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.

Simultaneous Compression of the Celiac Trunk, Superior Mesenteric Artery, and Renal Arteries by the Median Arcuate Ligament: About One Case

Median arcuate ligament syndrome (MALS), is a rare abdominal vascular compression syndrome caused by the compression of the proximal celiac trunk by the median arcuate ligament. According to many authors, a low insertion of the diaphragmatic crura or an abnormally high origin of the celiac trunk from the aorta can cause compression of the celiac artery. Usually, patients with MALS are asymptomatic. Computed tomography (CT) angiography of the abdomen is the main imaging modality to confirm the diagnosis. The coexistence of celiac trunk and superior mesenteric artery compression by the median arcuate ligament is rarely described in the literature. To our knowledge, until now, a simultaneous combination of three abdominal vascular compressions by the median arcuate ligament has never been described. From this case, we report a simultaneous compression of the celiac trunk, superior mesenteric artery, and renal arteries by the median arcuate ligament.

Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome:Two case reports and review of literature

BACKGROUND Superior mesenteric artery(SMA)syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta(SMA-Ao).Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome,individual variations in the optimal patient position have been noted.In this report,we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient.CASE SUMMARY Case 1:A 90-year-old man with nausea and vomiting.Following diagnosis of SMA syndrome by computed tomography(CT),ultrasonography(US)revealed the SMA-Ao distance in the supine position(4 mm),which slightly improved in the lateral position(5.7–7.0 mm)without the passage of duodenal contents.However,in the sitting position,the SMA-Ao distance was increased to 15 mm accompanied by improved content passage.Additionally,US indicated enhanced passage upon abdominal massage on the right side.By day 2,the patient could eat comfortably with the optimal position and massage.Case 2:An 87-year-old woman with vomiting.After the diagnosis of SMA syndrome and aspiration pneumonia by CT,dynamic US confirmed the optimal position(SMA-Ao distance was improved to 7 mm in forward-bent position,whereas it remained at 5 mm in the supine position).By day 7 when her pneumonia recovered,she could eat with the optimal position.CONCLUSION The optimal position for SMA syndrome varies among individuals.Dynamic US appears to be a valuable tool in improving patient outcomes.

Emergency rescue of a patient with hemorrhagic shock caused by superior mesenteric artery rupture:A case report

BACKGROUND Superior mesenteric artery(SMA)injuries rarely occur during blunt abdominal injuries,with an incidence of<1%.The clinical manifestations mainly include abdominal hemorrhage and peritoneal irritation,which progress rapidly and are easily misdiagnosed.Quick and accurate diagnosis and timely effective treatment are greatly significant in managing emergent cases.This report describes emergency rescue by a multidisciplinary team of a patient with hemorrhagic shock caused by SMA rupture.CASE SUMMARY A 55-year-old man with hemorrhagic shock presented with SMA rupture.On admission,he showed extremely unstable vital signs and was unconscious with a laceration on his head,heart rate of 143 beats/min,shallow and fast breathing(frequency>35 beats/min),and blood pressure as low as 20/10 mmHg(1 mmHg=0.133 kPa).Computed tomography revealed abdominal and pelvic hematocele effusion,suggesting active bleeding.The patient was suspected of partial rupture of the distal SMA branch.The patient underwent emergency mesenteric artery ligation,scalp suture,and liver laceration closure.In view of conditions with acute onset,rapid progression,and high bleeding volume,key points of nursing were conducted,including activating emergency protocol,opening of the green channel,and arranging relevant examinations with various medical staff for quick diagnosis.The seamless collaboration of the multidisciplinary team helped shorten the preoperative preparation time.Emergency laparotomy exploration and mesenteric artery ligation were performed to mitigate hemorrhagic shock while establishing efficient venous accesses and closely monitoring the patient’s condition to ensure hemodynamic stability.Strict measures were taken to avoid intraoperative hypothermia and infection.CONCLUSION After 3.5 h of emergency rescue and medical care,bleeding was successfully controlled,and the patient’s condition was stabilized.Subsequently,the patient was transferred to the intensive care unit for continuous monitoring and treatment.On the sixth day,the patient was weaned off the ventilator,extubated,and relocated to a specialized ward.Through diligent medical intervention and attentive nursing,the patient made a full recovery and was discharged on day 22.The follow-up visit confirmed the patient’s successful recovery.

