Factors that may affect the outcome of acute occlusive mesenteric ischemia. A single-center study

BACKGROUND

Acute mesenteric ischemia is a rare but lethal disease. Acute occlusive mesenteric ischemia consists of mesenteric artery embolism, mesenteric artery thrombosis, and mesenteric vein thrombosis. This study aimed to investigate the factors that may affect the outcome of acute occlusive mesenteric ischemia.

METHODS

Data from acute occlusive mesenteric ischemia patients admitted between May 2016 and May 2022 were reviewed retrospectively. Patients were divided into 2 groups according to whether complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission. Demographics, symptoms, signs, laboratory results, computed tomography angiography features, management and outcomes were analyzed.

RESULTS

59 patients were enrolled in this study. Complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission in 17 patients. Transmural intestinal necrosis, peritonitis, white blood cell count, percentage of neutrophils, percentage of lymphocytes, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, creatine kinase isoenzyme, cardiac troponin I, laparoscopic exploration rate, open embolectomy rate, enterostomy rate, length of necrotic small bowel, length of healthy small bowel, surgical time and intraoperative blood loss differed significantly between groups. Creatine kinase isoenzyme (OR = 1.415, 95% CI: 1.060-1.888) and surgical time (OR = 1.014, 95% CI: 1.001-1.026) were independent risk factors associated with complications(Clavien‒Dindo ≥ 2).

CONCLUSIONS

Our analysis suggests that acute occlusive mesenteric ischemia patients with a creatine kinase isoenzyme level greater than 2.22 ng/mL or a surgical time longer than 156 min are more likely to experience complications'(Clavien‒Dindo ≥ 2) occurrence within 6 months of the first admission.

Outcomes of open revascularization for chronic mesenteric ischemia at a tertiary care center in India

OBJECTIVE

Chronic mesenteric ischemia (CMI) is a rare, debilitating disease associated with higher morbidity and mortality if not treated on time. In the past two decades, there has been a paradigm shift in its management with endovascular modality due to reduced perioperative morbidity and mortality. In the endovascular era, only a few patients require surgical therapy. We conducted this study to report our experience with open surgical revascularization at our hospital.

METHODS

We have conducted a retrospective study after obtaining approval from Institutional Ethics Committee. Data regarding patients who underwent open revascularization for CMI with long-segment occlusion from 2016 to 2021 has been retrieved from the institutional database. The demographic data, clinical presentation, type of surgery and graft used, perioperative mortality and morbidity and length of hospital stay were evaluated. Overall survival and disease-free survival were assessed using Kaplan-Meier analysis.

RESULTS

Twenty-one patients underwent open surgical revascularization; 16 were males and five females. The median age was 43 years. Fourteen (66.7%) were smokers. The mean duration of follow-up was 28.4 ± 13.6 months. Thirty-day postoperative mortality was 0% and morbidity was 28%. The average duration of hospital stay and postoperative weight gain were 6.9 ± 3.7 days and 11 ± 4.9 kgs, respectively. One patient died at two years of follow-up due to myocardial infarction and one had a recurrence. Long-term survival at 60 months of follow-up was 91.6% and the primary-patency rate was 95.2%.

CONCLUSION

Owing to better long-term and reintervention-free patency, open revascularization should be considered in patients who are fit for surgery, particularly in patients with long-segment mesenteric artery occlusion.

Hospital-based Delays to Revascularization Increase Risk of Post-operative Mortality and Short Bowel Syndrome in Acute Mesenteric Ischemia

OBJECTIVE

Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on post-operative morbidity and mortality in AMI.

METHODS

All patients who underwent any surgery for acute mesenteric ischemia (AMI) from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤ 12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and post-operative data was performed. Effect of DR on major post-operative outcomes including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on sub-group analyses.

RESULTS

A total of 212 patients were analyzed. 99 patients received ER while the remaining 113 patients experienced a delay to revascularization after hospital presentation. Among the DR group, 55 (25.9%) patients had delayed vascular consultation while vascular surgery was deferred until after the initial operation in 37 (17.4%) patients. 51 (24.0%) patients were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio (OR) 2.09, 95% confidence interval (CI) [1.4-4.9], P=0.03) and 2-year mortality (hazard ratio (HR) 1.55, CI [1.0-2.3], P= 0.04). DR was also independently associated with increased bowel resection length (OR 7.47, P <0.01) and post-operative short bowel syndrome (OR 2.4, P=0.03) on multivariate analyses. When examined separately on sub-group analysis, both delayed vascular consultation (OR 3.38, P=0.03) and vascular surgery (OR 4.31, P <0.01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR 2.94, P <0.01) and late mortality (HR 1.60, P=0.04).

