sensitive or specific for diagnosing AMI; therefore, MDCT is still the first-line imaging method in suspected AMI.

• Although a number of scoring systems for prognosis have been proposed, these have not been validated in large-scale studies.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.

Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

Fatal Acute Hemorrhagic Bowel Infarction Caused by Mesenteric Venous Thrombosis

Acute mesenteric venous thrombosis (MVT) is a rare, but life-threatening medical phenomenon. MVT is normally characterized by insidious onset, with nonspecific signs and symptoms. A high index of clinical suspicion is required for diagnosis, and emergency surgery is necessary to optimize the chances of patient survival, especially in the people aged more than 70 years. Surprisingly, based on my review of the literature, no fatal acute MVT case has been reported in the forensic literature. All reported such cases have been documented in medical literature, and most of them have been associated with underlying risk factors for venous thrombosis, such as hypercoagulable state, certain cancers, and stasis of the blood flow. Here, I report the case of a sudden unexpected death due to extensive intestinal ischemia and infarction with massive abdominal hemorrhage caused by acute MVT in a 72-year-old man without known underlying risk factors.

A rare anastomosis between the common hepatic artery and the superior mesenteric artery: a case report

For decades, anastomoses between unpaired branches of the abdominal aorta have attracted the attention of anatomists, surgeons and radiologists, due to their significance in many clinical procedures. This report presents a rare anastomosis between the common hepatic artery and the superior mesenteric artery, which gave off three branches to the jejunum. The diameter of the anastomosis measured at the point of its branching off the common hepatic artery and at the level of union with the superior mesenteric artery was 4.46 and 4.19 mm, respectively. Moreover, the anastomosis gave off the branch to the head of the pancreas. Both embryological background and potential clinical implications of this variation are discussed. Knowledge of these vascular connections may be important for diagnostic and surgical procedures.

Laparoscopic Complete Mesocolic Excision for Stage II/III Left-Sided Colon Cancers: A Prospective Study and Comparison with D3 Lymph Node Dissection

BACKGROUND

To investigate the similarities and differences of laparoscopic complete mesocolic excision (CME) to a colon resection with a D3 lymphadenectomy for the stage II/III left-sided colon carcinoma.

METHODS

Patients between July 2011 and August 2014 were randomized into D3 and CME groups. Mesenteric area, log odds of positive lymph nodes (LODDS), and other operative parameters were collected and assessed.

RESULTS

The average specimen sizes were 5730 ± 828 mm(2) in superior rectal artery (SRA)-preserving D3, 8145 ± 1022 mm(2) in SRA-nonpreserving D3, and 8745 ± 1039 mm(2) in the CME group; the differences were significant (P < .0001). The number of lymph nodes collected from CME specimens was larger, but the CME specimens did not contain an elevated value of LODDS or positive nodes or lymph node ratio (LNR). There were also no significant differences between recovery times of bowel function. Although it took more operation time in D3 approach, especially in SRA-preserving D3 operation, the difference was not significant. Concerning the leakage rate (P = .34) and vessel-related complications (P = .64), there were no significant differences either.

CONCLUSIONS

Both standard D3 resection and CME could achieve a high quality of mesocolic plane grade for stage II/III colon cancer. The LODDS and LNR were comparable, and those were not relevant to mesenteric size.

The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes

BACKGROUND

Concomitant procedures during endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm are performed to facilitate endograft delivery, to simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aimed to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR.

METHODS

We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014 and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes.

RESULTS

The study included 4033 patients, with 1168 (29.0%) patients undergoing one or more additional procedures. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.1-11.2) and renal angioplasty or stenting (OR, 3.1; 95% CI, 1.2-8.3). Postoperative bowel ischemia was associated with hypogastric embolization (OR, 3.8; 95% CI, 1.1-13.4) and iliac angioplasty or stenting (OR, 3.5; 95% CI, 1.3-9.6). Leg ischemia was associated with unplanned graft extension (OR, 2.3; 95% CI, 1.02-5.0), other artery reconstruction (OR, 5.2; 95% CI, 1.8-15.1), thromboembolectomy (OR, 5.2; 95% CI, 1.3-20.8), and repair of arterial injury (OR, 4.6; 95% CI, 1.2-18.3). Risk factors for deterioration of renal function were iliofemoral bypass (OR, 3.9; 95% CI, 1.3-12.2), other artery reconstruction (OR, 2.7; 95% CI, 1.3-5.8), renal angioplasty or stenting (OR, 2.5; 95% CI, 1.3-4.6), and repair of arterial injury (OR, 4.5; 95% CI, 1.6-12.2). Myocardial infarction was associated with femorofemoral bypass (OR, 3.9; 95% CI, 1.7-8.7), other artery reconstruction (OR, 3.9; 95% CI, 1.6-9.2), and repair of arterial injury (OR, 6.1; 95% CI, 1.8-21.0). Wound complications were predicted by femorofemoral bypass (OR, 13.4; 95% CI, 5.8-31.1).

CONCLUSIONS

Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thromboembolic events where possible.