Superior Mesenteric Artery Syndrome, a Rare Complication of Severe Malnutrition: Two Cases from a Subsaharian Endocrinology Department

Introduction: Superior mesenteric artery syndrome (SMAS), a rare diagnosis due to compression of the third duodenum between the superior mesenteric artery (SMA) and the aorta resulting in bowel obstruction, may lead to severe malnutrition. We report two cases of patients hospitalised in the Internal Medicine, Endocrinology, Diabetology, and Nutrition Department of the National Hospital Center (NHC) of Pikine. Observations: Patient 1: A 35-year-old female was referred for an aetiological diagnosis due to a rapid weight loss of 15 kilograms in one month, accompanied by persistent vomiting, following an appendectomy performed a month before admission. Upon clinical examination, she presented severe malnutrition (Buzby index of 76%), early post-prandial chronic vomiting, and a poor general condition. An abdominal CT scan revealed aortomesenteric clamp syndrome (AMCS) with an angulation between the aorta and the SMA of 13˚. The underlying cause in this patient was severe malnutrition. Fortunately, her condition improved with medical treatment. Patient 2: We report the case of a 30-year-old female hospitalized due to unusual weight-bearing post-prandial epigastric pain and intermittent vomiting over the past six months. Upon physical examination at admission, she exhibited severe malnutrition with a body mass index (BMI) of 14 kg/m2, a Buzby index of 71%, trophic disorders, and a stage IV general condition assessment according to the World Health Organization (WHO). An abdominal CT scan revealed AMCS with an angle between the aorta and the SMA of 22˚ and an aortomesenteric space of 4 mm. The outcome was poor with medical treatment failure and, unfortunately, the patient died before surgery. Conclusion: SMAS is rarely evoked in clinical practice despite the presence of contributing factors and suggestive clinical signs. The prognosis depends on management time.

Isolated superior mesenteric artery dissection:An updated review of the literature

Isolated superior mesenteric artery dissection(ISMAD)is a rare but potentially life-threatening cause of acute abdominal pain.Owing to the availability of computed tomography angiography,more cases have been detected during screening for acute abdomen in recent years.With increasing knowledge of ISMAD,a better management strategy is being developed.To enhance our understanding and improve treatment outcomes of ISMAD,a systematic literature review was conducted with a focus on diagnosis and management strategies based on existing evidence.

Comprehensive interventions for adult cyclic vomiting syndrome complicated by superior mesenteric artery syndrome:A case report

BACKGROUND Cyclic vomiting syndrome(CVS)is a chronic functional gastrointestinal disorder involving the gut–brain interaction that is characterized by recurring episodes of nausea,vomiting,abdominal pain,and interspersed complete normal periods.Superior mesenteric artery(SMA)syndrome(SMAS)is a vascular condition in which the horizontal portion of the duodenum is compressed due to a reduced angle between the aorta and the SMA.This condition presents with symptoms similar to CVS,posing challenges in distinguishing between the two and often resulting in misdiagnosis or inappropriate treatment.CASE SUMMARY A 20-year-old female patient presented with recurrent episodes of vomiting and experienced a persistent fear of vomiting for the past 2 years.She adopted conscious dietary restrictions,which led to severe malnutrition.Initially,she was diagnosed with SMAS,as revealed by computed tomography angiography.Despite efforts to increase the angle between the aorta and the SMA through weight gain,her vomiting did not improve.Finally,she was diagnosed with comorbidities including CVS,SMAS and anxiety disorder.She underwent comprehensive interventions,including enteral and parenteral nutritional supplementation,administration of antiemetic and anti-anxiety agents,and participation in mindfulness-based cognitive therapy.The patient eventually experienced a notable improvement in both body weight and clinical symptoms.CONCLUSION We present a rare case of CVS in an adult complicated with SMAS and propose additional treatment with nutritional support,pharmacological intervention,and psychotherapy.