CONCLUSIONS

Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of post-operative mortality and short bowel syndrome in AMI. Timing-based management protocols which emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

ACUTE EMBOLISM OF THE SUPERIOR MESENTERIC ARTERY AND SIGNIFICANT STENOSIS OF THE CELIAC TRUNK SUCCESSFULLY TREATED WITH PERCUTANEOUS ANGIOPLASTY AND STENT IMPLANTATION

Among patients presenting with acute abdominal symptoms, patients with acute mesenteric ischemia (AMI) constitute 0.09% - 0.2% of cases. Unfortunately, due to the short period between the first symptoms and irreversible ischemic changes in the intestine, the mortality rate in this group is high - up to 60% - 100%. We present a case of a 75-yearold female with severe comorbidities (ischemic heart disease, atrial fibrillation, poorly controlled arterial hypertension, and a history of colorectal carcinoma previously treated with radio- and chemotherapy). The patient was admitted due to severe abdominal pain. Computed tomography (CT) confirmed superior mesenteric artery (SMA) and celiac trunk embolism. Due to the relatively short time of symptoms onset as well as the soft abdomen, the patient was qualified for percutaneous treatment. Successful percutaneous transluminal angioplasty was performed with stent implantation to SMA and celiac trunk (Neptun C, Balton, Poland). As a result, the patency of both arteries was fully restored. The patient's condition improved within 24 hours, and she was discharged home.

Gangrenous Gastritis: Unusual Cause Of Upper Gi Bleeding

Chronic Mesenteric ischemia is an episodic hypoperfusion of small intestine due to atherosclerotic narrowing of mesenteric vessels. Typically, patients report postprandial epigastric pain. The association of abdominal pain with eating results in fear of eating and weight loss. Some patients present atypically with nausea, vomiting and/or GI bleeding likely from gut ischemia. We present here a case of 67-yearold male with history of COPD, Coronary artery disease and atrial fibrillation presented with hematemesis and black stools for one day. Patient reports no abdominal pain or weight loss. He was dizzy and nauseous. He was vitally stable and physical exam including abdominal exam was unremarkable except for the rectal exam which revealed black stools. Investigations revealed Haemoglobin of 16.1 and hematocrit of 45, WBCs of 34000 with 83% neutrophils and bicarbonate of 20. Patient underwent EGD for localizing the site of bleeding and showed stomach lumen completely filled with thrombus which prevented the accurate assessment if gastric mucosa. Repeat EGD was recommended and it revealed gangrenous appearing gastritis throughout with multiple clean ulcers which raised the suspicion of vascular compromise. CT angiography abdomen revealed complete proximal occlusion of Superior Mesenteric artery and near complete occlusion of celiac artery. He underwent successful SMA bypass from left iliac to mid SMA with PTFE graft. Symptoms of mesenteric ischemia can be non-specific and can mimic other aetiologies. Clinicians should consider this diagnosis in elderly patient with risk factors of atherosclerosis as early diagnosis reduces complication associated with serious life-threatening disease.

Hemodynamic Analysis to Assist Treatment Strategies in Complex Visceral Arterial Pathologies: Case Reports and discussion from Pancreaticoduodenal Artery Aneurysm with Superior Mesenteric Artery Occlusion

BACKGROUND

Pancreaticoduodenal artery aneurysms (PDAAs) with occlusion of the superior mesenteric artery (SMA) are extremely rare. In the present study, we used computational fluid dynamics (CFD) to analyze the hemodynamics of a patient-specific PDAA with occlusion of the SMA preoperatively and then decide the treatment strategy in terms of the potential postoperative hemodynamics.

METHODS

A 3D model of a 69-old-year female with PDAA was reconstructed based on CT images. The virtual postoperative models of the aneurysmectomy with or without revascularization were numerically simulated in terms of hemodynamics including the flow field and wall shear stress (WSS).

RESULTS

Aneurysmectomy with revascularization would result in the original aneurysm site experiencing abnormally high WSS and pressure, which may possibly lead to the recurrence of PDAA. However, aneurysmectomy without revascularization would lead to stagnant flow in the blocked posterior-inferior pancreaticoduodenal artery (PIPDA). As a result, the PIPDA may soon be completely occluded after surgery and the SMA perfusion would be guaranteed. Finally, aneurysmectomy without revascularization was performed in this patient. The postoperative six-month computed tomography angiography result finely matched to the preoperative CFD simulation result.

CONCLUSIONS

This study gained insights into hemodynamics of PDAA. In addition, it demonstrated that utilization of CFD analysis also possibly helps assist the operation strategies for vascular diseases.

Aspiration therapy for acute embolic occlusion of the superior mesenteric artery

BACKGROUND

Embolic superior mesenteric artery (SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However, most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure.

AIM

To evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA.

METHODS

This retrospective study reviewed eight patients (six males and two females) from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography (CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed.

RESULTS

Six (75%) patients were male, and the mean patient age was 70.00 ± 8.43 years (range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications (the clot broke off during aspiration).

CONCLUSION

Aspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients’ death, resolving thrombi, and improving symptoms.

Ischemia/reperfusion injury in porcine intestine - Viability assessment

AIM

To investigate viability assessment of segmental small bowel ischemia/reperfusion in a porcine model.

METHODS

In 15 pigs, five or six 30-cm segments of jejunum were simultaneously made ischemic by clamping the mesenteric arteries and veins for 1 to 16 h. Reperfusion was initiated after different intervals of ischemia (1-8 h) and subsequently monitored for 5-15 h. The intestinal segments were regularly photographed and assessed visually and by palpation. Intraluminal lactate and glycerol concentrations were measured by microdialysis, and samples were collected for light microscopy and transmission electron microscopy. The histological changes were described and graded.

