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Pancreaticoduodenectomy (Whipple's procedure) is a technically demanding operation performed for malignant and premalignant conditions of the pancreatic head, duodenum and bile duct. Awareness of the vascular anatomy, variations, and pathology of this area is essential to achieve safe surgery and good outcomes. The operation involves division of the gastroduodenal artery (GDA) which provides communication between the foregut and midgut blood supply. In patients with coeliac or superior mesenteric artery (SMA) stenosis, this can lead to reduced blood supply to the foregut or midgut organs, with consequent severe ischaemic complications leading to significant morbidity and mortality. Coeliac artery stenosis is caused by median arcuate ligament syndrome (MALS) in the majority of patients with atherosclerosis being the second most common cause. SMA stenosis is much less common and is caused in the majority of cases by atherosclerosis. A review of preoperative imaging and intraoperative gastroduodenal artery clamp test is important to identify cases that may need additional procedures to preserve the blood supply. In this paper, we present a literature review for studies reporting patients undergoing Whipple's operation with concomitant coeliac axis stenosis (CAS) or SMA stenosis. Analysis of causes of stenosis or occlusion, prevalence, risk factors, different management strategies and outcomes was conducted.
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INTRODUCTION: Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings. METHODS: A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review. RESULTS: Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients. CONCLUSION: Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.
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Embolización Terapéutica , Procedimientos Endovasculares , Humanos , Embolización Terapéutica/métodos , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Procedimientos Endovasculares/métodos , Arteria Celíaca/diagnóstico por imagen , Aneurisma/diagnóstico por imagen , Aneurisma/terapia , Anciano , Duodeno/irrigación sanguínea , Duodeno/diagnóstico por imagen , Adulto , Páncreas/irrigación sanguínea , Páncreas/diagnóstico por imagen , Resultado del Tratamiento , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/terapiaRESUMEN
Introduction: Coeliac artery aneurysms are rare and have a high mortality rate when ruptured. Although they are often asymptomatic, treatment is recommended for patients with true coeliac aneurysms >2.5 cm, noted enlargement, or associated symptoms. Less invasive endovascular treatment is predominantly performed for coeliac artery aneurysms, while open surgery is preferred for patients with compression symptoms. Here, a case of symptomatic giant coeliac artery aneurysm that was successfully treated with hybrid surgery is reported. Report: A 73 year old man was referred with continuous epigastric discomfort and loss of appetite for two weeks. Abdominal ultrasound and computed tomography revealed a 12 cm aneurysm of the coeliac artery. The splenic and common hepatic arteries were severely distorted and compressed by the aneurysm, making their origins unclear. Considering the risk of rupture, semi-urgent surgery was performed with interruption of the inflow and outflow arteries using open and endovascular techniques together with aneurysmorrhaphy. Vascular reconstruction was omitted because abundant collateral flow to the liver and spleen was confirmed on angiography. Discussion: With the hybrid approach, aneurysmorrhaphy was performed safely with minimal incision and dissection. Short term outcomes were satisfactory, with complete resolution of compression symptoms and remarkable sac shrinkage at 12 months. Owing to the possibility of the pancreaticoduodenal arcade developing as a collateral pathway, periodic surveillance for de novo aneurysms is warranted.
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OBJECTIVE: To report outcomes following open or endovascular treatment of true hepatic and coeliac artery aneurysms at a single referral centre. METHODS: This was a retrospective cohort study of consecutive patients treated for true hepatic and coeliac artery aneurysms between May 2002 and December 2021. Outcome measures included complications, graft patency, and survival rate. RESULTS: Overall, 84 patients were included with a median age of 63 years (interquartile range 55, 79). The majority (76%) of the patients were men. Frequent comorbidities included a history of tobacco (69%), hypertension (65%), hyperlipidaemia (32%), and diabetes (15%). Multiple synchronous aneurysms were detected in 22 patients (26%). There were 33 (39%) symptomatic aneurysms (abdominal pain without rupture [n = 18], rupture [n = 10], and sepsis [n = 5]). Seventeen patients (20%) had mycotic aetiology. Fifty patients (60%) underwent endovascular treatment with either covered stent placement (n = 29) or coil embolisation (n = 21), and 34 patients (40%) were treated with open surgery using allogenic iliac artery (n = 15), autologous saphenous vein (n = 15), GoreTex graft (n = 2), or ligation (n = 2). The complication rate was 32% in the open group and 18% in the endovascular group (p = .048). The overall 90 day post-operative mortality rate was 1.2%, five year primary patency was 90.0%, five year survival rate was 81.2%, and mean follow up was 6.9 ± 4.2 years. CONCLUSION: Endovascular treatment is the preferred approach whenever technically possible. Despite higher post-operative morbidity, an open approach with vascular reconstruction using autologous or allogenic vascular grafts yields acceptable long term results.