Successful recanalization of chronic total occlusion of the superior mesenteric artery by transradial approach

It is a challenge to confirm chronic mesenteric ischemia(CMI) as a cause of gastrointestinal(GI) symptoms such as postprandial epigastric bloating,anorexia,and debilitating weight loss.Endovascular intervention for CMI has been gaining popularity because of the high morbidity associated with surgical revascularization.However,in EVI for superior mesenteric artery(SMA) occlusion,the transfemoral approach is limited by difficulty in coaxial alignment of the guiding catheter,which leads to insufficient back-up support.Herein,we report on a 58-year-old male patient with chronic total occlusion of the SMA,which was successfully revascularized by endovascular intervention via the left radial artery.Transradial endovascular therapy may be another treatment option for the treatment of CMI.

Abdominal Aortic Aneurysm Repair in a Patient with Superior Mesenteric Artery Occlusion with Transient Intraoperative Infusion of the Inferior Mesenteric Artery: A Surgical Case Report

Abdominal aortic aneurysms (AAA) with mesenteric artery stenosis or obstructive lesions are occasionally recognized. While performing the graft replacement operation in such cases, if the collateral circulation supplying the gastrointestinal tract is well developed, it is necessary that this collateral circulation should be well perfused during aortic cross-clamping. A 72-year-old woman was admitted because of expansion of AAA. Computed tomography (CT) scan examination revealed occlusion at the origin of the superior mesenteric artery (SMA) and the development of a collateral circulatory pathway via the inferior mesenteric artery (IMA). During this operation, a vein cannula was placed in the IMA, through which blood was supplied with an extension tube for the protection of the intra-abdominal organs. The IMA was reimplanted after the graft replacement. Previous reports indicate that intestinal ischemia may be successfully prevented by supplying blood to the collateral circulation using various techniques. We report the surgical approach for treatment of AAA using a simple and convenient method to maintain intra-operative blood supply to vital organs.

How to deal with right hepatic artery coming from the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review

Background: Anatomical variations in the liver arterial supply are quite common and can affect the surgical strategy when performing a minimally invasive pancreaticoduodenectomy(MIPD). Their presence must be preemptively detected to avoid postoperative liver and biliary complications. Data sources: Following the PRISMA guidelines and the Cochrane protocol we conducted a systematic review on the management of an accessory or replaced right hepatic artery(RHA) arising from the superior mesenteric artery when performing an MIPD. Results: Five studies involving 118 patients were included. The most common reported management of the aberrant RHA was conservative(97.0%);however, patients undergoing aberrant RHA division without reconstruction did not develop liver or biliary complications. No differences in postoperative morbidity or long-term oncological related overall survival were reported in all the included studies when comparing MIPD in patients with standard anatomy to those with aberrant RHA. Conclusions: MIPD in patients with aberrant RHA is feasible without increase in morbidity and mortality. As preoperative strategy is crucial, we suggested planning an MIPD with an anomalous RHA focusing on preoperative vascular aberrancy assessment and different strategies to reduce the risk of liver ischemia.

Causes of epigastric pain and vomiting after laparoscopic-assisted radical right hemicolectomy-superior mesenteric artery syndrome

BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition causing functional obstruction of the third portion of the duodenum.Postoperative SMAS following laparoscopic-assisted radical right hemicolectomy is even less prevalent and can often be unrecognized by radiologists and clinicians.AIM To analyze the clinical features,risk factors,and prevention of SMAS after laparoscopic-assisted radical right hemicolectomy.METHODS We retrospectively analyzed clinical data of 256 patients undergoing laparoscopicassisted radical right hemicolectomy in the Affiliated Hospital of Southwest Medical University from January 2019 to May 2022.The occurrence of SMAS and its countermeasures were evaluated.Among the 256 patients,SMAS was confirmed in six patients(2.3%)by postoperative clinical presentation and imaging features.All six patients were examined by enhanced computed tomography(CT)before and after surgery.Patients who developed SMAS after surgery were used as the experimental group.A simple random sampling method was used to select 20 patients who underwent surgery at the same time but did not develop SMAS and received preoperative abdominal enhanced CT as the control group.The angle and distance between the superior mesenteric artery and abdominal aorta were measured before and after surgery in the experimental group and before surgery in the control group.The preoperative body mass index(BMI)of the experimental group and the control group was calculated.The type of lymphadenectomy and surgical approach in the experimental and control groups were recorded.The differences in angle and distance were compared preoperatively and postoperatively in the experimental group compared.The differences in angle,distance,BMI,type of lymphadenectomy and surgical approach between the experimental and control groups were compared,and the diagnostic efficacy of the significant parameters was assessed using receiver operating characteristic curves.RESULTS In the experimental group,the aortomesenteric angle and distance after surgery were significantly decreased than those before surgery(P<0.05).The aortomesenteric angle,distance and BMI were significantly higher in the control group than in the experimental(P<0.05).There was no significant difference in the type of lymphadenectomy and surgical approach between the two groups(P>0.05).CONCLUSION The small preoperative aortomesenteric angle and distance and low BMI may be important factors for the complication.Over-cleaning of lymph fatty tissues may also be associated with this complication.