RESULTS

Using light microscopy, the jejunum was considered as viable until 6 h of ischemia, while with transmission electron microscopy the ischemic muscularis propria was considered viable until 5 h of ischemia. However, following ≥ 1 h of reperfusion, only segments that had been ischemic for ≤ 3 h appeared viable, suggesting a possible upper limit for viability in the porcine mesenteric occlusion model. Although intraluminal microdialysis allowed us to closely monitor the onset and duration of ischemia and the onset of reperfusion, we were unable to find sufficient level of association between tissue viability and metabolic markers to conclude that microdialysis is clinically relevant for viability assessment. Evaluation of color and motility appears to be poor indicators of intestinal viability.

CONCLUSION

Three hours of total ischemia of the small bowel followed by reperfusion appears to be the upper limit for viability in this porcine mesenteric ischemia model.

[A Case of Acute Superior Mesenteric Artery Occlusion Rescued by Thrombus Aspiration without Bowel Resection]

Acute superior mesenteric artery (SMA) occlusion is rare and associated with high morbidity and mortality.One of the reasons is the difficulty to diagnose the disease soon after the abdominal pain initially occurs. A 79-year-old woman with atrial fibrillation was admitted because of progressive left abdominal pain and nausea. Two hours after the onset, computed tomography revealed an occlusion of the SMA. No signs of intestinal infarction were present. Abdominal angiography revealed complete obstruction from the distal portion of the SMA to the ileocolic artery, so we could have a diagnosis of SMA occlusion early. Continuous per-catheteric thrombus aspiration for the occlusion successfully removed the thrombus and led to complete revascularization laparotomy. We encountered a case of acute mesenteric ischemia due to SMA occlusion with atrial fibrillation. Early diagnosis is necessary to survive without bowel resection.

[Stenting of the superior mesenteric artery in a patient with severe chronic intestinal ischaemia]

Presented herein is a clinical case report concerning endovascular treatment of severe chronic ischaemia of digestive organs in a patient with lesions of all three visceral arteries. Peculiarities of endovascular technique in mechanical revascularization of the superior mesenteric artery are described. Restoration of blood flow through even one visceral artery, i. e., superior mesenteric artery, is an effective and safe method of treatment for chronic intestinal ischaemia.

Intestinal Infarction Through Arterial Vascular Obstruction - Case Series from 1st and 3rd Surgery Clinics Cluj-Napoca

This article presents a case series of intestinal infarction through obstruction of superior mesenteric artery - two cases of acute mesenteric artery embolism, two cases of acute mesenteric artery thrombosis and a case of volvulus.

Protective role of adiponectin in a rat model of intestinal ischemia reperfusion injury

AIM: To determine the potential protective role of adiponectin in intestinal ischemia reperfusion (I/R) injury.

METHODS: A rat model of intestinal I/R injury was established. The serum level of adiponectin in rats with intestinal I/R injury was determined by enzyme-linked immunosorbent assay (ELISA). The serum levels of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α were also measured by ELISA. Apoptosis of intestinal cells was detected using the terminal deoxynucleotidyl transferase dUTP nick end labeling assay. The production of malondialdehyde (MDA) and superoxide dismutase (SOD) and villous injury scores were also measured.

RESULTS: Adiponectin was downregulated in the serum of rats with intestinal I/R injury compared with sham rats. No significant changes in the expression of adiponectin receptor 1 and adiponectin receptor 2 were found between sham and I/R rats. Pre-treatment with recombinant adiponectin attenuated intestinal I/R injury. The production of pro-inflammatory cytokines, including IL-6, IL-1β, and TNF-α, in rats with intestinal I/R injury was reduced by adiponectin pre-treatment. The production of MDA was inhibited, and the release of SOD was restored by adiponectin pre-treatment in rats with intestinal I/R injury. Adiponectin pre-treatment also inhibited cell apoptosis in these rats. Treatment with the AMP-activated protein kinase (AMPK) signaling pathway inhibitor, compound C, or the heme oxygenase 1 (HO-1) inhibitor, Snpp, attenuated the protective effects of adiponectin against intestinal I/R injury.

CONCLUSION: Adiponectin exhibits protective effects against intestinal I/R injury, which may involve the AMPK/HO-1 pathway.

[Endovascular interventions for acute ischemia of intestine]

It is presented 5 clinical observations of acute ischemia of intestine in which different endovascular interventions including isolated superior mesenteric artery stenting, rheolytic and aspiration thrombectomy and combination of techniques were applied. Surgical success with blood flow restoration in superior mesenteric artery was achieved in 4 of 5 patients. 2 patients have required laparotomy and intestinal resection. In 1 case extent of resection was significantly reduced after previous endovascular thrombectomy. There were no deaths. It is concluded that endovascular interventions may be considered as independent method of treatment of patients with acute mesenteric ischemia.

Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion

Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase. Most patients have acute superior mesenteric artery (SMA) occlusion, and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization, and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia, and to perform bowel resections. The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization. This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion. Explorative laparotomy needs to be performed first. Curative treatment is based upon intestinal revascularization followed by bowel resection. If no vascular imaging has been carried out, SMA angiography is performed. In case of embolic occlusion of the SMA, open embolectomy is performed followed by angiography. In case of thrombotic occlusion, the occlusive lesion can be recanalized retrograde from an exposed SMA, the guidewire snared from either the femoral or brachial artery, and stented with standard devices from these access sites. Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy, leaving definitive bowel reconstructions to a planned second look laparotomy, according to the principles of damage control surgery. Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon, and a hybrid revascularization approach is of utmost importance to improve outcomes.

[A case of superior mesenteric artery occlusion with ischemic enteritis after transcatheter therapy]

An 84-year-old female was admitted with sudden-onset upper abdominal pain. Contrast-enhanced computed tomography (CECT) revealed complete occlusion of the superior mesenteric artery (SMA). After transcatheter infusion of urokinase, embolic occlusion resolved. However, the pain recurred when she started eating. CECT revealed a lesion with thickening of the intestinal wall; therefore, laparoscopy-assisted surgery was undertaken. Histological examination yielded a definitive diagnosis of ischemic enteritis caused by SMA occlusion. Rapid diagnosis and treatment are important in SMA occlusion, and careful observation of the clinical course is recommended after transcatheter therapy.

[Possibilities of endovascular surgery in treatment of acute arterial impairment of mesenteric blood circulation]

The authors demonstrate herein their experience (3 clinical case reports) in endovascular interventions in the basin of the superior mesenteric artery, performed for its thromboembolism (2 patients) and thrombosis (1 patient). Rheolytic thrombectomy from the superior mesenteric artery turned out inefficient in one patient and he was operated on in the scope of laparotomy, vast resection of the small intestine and the right half of the large intestine and indirect embolothrombectomy from the superior mesenteric artery. Aspiration thrombectomy had only a partial effect in the second patient presenting with thromboembolism of the proximal segment of the superior mesenteric artery: the major blood flow through the artery was restored and the scope of intestinal resection was reduced to 20 cm of the jejunum. Finally, the third patient underwent combined endovascular (rheolytic and aspiration) thrombectomy performed in an isolated manner, with neither laparotomy nor intestinal resection employed. In the last two cases, endovascular thrombectomy was supplemented by selective administration of platelet glycoprotein IIb/IIIa receptor inhibitors injected into the basin of the mesenteric artery. Endovascular intervention is an operation of choice in patients presenting with acute impairment of mesenteric blood circulation at the stage of intestinal ischaemia.

[Modern approach to diagnosis and treatment of acute mesenteric ischemia]

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.

Tumor necrosis factor-α mediates JNK activation response to intestinal ischemia-reperfusion injury

AIM: To investigate whether tumor necrosis factor-α (TNF-α) mediates ischemia-reperfusion (I/R)-induced intestinal mucosal injury through c-Jun N-terminal kinase (JNK) activation.

METHODS: In this study, intestinal I/R was induced by 60-min occlusion of the superior mesenteric artery in rats followed by 60-min reperfusion, and the rats were pretreated with a TNF-α inhibitor, pentoxifylline, or the TNF-α antibody infliximab. After surgery, part of the intestine was collected for histological analysis. The mucosal layer was harvested for RNA and protein extraction, which were used for further real-time polymerase chain reaction, enzyme-linked immunosorbent assay and Western blotting analyses. The TNF-α expression, intestinal mucosal injury, cell apoptosis, activation of apoptotic protein and JNK signaling pathway were analyzed.

RESULTS: I/R significantly enhanced expression of mucosal TNF-α at both the mRNA and protein levels, induced severe mucosal injury and cell apoptosis, activated caspase-9/caspase-3, and activated the JNK signaling pathway. Pretreatment with pentoxifylline markedly downregulated TNF-α at both the mRNA and protein levels, whereas infliximab pretreatment did not affect the expression of TNF-α induced by I/R. However, pretreatment with pentoxifylline or infliximab dramatically suppressed I/R-induced mucosal injury and cell apoptosis and significantly inhibited the activation of caspase-9/3 and JNK signaling.

CONCLUSION: The results indicate there was a TNF-α-mediated JNK activation response to intestinal I/R injury.

Postmortem evaluation of death in an inoperable case of ischaemic enterits with focal infarction

Now-a-days, medical profession is facing with repeated allegations of medical negligence; hence the doctors ought to be very careful in treating the patients and also in giving agreeable explanation in case of death to the public. Here is a case of a 6 years old, male, Muslim boy brought to the department of forensic medicine, Rangaraya Medical College, Kakinada with the cause of death as severe shock, secondary to abdominal colic as per the treating paediatric surgeon. The parents and relatives alleged negligence by the treating doctors as the child was brought with the complaints of pain abdomen, vomiting and loose motion and if he was operated at an early time, definitely he might be survived with a false belief of pain abdomen due to appendicitis. Clinical correlation, postmortem findings and histopathological findings revealed the cause of death was due to ischaemic enteritis with focal infarction - whether amounted to medical negligence as alleged by parents.