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Aneurisma , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Masculino , Humanos , Femenino , Persona de Mediana Edad , Arteria Hepática/diagnóstico por imagen , Arteria Hepática/cirugía , Estudios Retrospectivos , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Aneurisma/diagnóstico por imagen , Aneurisma/etiología , Aneurisma/cirugía , Stents , Procedimientos Endovasculares/efectos adversosRESUMEN
OBJECTIVES: To understand the effect of 50-g oral glucose tolerance test (OGTT) on fetal celiac artery and superior mesenteric artery (SMA) Doppler parameters. METHODS: A total of 43 healthy pregnant women followed in our hospital were included in the study. All Doppler parameters of the celiac artery and SMA (peak systolic velocity (PSV); pulsatility index (PI); resistance index (RI); systolic/diastolic ratio (SD); time average maximum velocity (TAMAX)) were obtained by ultrasonography before and 1â¯h after OGTT. RESULTS: The mean PSV value of the celiac artery decreased statistically significantly after OGTT (37.29 ± 11.96â¯cm/s; 29.51 ± 10.07â¯cm/s; p=0.002). While the mean of the PI was 2.09 ± 0.57 before the test, it was found to be 1.84 ± 0.64 after the test (p=0.027). Mean PSV (39.82 ± 13.07â¯cm/s; 35.19 ± 15.27â¯cm/s; p=0.104) and PI (2.21 ± 0.65; 2.11 ± 0.80; p=0.375) values of SMA were also found to be decreased without statistically significancy. CONCLUSIONS: The data obtained from our study reveals that the PSV and PI values of celiac artery and SMA slightly decrease after OGTT.
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Arteria Celíaca , Arteria Mesentérica Superior , Humanos , Femenino , Embarazo , Arteria Mesentérica Superior/diagnóstico por imagen , Prueba de Tolerancia a la Glucosa , Arteria Celíaca/diagnóstico por imagen , Velocidad del Flujo Sanguíneo , Ultrasonografía DopplerRESUMEN
OBJECTIVE: Since the first description of the median arcuate ligament syndrome (MALS), the existence for the syndrome and the efficacy of treatment for it have been questioned. METHODS: A systematic review conforming to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted, with a broader view on treatment for MALS including any kind of coeliac artery release, coeliac plexus resection, and coeliac plexus blockage, irrespective of age. Online databases were used to identify papers published between 1963 and July 2021. The inclusion criteria were abdominal symptoms, proof of MALS on imaging, and articles reporting at least three patients. Primary outcomes were symptom relief and quality of life (QoL). RESULTS: Thirty-eight studies describing 880 adult patients and six studies describing 195 paediatric patients were included. The majority of the adult studies reported symptom relief of more than 70% from three to 228 months after treatment. Two adult studies showed an improved QoL after treatment. Half of the paediatric studies reported symptom relief of more than 70% from six to 62 months after laparoscopic coeliac artery release, and four studies reported an improved QoL. Thirty-five (92%) adult studies and five (83%) paediatric studies scored a high or unclear risk of bias for the majority of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) items. The meaning of coeliac plexus resection or blockage could not be substantiated. CONCLUSION: This systematic review suggests a sustainable symptom relief of more than 70% after treatment for MALS in the majority of adult and paediatric studies; however, owing to the heterogeneity of the inclusion criteria and outcome parameters, the risk of bias was high and a formal meta-analysis could not be performed. To improve care for patients with MALS the next steps would be to deal with reporting standards, outcome definitions, and consensus descriptions of the intervention(s), after which an appropriate randomised controlled trial should be performed.