Clinical outcomes of transcatheter selective superior mesenteric artery urokinase infusion therapy vs transjugular intrahepatic portosystemic shunt in patients with cirrhosis and acute portal vein thrombosis

AIM To compare the outcomes of transcatheter superior mesenteric artery(SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt(TIPS) for acute portal vein thrombosis(PVT) in cirrhosis.METHODS From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapyand TIPS, respectively. The total follow-up time was24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound.Secondary outcomes were rebleeding and hepatic encephalopathy.RESULTS A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17(85%) patients in the SMA group and 14(70%) patients in the TIPS group. The main portal vein(MPV) thrombosis was significantly reduced in both groups(P < 0.001), and there was no significant difference between them(P= 0.304). In the SMA group, superior mesenteric vein(SMV) thrombosis and splenic vein(SV) thrombosis were significantly reduced(P = 0.048 and P = 0.02),which did not occur in the TIPS group. At 6-, 12-,and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%,and 60%, respectively(P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%,respectively(P = 0.022).CONCLUSION Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.

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.

Mesenteric lymph reperfusion may exacerbate brain injury in a rat model of superior mesenteric artery occlusion shock

BACKGROUND：The intestinal lymphatic pathway and intestinal ischemia/reperfusion are mainly involved in mesenteric lymph duct ligation or drainage; moreover,intervention by reducing the lymph liquid reflux might relieve lung and other organ dysfunction induced by intestinal ischemia/reperfusion; however,research addressing mesenteric lymph reperfusion （MLR） and brain injury has not yet to be reported.OBJECTIVE：To observe the effect of MLR on brain tissue in a rat model of superior mesenteric artery occlusion （SMAO） shock,and to explore the molecular mechanism of MLR.DESIGN,TIME AND SETTING：A randomized,controlled,animal experiment at a neuro-pathophysiology level was performed at the Institute of Microcirculation,Hebei North University; Department of Pathophysiology,Basic Medical College; Department of Pathology,the First Hospital of Hebei North University between December 2007 and March 2009.MATERIALS：Adenosine triphosphate （ATP） standard was provided by the National Institute for the Control of Pharmaceutical and Biological Products; lactic acid （LA）,superoxide dismutase （SOD）,malonaldehyde （MDA）,nitrogen monoxidum （NO）,nitric oxide synthase （NOS）,myeloperoxidase （MPO） and ATPase assay kits were provided by Nanjing Jiancheng Bioengineering Institute,China.METHODS：A total of 24 male Wistar rats were randomly divided into four groups.In the sham-surgery group （n = 6）,both the mesenteric lymph duct and the superior mesenteric artery were not blocked; in the MLR group （n = 6）,the mesenteric lymph duct was occluded for 1 hour followed by 2-hour reperfusion; in the SMAO group （n = 6）,the superior mesenteric artery was occluded for 1 hour followed by 2-hour reperfusion; in the MLR ＋ SMAO group （n = 6）,both the mesenteric lymph duct and superior mesenteric artery were occluded for 1 hour followed by 2-hour reperfusion.MAIN OUTCOME MEASURES：Mean arterial blood pressure prior to and following ischemia/reperfusion; brain tissue morphology levels of LA,MDA,SOD,NO,NOS,MPO,ATPase and ATP following reperfusion.RESULTS：MLR did not cause changes in mean arterial blood pressure,brain tissue morphology,LA,MDA,NO,ATP,SOD,NOS,MPO and ATPase.However,SMAO caused a rapid decrease and gradual increase of mean arterial blood pressure.Neuronal necrosis,degeneration and swelling were observed in brain tissue.Contents of MDA,NO,LA and ATP as well as activities of NOS and MPO were significantly increased （P〈 0.05）,but activities of SOD and Na＋-K＋-ATPase were significantly decreased （P 〈 0.05）.MLR aggravated neuronal damage in a rat model of SMAO shock.Following MLR,mean arterial blood pressure was significantly decreased （P 〈 0.05）,contents of MDA and NO as well as activities of NOS and MPO were significantly increased （P 〈0.05）,but activities of Ca2＋-ATPase,Mg2＋-ATPase and Ca2＋-Mg2＋-ATPase as well as ATP content were significantly decreased （P〈 0.05）.CONCLUSION：MLR aggravates brain injury in a rat model of SMAO shock,which correlates with oxygen-derived free radical injury,NO synthesis and release,sequestration of neutrophilic granulocytes,decreasing activity of cell membrane pumps and energy metabolism dysfunction.Pathogenesis of the intestinal lymphatic pathway should be thoroughly investigated to prevent ischemia/reperfusion injury.