Mesenteric venous thrombosis

The prevalence of mesenteric venous thrombosis has increased over the past 2 decades with the routine use of contrast-enhanced computed tomography (CT) in patients presenting with abdominal pain and those with portal hypertension. Concurrent with increasing recognition, routine and frequent use of anticoagulation has reduced the need for surgical intervention and improved outcome in these patients. Acute thrombosis often presents with abdominal pain, whereas chronic disease manifests either as an incidental finding on CT or with features of portal hypertension. Contrast-enhanced CT diagnoses about 90% of cases. The presence of collateral circulation and cavernoma around a chronically thrombosed vein differentiates chronic from acute disease. The superior mesenteric vein is often involved, whereas involvement of the inferior mesenteric vein is rare. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Thrombophilia and local abdominal inflammatory conditions are common causes. Management is aimed at preventing bowel infarction and recurrent thrombosis. Anticoagulation, the mainstay of management, has also been safely used in patients with cirrhosis and portal hypertension. This review discusses the pathogenesis of thrombosis of mesenteric veins, the diagnosis and differentiation from arterial ischemia, the emergence of the JAK2 (Janus kinase 2) sequence variation as a marker of thrombophilia and myelodysplastic neoplasms, and new anticoagulants. Algorithms for the management of acute and chronic mesenteric venous thrombosis are provided to help readers understand and remember the approach to the management of acute and chronic mesenteric venous thrombosis.

[Tactics by the acute intestinal ischemia]

Treatment results of the acute intestinal ischemia in 72 patients were analyzed. Patients aged 69.2 ± 5.8 years. Occlusive vascular lesions of the intestinal vessels (thrombosis and embolism of the superior mesenteric artery and thrombosis of the superior mesenteric vein) were obliged to the ischemic disorders in 84.5% of patients. The rest 15.5% of patients demonstrated microvascular disorders (nonocclusive ischemia). The issue presents the novel algorithm for treatment and diagnostics of the acute intestinal ischemia.

Weight loss caused by visceral artery disease

Dramatic unintentional weight loss can be caused by a spectrum of diseases ranging from very serious to benign and treatable. We describe the case of a 70-year-old woman with an extensive history of cardiovascular disease who presented with unintentional weight loss. Although she was diagnosed and treated for colitis, the patient continued to lose 50 pounds over 8 months, which prompted an angiogram. The angiogram revealed occlusion of her superior and inferior mesenteric arteries just distal to their origins, together with high-grade (80%-90%) stenosis at the origin of the celiac axis. After a stent was placed in the ostium of the celiac axis, the patient immediately began to regain weight. We suggest that clinicians consider chronic mesenteric ischemia when treating patients with undiagnosed unintentional weight loss and a history of atherosclerotic disease.

Postsurgical segmental mesenteric ischemic thrombosis in a horse

A 16-year-old, Lusitanian stallion was admitted to the Veterinary Teaching Hospital with a 12-hour history of signs of abdominal pain. Exploratory celiotomy was performed due to an inguinal hernia, and a second celiotomy was performed in response to the abdominal pain. The horse was euthanized and mesenteric venous thrombosis was diagnosed and considered likely due to peritonitis and systemic inflammatory response syndrome (SIRS).

Capture and repositioning of third-generation migrated abdominal endovascular graft by bilateral femoral wire externalization and pulling by "horse-riding" technique followed by balloon EVG stabilization

Endovascular aneurysm repair is becoming the treatment of choice for elderly patients bearing abdominal aortic aneurysms with particular anatomical characteristics. Endovascular grafts are usually oversized to achieve sealing and minimize graft migration, the likelihood of which is also reduced by fixation hooks and barbs in the newer generation grafts. Yet, upward migration of the prosthesis, potentially compromising flow to renal and splanchnic vessels, may still occur acutely and requires timely management. We describe a patient with abdominal aortic aneurysm in whom proximal migration of an endovascular graft occurred, leading to renal and mesenteric artery obstruction, which was successfully managed by means of capturing and repositioning the device with a "horse-riding" technique followed by balloon stabilization of the graft to reduce the risk of re-dislodgment during controlateral leg insertion.

[Chronic intestinal ischaemia in a younger patient]

A 46-year-old woman presented with classic symptoms. Computed tomography-angiography and duplex ultrasonography showed stenosis of the aa. mesenteria superior et inferior. The patient was moved to a university hospital and a percutaneous transluminal angioplasty with insertion of stents was performed. She was discharged shortly after feeling well.

[Intrathrombus embolization of giant mesenteric inferior artery to prevent type II endoleak]

INTRODUCTION

One of the most common complications of endovascular repair of abdominal aortic aneurysm is type II endoleak - retrograde branch flow.

CASE REPORT

A 76-year-old man with abdominal aortic aneurysm, 7.1 cm in diameter and aneurysm of the right common iliac artery, 3.2 cm in diameter was admitted to our Department with abdominal pain. The patient had no chance of having open repair of abdominal aortic aneurysm because of high perioperative risk (cardiac ejection fraction of 23%, chronic pulmonary obstructive disease). Multislice computed angiography also revealed a large inferior mesenteric artery, 6mm in diameter with the origin in thrombus of aneurysm. We decided to repair abdominal aortic aneurysm with GORE EXCLUDER stent-graft with crossed right hypogastric, but first we decided to embolize the inferior mesenteric artery. Angiography was performed through the right femoral approach and the good Riolan arcade was found. After that the inferior mesenteric artery was embolized with two coils, 5 mm in diameter, at the origin of artery in aneurysm thrombus. At the end of procedure, abdominal aortic aneurysm was repaired with GORE stent-graft, and the control angiography was performed. There was no endoleak, and the Riolan arcade was very good. The patient was discharged after 5 days. There were no signs of ischemia of the left colon, and peristaltic was excellent. Control multislice computed angiography was done after 1 and 3 months. There were no signs of endoleak. On the control colonoscopy there were no signs of ischemia of the colon.