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Síndrome del Ligamento Arcuato Medio , Adulto , Humanos , Niño , Síndrome del Ligamento Arcuato Medio/diagnóstico , Síndrome del Ligamento Arcuato Medio/etiología , Síndrome del Ligamento Arcuato Medio/cirugía , Calidad de Vida , Constricción Patológica/etiología , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/cirugía , Descompresión Quirúrgica/métodosRESUMEN
NEW FINDINGS: What is the central question of this study? Increased work of breathing and the accumulation of metabolites have neural and cardiovascular consequences through a respiratory muscle-induced metaboreflex. The influence of the respiratory muscle-induced metaboreflex on splanchnic blood flow in humans remains unknown. What is the main finding and its importance? Coeliac artery blood flow decreased gradually during inspiratory resistive breathing, accompanied by a progressive increase in arterial blood pressure. It is possible that the respiratory muscle-induced metaboreflex contributes to splanchnic blood flow regulation. ABSTRACT: The purpose of this study was to clarify the effect of increasing inspiratory muscle work on coeliac artery blood flow. Eleven healthy young males completed the study. The subjects performed voluntary hyperventilation with or without inspiratory resistance (loading or non-loading trial; tidal volume of 40% of vital capacity and breathing frequency of 20 breaths/min). The loading trial was conducted with inspiratory resistance (40% of maximal inspiratory pressure) and was terminated when the subjects could no longer maintain the target tidal volume or breathing frequency. The non-loading trial was conducted without inspiratory resistance and was of the same duration as the loading trial. Arterial blood pressure was recorded using finger photoplethysmography, and coeliac artery blood flow was measured using Doppler ultrasound. Mean arterial blood pressure increased gradually during the loading trial (mean ± SD; from 89.0 ± 10.8 to 103.9 ± 17.3 mmHg) but not in the non-loading trial (from 88.7 ± 5.9 to 90.4 ± 9.9 mmHg). Coeliac artery blood flow and coeliac vascular conductance decreased gradually during the loading trial (from 601.2 ± 155.7 to 482.6 ± 149.5 mL/min and from 6.9 ± 2.2 to 4.8 ± 1.7 mL/min/mmHg, respectively) but were unchanged in the non-loading trial (from 630.7 ± 157.1 to 635.6 ± 195.7 mL/min and from 7.1 ± 1.8 to 7.2 ± 2.9 mL/min/mmHg, respectively). These results show that increasing inspiratory muscle work affects splanchnic blood flow regulation, and we suggest that this might be mediated by the inspiratory muscle-induced metaboreflex.
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Inhalación , Trabajo Respiratorio , Presión Sanguínea/fisiología , Arteria Celíaca , Humanos , Inhalación/fisiología , Masculino , Músculos Respiratorios/fisiologíaRESUMEN
Objective: Two cases of haemosuccus pancreaticus (HP), a rare cause of gastrointestinal bleeding caused by splenic artery aneurysm derived from isolated spontaneous coeliac artery dissection (ISCAD), are reported. Case report: The first case was a 62-year-old man with a history of hypertension who presented with abdominal pain and melaena. Laboratory tests indicated slight anaemia and a high serum amylase level. Computed tomography (CT) showed coeliac artery dissection and a splenic aneurysm. Endoscopic retrograde cholangiopancreatography suggested a communication between the main pancreatic duct and the aneurysm. A laparoscopic distal pancreatectomy was performed. The second case was a 49-year-old man who had been followed up with coeliac artery dissection and a splenic aneurysm, and developed abdominal pain, haematemesis, and melaena. CT did not show degeneration of the coeliac and splenic lesions, and multiple endoscopies failed to detect the source of bleeding. However, the patient was clinically diagnosed with HP and had a successful transcatheter arterial embolisation. There was no recurrence in either case. Conclusion: HP should be considered in cases with adjacent splenic aneurysms, especially under fragile arterial conditions such as ISCAD.