Influence of mesenteric lymph reperfusion on neurotransmitter expression in brain tissue of a superior mesenteric artery occlusion shock rat model

BACKGROUND： Previous studies have shown that mesenteric lymph reperfusion （MLR） exacerbates brain injury in a rat model of superior mesenteric artery occlusion （SMAO） shock. However, little is known about the influence of MLR on neurotransmitter expression in brain tissue. OBJECTIVE： To observe the effect of MLR on brain tissue injury by measuring monoamine and cholinergic neurotransmitter levels. DESIGN, TIME AND SETTING： A randomized, controlled, animal experiment was performed at the Institute of Microcirculation, Hebei North University, China; Research Room of Microcirculation and Laboratory of Biochemistry, Department of Pathophysiology, Basic Medical College, Hebei North University between December 2007 and March 2009. MATERIALS： Choline acetyltransferase （CHAT） and acetylcholine esterase （ACHE） kits were provided by Nanjing Jiancheng Bioengineering Institute, China; dopamine （DA） and noradrenalin （NE） standards were provided by the National Institute for the Control of Pharmaceutical and Biological Products; HP1100 chromatograph of liquid was provided by Agllent, USA. METHODS： A total of 24 male, Wistar rats were randomly assigned to 4 groups： sham-surgery, MLR SMAO, and MLR ＋ SMAO groups, with 6 rats in each group. In the MLR or SMAO groups, the mesenteric lymph duct or superior mesenteric artery was blocked for 1 hour. In the MLR ＋ SMAO group, the mesenteric lymph duct and superior mesenteric artery were occluded for 1 hour, followed by 2-hour repeffusion. ChAT and AChE levels were measured using the synthesized and hydrolyzed acetylcholine method, respectively. Liquid chromatography was employed to quantitatively analyze DA and NE levels, using relative retention time and the external standard method. MAIN OUTCOME MEASURES： CHAT, ACHE, DA, and NE levels. RESULTS： AChE levels were significantly increased, but ChAT levels were significantly decreased in the MLR and MLR ＋ SMAO groups following 2-hour repeffusion （P〈 0.01）. However, AChE activity in the MLR ＋ SMAO group was greater than in the MLR group （P 〈 0.05）. DA and NE levels were significantly decreased in the SMAO and MLR ＋ SMAO groups （P〈 0.01）, while DA levels in the MLR ＋ SMAO group were less than in the SMAO group （P 〈 0.05）. CONCLUSION： MLR exacerbated brain injury in a rat model of SMAO shock, which correlated with the intestinal lymphatic pathway. MLR decreased DA levels, but increased AChE activity, in a rat model of SMAO shock.

Successful recanalization of acute superior mesenteric artery thrombotic occlusion with primary aspiration thrombectomy

Prompt revascularization of the superior mesenteric artery(SMA) thrombotic occlusion can prevent intestinal infarction and decrease necrosis of the bowel segment.Herein,we describe two cases who underwent successful endovascular recanalization for acute SMA thrombosis using a primary aspiration thrombectomy because of possible consequent laparotomy for survey of bowel viability.The two patients had dramatic pain reliefimmediately after the procedure and remained symptomfree during the follow-up period.