CONCLUSION

Endovascular repair of symptomatic abdominal aortic aneurysm in high risk patients with preoperative embolization of large branch is the best choice to prevent rupture of abdominal aortic aneurysm and to prevent type II endoleak.

Mesenteric ischemia-reperfusion injury: specific impact on different cell populations within the jejunal wall in rats

The progress of jejunal damage and recovery in the course of mesenteric ischemia-reperfusion injury in rats at different time periods was investigated. Mesenteric ischemia lasting 1h followed by 1h of reperfusion caused a significant disintegration of the mucosa, reduction of the muscular layer and diminution of the wall thickness. The loss of epithelium included enterocytes, goblet cells and Paneth cells. Paradoxically, increasing numbers of serotonin-producing cells and the beginning of regenerative processes, expressed by significantly higher proliferation, were recorded in the epithelium during this period. Disintegration of connective tissue and massive degranulation of serotonin-positive cells were found in the lamina propria. After 24h of reperfusion, restitution of the mucosa was found, expressed by normal villous morphology and re-epithelialization. However, some parameters were still significantly affected even more than in the acute phase of reperfusion. In the epithelium, decreased numbers of Paneth cells and increased population of serotonin-producing cells were found. The greatest proliferation of connective tissue cells and intensified reduction of the muscular layer were also detected in this reperfusion period. After 30 days of reperfusion, moderate damage remained, but only the increased number of Paneth cells and decreased number of serotonin-producing cells in the lamina propria were significant.

Enterocolic lymphocytic phlebitis: an unusual cause of abdominal complaints

Enterocolic lymphocytic phlebitis (ELP) is a rare disease of unknown etiology involving most often the intramural and mesenteric small and medium-sized veins of the gastrointestinal tract. The diagnosis of the disorder is based on the histopathological examination of a surgical specimen as endoscopically obtained diagnostic material is usually too superficial. Clinical manifestation of ELP most frequently is characterized by acute symptoms, such as acute abdomen, signs suggesting acute appendicitis, gastrointestinal hemorrhage, sometimes it manifests as chronic gastrointestinal complaints. We report, to our knowledge for the first time in Poland, a case of ELP with clinical symptoms pointing to acute appendicitis, on laparoscopy manifesting as a tumorous mass in the colonic wall with an unchanged appendix.

[Computed tomography and CT angiography in diagnosis of acute disorders impairment of mesenteric circulation]

Presented herein is the first experience in using two instrumental methods (remote contrast- free computed tomography and CT angiography) in a total of twenty-one patients suspected of having acute mesenteric ischaemia. Contrast-free computed tomography allowed of making a correct diagnosis of acute mesenteric ischaemia in 6 of 7 patients (with sensitivity of 85.7% and specificity amounting to 90%). Thrombosis of mesenteric vessels was revealed in all cases on CT angiography, with both sensitivity and specificity of the method equalling 100%. Also described herein is the incidence rate of various CT signs of intestinal lesions depending on aetiology and the stage of the disease. Minimally invasive nature, high spatial resolution of these two methods, high sensitivity and specificity make it possible to recommend them as the first step for instrumental diagnosis of acute mesenteric ischaemia.

Elective bypass surgery for chronic mesenteric ischemic disease: report of 3 cases and review of the literature

Chronic mesenteric ischemic disease is an unusual cause of chronic abdominal pain. We present our experience from open surgical treatment of patients with this rare disease followed by a short review of the literature. During the period 2006-2008, three patients were referred to our department with clinical and radiological findings of chronic mesenteric ischemic disease. In all patients, at least 2 out of 3 splachnic vessels (celiac artery, superior and inferior mesenteric artery) were occluded, with severe stenosis of the third. Open surgical revasculation was performed in all patients, using autologous or synthetic (Dacron) bypass grafts. Graft patency was examined with triplex ultrasound studies at 3, 6 and 12 months postoperatively and/or follow up CT angiography. All patients had patent grafts during the follow up period and have regained their normal body weight. Immediate and late results, technical details and controversies in open surgical revasculation for chronic mesenteric ischemic disease are reviewed. In conclusion open surgical revasculation for chronic mesenteric ischemic disease is a technically challenging procedure with good results in patients younger than 70 years old , with long occlusions of the splachnic vessels and severe calcification of the vessel wall.

The role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia

INTRODUCTION

Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS).

METHODS

We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test.

RESULTS

68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS.

CONCLUSIONS

These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain.

[Acute superior mesenteric ischemia: a contrast study on short-and mid-term result between stent implantation and pharmaceutical thrombolysis]

OBJECTIVE

To compare the short-term and medium-term result of stent implantation with pharmaceutical thrombolysis in patients with acute superior mesenteric artery occlusion.