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OBJECTIVE: To investigate the clinical impact of coeliac artery (CA) coverage during thoracic endovascular aortic repair (TEVAR). METHODS: This systematic review and meta-analysis was conducted according to the PRISMA guidelines. Electronic databases were searched from 1989 to 2020 for studies reporting visceral ischaemia, spinal cord ischaemia (SCI), 30 day/in hospital mortality, endoleaks, re-intervention, and caudal stent graft migration following CA coverage in patients undergoing TEVAR. Meta-analysis was conducted using random effects modelling. The quality of the evidence was graded using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS: Fifteen observational studies with 236 patients (108 male, age range 61.3 - 79 years) were included. The pooled visceral ischaemia rate was 13% with significant heterogeneity between studies (95% confidence intervals [CI] 4 - 24; I2 = 72%, p < .001). The SCI rate was 5% (95% CI 2 - 9; I2 = 0%); the 30 day/in hospital mortality was 4% (95% CI 1 - 7; I2 = 0%); the overall endoleak rate was 21% (95% CI 13 - 29; I2 = 35%) with a 5% (95% CI 0 - 13; I2 = 38%) rate of type Ib and 2% (95% CI 0 - 8; I2 = 43%) rate of type II endoleak from retrograde CA flow. The re-intervention rate was 13% (95% CI 6 - 22; I2 = 54%); the caudal stent graft migration rate was 3% (95% CI 0 - 9, I2 = 0%). The certainty of the body of evidence was judged to be very low for all outcomes. CONCLUSION: CA coverage during TEVAR is associated with high rates of visceral ischaemia, spinal cord ischaemia, 30 day/in hospital mortality, endoleaks, and re-intervention. Although the literature is of poor quality and questions remain over effects estimates, there is evidence that CA coverage should be avoided if at all possible, during TEVAR. REGISTRATION: PROSPERO registration number 244084.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Isquemia de la Médula Espinal , Anciano , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Arteria Celíaca/cirugía , Endofuga/epidemiología , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Humanos , Isquemia/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Isquemia de la Médula Espinal/etiología , Isquemia de la Médula Espinal/cirugía , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by the compression of the coeliac trunk and plexus by fibrous arches of the median ligament. It commonly occurs in young women with postprandial epigastric pain, weight loss and nausea. We present a single surgeon experience on the diagnostic approach and management of MALS with a focus on laparoscopic surgery. METHODS: A retrospective review of adult patients diagnosed with MALS during a 10-year period (2011-2021) was conducted at Bankstown-Lidcombe hospital in New South Wales, Australia. RESULTS: MALS was diagnosed in six patients (mean 46 years, range: 27-74 years old), all confirmed on mesenteric duplex ultrasound and computed tomography angiography. The most common presentations were women with post-prandial pain, exercise induced pain and an average weight loss of 14.5 kg. The median interval from onset of symptoms to surgical referral was 10.5 months. The average BMI was 24.1 kg/m2 and most had a grade III American Society of Anaesthesiologist physical status. All patients underwent laparoscopic release of median arcuate ligament with one patient requiring endovascular stenting. The mean operative time was 119 minutes with two minor post-operative complications, but no mortalities. The median hospital length of stay was 3.5 days with a median follow up of 3.5 years. CONCLUSION: Laparoscopic median arcuate ligament release with endovascular support for selected cases provides sound clinical resolution of symptoms and long-term results.
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Laparoscopía , Síndrome del Ligamento Arcuato Medio , Dolor Abdominal/complicaciones , Dolor Abdominal/etiología , Adulto , Anciano , Arteria Celíaca/diagnóstico por imagen , Arteria Celíaca/cirugía , Femenino , Humanos , Laparoscopía/métodos , Masculino , Síndrome del Ligamento Arcuato Medio/complicaciones , Síndrome del Ligamento Arcuato Medio/diagnóstico , Síndrome del Ligamento Arcuato Medio/cirugía , Persona de Mediana Edad , Pérdida de PesoRESUMEN
Aims: The study aimed to review the use of synthetic grafts (SGs) and autologous vein grafts (AVGs) in visceral arterial reconstruction (VAR) in chronic visceral ischaemia. Methods: Systematic review methodology was employed. Results: Six studies were included (218 patients and 281 vessels). Two studies had data about AVG only, 3 had data about SG only and 1 had both AVG and SG data. Three studies reported outcomes for AVG (117 patients and 132 vessels revascularized). One-year primary patency was 87% (95% CI 71%, 97%). Graft thrombosis rate was 6% (95% CI 0%, 16%). Pooled stenosis rate at one-year was 11% (95% CI 1%, 28%). The 30-day (n = 96), one-year (n = 72) and 5-year mortality (n = 30) were 0%, 0% and 12%, respectively. Four studies reported outcomes for SGs (106 patients and 147 vessels). The pooled primary patency at one year was 100% (95% CI 99%, 100%). Pooled primary 5-year patency rate was 88% (95% CI 69%, 100%). There was no graft infection in 2 of the 3 studies. Overall pooled percentage of graft thrombosis and stenosis at one year was 0%. Jimenez et al. (2002) reported one graft thrombosis at 20 months and graft stenosis in 2 patients at 46 and 49 months. Illuminati et al (2017) reported graft thrombosis in 2/24 patients at 22 and 52 months. Thirty days, one-year and 5-year mortality was 1% (95% CI 0%, 6), 7% (95% CI 0%, 20%) and 39% (95% CI 11%), respectively. Conclusion: Patency was better with SG compared with AVG. Mortality was higher in the SG group. Graft dilatation does occur with vein grafts, but in this review no intervention was found necessary. Poorly designed studies, incomplete reporting and absence of morbidity and mortality indices preclude emphatic conclusions.