The ratio of superior mesenteric artery diameter to superior mesenteric vein diameter based on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection

BACKGROUND:Spontaneous isolated superior mesenteric artery(SMA)dissection(SISMAD)is a rare cause of abdominal pain.The aim of the study is to investigate the role of a new parameter,the ratio of the SMA diameter to the superior mesenteric vein(SMV)diameter(SMA/SMV)based on non-enhanced computed tomography(CT),in the early diagnosis of SISMAD.METHODS:In a registry study from December 2013 to June 2021,97 abdominal pain SISMAD patients(SISMAD group)admitted to our hospital were enrolled.Meanwhile,the matched sex and age abdominal pain non-SISMAD patients at 1:2 were collected in reverse chronological order as the control group.Student’s t-test,Wilcoxon rank-sum test,and Chi-square test were used to compare differences between the SISMAD and control groups.Med Calc was used to generate receiver operating characteristic(ROC)curve.RESULTS:A total of 291 abdominal pain patients,including 97 SISMAD patients and 194 nonSISMAD patients,were included in the current study.The maximum SMA diameter,perivascular exudation,and SMA/SMV based on non-enhanced CT were significant between the two groups(all P<0.05).ROC curves showed that for the maximum SMA diameter,the area under the curve(AUC),cut-off,sensitivity,and specificity were 0.926,9.80,93.8%,and 79.4%,respectively.For SMA/SMV,its AUC,cut-off,sensitivity,and specificity were 0.956,0.83,88.7%,and 92.3%,respectively.The diagnostic efficiency of SMA/SMV was better than that of the maximum SMA diameter(P<0.05).The combined parameters of SMA/SMV and maximum SMA diameter had the best diagnostic efficiency(AUC=0.970).CONCLUSION:SMA/SMV may be a potential marker for SISMAD.

Superior mesenteric artery syndrome:Diagnosis and management

Superior mesenteric artery(SMA)syndrome(also known as Wilkie's syndrome,cast syndrome,or aorto-mesenteric compass syndrome)is an obstruction of the duodenum caused by extrinsic compression between the SMA and the aorta.The median age of patients is 23 years old(range 0-91 years old)and predominant in females over males with a ratio of 3:2.The symptoms are variable,consisting of postprandial abdominal pain,nausea and vomiting,early satiety,anorexia,and weight loss and can mimic anorexia nervosa or functional dyspepsia.Because recurrent vomiting leads to aspiration pneumonia or respiratory depression via metabolic alkalosis,early diagnosis is required.The useful diagnostic modalities are computed tomography as a standard tool and ultrasonography,which has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage.The initial treatment is usually conservative,including postural change,gastroduodenal decompression,and nutrient management(success rates:70%-80%).If conservative therapy fails,surgical treatment(i.e.,laparoscopic duodenojejunostomy)is recommended(success rates:80%-100%).

Value of Multi-detector CT in Detection of Isolated Spontaneous Superior Mesenteric Artery Dissection

Objective To investigate the role of multi-detector computed tomography(CT) in the diagnosis and classification of isolated spontaneous superior mesenteric artery dissection(ISSMAD). Methods From July 2012 to December 2016,30 consecutive patients with ISSMAD underwent CT scan at least two times. We retrospectively summarized the clinical characteristics and CT findings of them. The stenosis ratio of true lumen was compared between the patients without bowel ischemia and ones with bowel ischemia. Results There were 5 cases of type I ISSMAD,14 cases of type Ⅱ,1 case of type Ⅲ,7 cases of type Ⅳ and 3 cases of type V. Intestinal ischemia occurred in 5 patients. The stenosis ratio of true lumen in the patients without bowel ischemia was lower than that with bowel ischemia(45.6% vs. 76.0%,t=–14.5,P=0.000). Five patients with intestinal ischemia underwent superior mesenteric artery stenting and others received conservative therapy. The abdominal pain was alleviated for all the patients after treatment. Follow-up was complete in 30 cases. Follow-up CT angiography of superior mesenteric artery showed dissection remodeling in 12 patients. Conclusion Multi-detector CT is a valuable method in diagnosis and classification of ISSMAD and monitoring the changes of dissection.

Management of isolated superior mesenteric artery dissection

AIM: To evaluate our experience of the clinical management of spontaneous isolated superior mesenteric artery dissection (ISMAD).