METHODS

From January, 2004 to December, 2008, thirty-five patients diagnosed acute superior mesenteric ischemia, 12 patients treated with stent implantation (interventional therapy group) and 23 patients with pharmaceutical thrombolysis (thrombolytic therapy group). Interventional therapy group treated with balloon dilatation and stent implantation assisted with anticoagulation, antiplatelet and vascular dilation agents. Thrombolytic therapy group used urokinase combined with anticoagulation, antiplatelet and vascular dilation agents. All patients had taken clopidogrel and aspirin orally after discharged and followed up. The clinical effects of both groups were evaluated separately and the Fisher exact test was used to analysis the significant differences.

RESULTS

In the 23 cases of thrombolytic therapy group, 7 cases was effective, 16 cases was ineffective (7 cases aggravated or died, 9 cases turn to surgical operation). In the 12 cases of interventional therapy group, 10 cases treated with stent implantation (1 case died of acute cardiac infarction 3 days after interventional operation), 2 cases failed in recanalizing. All patients were followed up after discharged (range 1 - 48 months, mean 15 ± 12 months), 1 case in thrombolytic therapy group was stable, 6 cases died of the recurrence of acute superior mesenteric artery occlusion; 7 cases in interventional therapy group was stable, 1 case died of acute cardiac infarction 20 months after interventional operation (intestinal ischemia not appeared), 1 case had intestinal ischemia reoccurred and recovered by superior mesenteric artery thrombolysis.

CONCLUSIONS

In the treatment of acute superior mesenteric ischemia, stent implantation was obviously superior to pharmaceutical thrombolysis in improving intestinal ischemia and survival, therefore it could provided a reliable choice for the patients who had not appeared intestinal necrosis.

Semapimod a new pretreatment modality of acute intestinal ischemia-reperfusion syndrome: experimental study in rabbits

AIM

Semapimod is an experimental drug that strongly inhibits macrophages and stimulates the cholinergic anti-inflammatory pathway. The aim of this study was to evaluate the effect of semapimod on experimentally-induced acute intestinal ischemia-reperfusion syndrome in rabbits.

METHODS

The experimental protocol included 16 adult male White New Zealand rabbits divided into two equal groups, A and B. Animals were subjected to 150 min of intestinal ischemia, followed by 30 min of reperfusion. At 30, 90 and 150 min after the onset of ischemia the animals in group A received i.v. placebo (2 mg/kg; Cytokine PharmaSciences Inc, PA, USA) and those of group B received i.v. semapimod (2 mg/kg; Cytokine PharmaSciences Inc, PA, USA). Blood samples were taken for plasma measurements of tumor necrosis factor-a (TNF-a), interleukin 1β (IL-1β) and interleukin 6 (IL-6) at 0, 60, 120 and 180 min after the onset of ischemia. At the same time points, wedge intestinal biopsies were taken for histopathological evaluation of mucosal injury. All data were analyzed by the non-parametric Mann-Whitney test as appropriate. The power effect of Semapimod was evaluated by mixed between-within Anova statistical analysis.

RESULTS

Measurements of TNF-a and IL-1β levels showed significant differences between groups A and B at 120 min (P=0.004 and P=0.003 respectively) and at 180 min (P=0.001 and p<0.005 respectively). IL-6 values were lower in animals of group B but the differences were not significant. Intestinal mucosal injuries were significantly milder in animals of group B at 120 and 180 min

CONCLUSION

Semapimod minimized intestinal mucosa injury and reduced the systemic inflammatory response during acute intestinal ischemia-reperfusion. Further studies are required to investigate the possible value of semapimod as a new pretreatment modality in acute vascular abdomen.

Diagnosis and treatment of abdominal angina

Abdominal angina refers to abdominal pain in which perfusion to digestive tissues has been compromised, usually due to mesenteric atherosclerosis. Pathology can progress to necrosis of vital viscera, sepsis, or even death. Practitioners need to be aware of this serious medical condition, especially in the ever-growing elderly population.

A case of phlebosclerotic colitis with involvement of the entire colon

Phlebosclerotic colitis is a rare type of ischemic colitis caused by obstruction of the veins in the intestinal wall and adjacent mesentery, and is most commonly seen in the ascending colon. We report a 56-year-old woman presenting with intermittent abdominal pain and diarrhea for three years. She had a liver abscess and two episodes of pancreatitis during this time and experienced progressive body weight loss. Initial radiologic findings showed multiple tortuous threadlike calcifications in the region of the right side of the colon and transverse colon on plain abdominal radiographs and computed tomography images. A colonoscopy demonstrated brownish-black pigmentation on the right side of the colon with scattered hyperemic patches. The more distal along the colon, the more normal the color of the bowel appeared. Follow-up studies revealed calcifications not only alongside the colonic and mesenteric veins, but also extending into the superior and inferior mesenteric veins. These findings have not been reported previously. As noted in our patient, this disease entity may not be confined to the tributaries of the superior mesenteric vein. The entire colon may be involved in advanced disease.

Therapeutic distant organ effects of regional hypothermia during mesenteric ischemia-reperfusion injury

INTRODUCTION

Mesenteric ischemia-reperfusion injury (IRI) leads to systemic inflammation and multiple organ failure in clinical and laboratory settings. We investigated the lung structural, functional, and genomic response to mesenteric IRI with and without regional intraischemic hypothermia (RIH) in rodents and hypothesized that RIH would protect the lung and preferentially modulate the distant organ transcriptome under these conditions.

METHODS

Sprague-Dawley rats underwent sham laparotomy or superior mesenteric artery occlusion (SMAO) for 60 minutes with or without RIH. Gut temperature was maintained at 15°-20°C during SMAO, and systemic normothermia (37°C) was maintained throughout the study period. At 6 or 24 hours, lung tissue was collected for (1) histology, (2) myeloperoxidase activity, (3) bronchoalveolar lavage (BAL) fluid protein concentrations, (4) lung wet/dry ratios, and (5) total RNA isolation and hybridization to Illumina's Sentrix BeadChips (>22,000 probes) for gene expression profiling. Significantly affected genes (false discovery rate <5% and fold change ≥1.5) were linked to gene ontology (GO) terms using MAPPFinder, and hypothermia-suppressed genes were further analyzed with Pubmatrix.

RESULTS

Mesenteric IRI-induced lung injury, as evidenced by leukocyte trafficking, alveolar hemorrhage, and increased BAL protein and wet/dry ratios, and activated a proinflammatory lung transcriptome compared with sham. In contrast, rats treated with RIH exhibited lung histology, BAL protein, and wet/dry ratios similar to sham. At 6 hours, GO analysis identified 232 hypothermia-suppressed genes related to inflammation, innate immune response, and cell adhesion, and 33 hypothermia-activated genes related to lipid and amine metabolism and defense response. Quantitative real-time polymerase chain reaction validated select array changes in top hypothermia-suppressed genes lipocalin-2 (lcn-2) and chemokine ligand 1 (CXCL-1), prominent genes associated with neutrophil activation and trafficking.

CONCLUSIONS

Therapeutic hypothermia during SMAO provides distant organ protection and preferentially modulates the IRI-activated transcriptome in the rat lung. This study identifies potential novel diagnostic and therapeutic targets of mesenteric IRI and provides a platform for further mechanistic study of hypothermic protection at the cellular and subcellular level.

Successful treatment in superior mesenteric artery embolism: a case report and literature review

The authors report a successful management of acute superior mesenteric artery embolism in a patient during the treatment of popliteal artery embolism. The diagnosis of this disease was confirmed by computerized tomographic angiography. Immediate surgical embolectomy and bowel resection were performed and postoperatively, he made an uneventful recovery except for minimal watery diarrhea for one week. In the present report the authors also review the in-patient records at Siriraj Hospital during 2005-2009 consisting of 14 cases with the claim diagnosis of this condition. Most of the patients developed peritonism on abdominal examinations showing a delay in diagnosis. The mortality rate was 86% (12 cases) which was higher than international reports. It is important to note that patients presenting with abdominal pain with underlying risk factors of arterial embolism is the clue in early diagnosis of this condition. CTA mesenteric artery is the most appropriate investigation to visualize the presence of embolism. Finally, immediate revascularization treatment is essential in the successful management of this fatal vascular problem.

[Multidetector-row CT evaluation of acute bowel ischemia induced by embolization of superior mesenteric artery in experimental porcine models]

OBJECTIVE

To evaluate the application of multi-detector row CT (MDCT) and CT angiography (CTA) for detecting early signs of acute bowel ischemia (ABI) in experimental porcine models.

METHODS

Twelve pigs were assigned to four groups with 3 in each group. The digital subtraction angiography of superior mesenteric artery (SMA) and the embolization of branches of SMA with gelatin sponge and blood clot were performed by percutaneous transfemoral artery puncture and catheterization. MDCT pre- and post-contrast scanning in the arterial, venous and delay phase and CTA with three-dimensional reconstruction were carried out at pre-operation, 3 h, 6 h, 9 h, and 12 h after occlusion. The normal mesenteric vascular anatomy, arterial occlusion, mesentery and bowel changes, and dynamic change were evaluated.

RESULTS

ABI changes were identified pathologically in all the 12 experimental pigs, and the severity of ischemia increased over time after embolization. CTA showed all 57 embolized branches of SMA and 29 of 34 unoccluded arterial branches with 5 false-positive vessel occlusions. The sensitivity and specificity of CTA were 100% and 85.3%, respectively. Thin-slab maximum intensity projection (TSMIP) revealed the disappearance of distal comb-like vessel branches and brush-like vasa recta, which were clearly delineated in the normal bowel segments. Using this criterion, TSMIP correctly defined 23 of 24 ischemic bowel segments and all the 12 normal bowel segments with a sensitivity of 95.8% and a specificity of 100%.

CONCLUSIONS

MDCT and CTA reliably define normal and occluded mesenteric vessels in the pig. It can easily detect ischemic bowel segment by identified early changes of ischemia. The early direct ischemic signs are occluded vessels, the disappearance of distal comb-like branches or brush-like vasa recta, and poor bowel enhancement. The early indirect sign is bowel dilatation with fluid collection.