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Implantación de Prótesis Vascular , Procedimientos Quirúrgicos Vasculares , Implantación de Prótesis Vascular/efectos adversos , Oclusión de Injerto Vascular/etiología , Humanos , Isquemia/etiología , Estudios Retrospectivos , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
This series involves a quiz pertaining to the identification of key anatomical landmarks and normal structures present at a given level on the computed tomography (CT) image. The current quiz demonstrates examples of normal and abnormal axial CT images at the level of origin of the coeliac artery. The representative image is subsequently followed by further images demonstrating various commonly encountered pathologies found at this level in clinical practice. In each image, readers are expected to identify highlighted anatomical structures and appreciate how given pathologies can alter the appearance of normal structures. This series aims to advance understanding of sectional anatomy and aid nuclear physicians in the interpretation of the CT component of single photon emission computed tomography (SPECT) and positron emission tomography (PET) studies.
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BACKGROUND: The topographic location of the superior mesenteric artery (SMA) and its branching pattern are usually arbitrary in textbooks. This study, therefore, aims to provide topographic information of SMA with reference to the vertebral bodies, ventral branches of aorta and branching pattern of SMA. MATERIALS AND METHODS: The study was conducted on 35 embalmed adult human cadavers. We performed detailed dissection of the SMA to topographically locate its origin in respect to vertebral level and other ventral branches of the abdominal aorta. We have categorised the branching pattern of SMA into three different types depending upon the number of arterial pedicles, traced from proximal to distal to look into their anastomoses and formation marginal artery of Drummond. RESULTS: Vertebral level of origin of SMA varied between the lower third of twelfth thoracic vertebra (T12) and lower third of first lumbar vertebra (L1), most commonly arose at the level of the lower third of L1 (77.14%). The average distances between the origin of SMA and coeliac trunk (CT), inferior mesenteric artery (IMA) and aortic bifurcation were 1.84 cm, 6.67 cm and 10.39 cm, respectively. Depending on the branching pattern, type A was found in 29 (82.85%) cases, type B in 5 (14.28%) and type C in 1 (2.85%). In 2 cases (both of type B), the marginal artery was incomplete. CONCLUSIONS: The most common topography of origin of the SMA was opposite the lower third of L1. The coeliac-superior mesenteric relationship was most consistent than between any other two points on the abdominal aorta; 85% of the SMAs were concentrated within a space of 1.00 cm (0.60-1.50 cm) from the CT. Type A branching pattern was most commonly seen in our study population.
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Arteria Celíaca , Arteria Mesentérica Superior , Adulto , Aorta Abdominal , Cadáver , Humanos , Arteria Mesentérica InferiorRESUMEN
INTRODUCTION: Visceral artery injuries are rare but lethal entities that pose significant management challenges in a patient who presents with blunt trauma. There is a paucity of specific guidelines both in the trauma and vascular literature regarding the management of blunt intra-abdominal vascular injuries. The midterm outcomes of two cases of blunt traumatic visceral artery injuries managed successfully with endovascular interventions are presented. REPORT: An 18 year old male victim of a motor vehicle accident was found to have infrarenal aortic, coeliac artery (CA), and superior mesenteric artery (SMA) injuries. The second patient was a 15 year old male who presented with traumatic occlusion of the CA after an all terrain vehicle collision. Both patients had other associated abdominal and bony injuries. All vascular injuries were addressed endovascularly, which was followed by repair of other associated injuries. In the first case, a self expanding non-covered nitinol stent was used in the injured but tortuous CA; for repair of the SMA, a covered balloon expandable stent was used. In the second patient, a balloon expandable non-covered stent was used to repair the CA occlusion. In both cases, the 12 month post-operative follow up showed that all stents were patent and the patients were asymptomatic. DISCUSSION: Endovascular repair of the mesenteric arteries following traumatic injury can be achieved safely, with good midterm outcomes. More data are needed to define the indications for and long term safety and patency of stents used in traumatic visceral artery injuries.
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BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare condition due to compression of the celiac artery (CA) by an anatomically abnormal median arcuate ligament. With ultrasonography (US) as first-line diagnostic modality in patients with unclear abdominal pain, there is limited data on its diagnostic performance in MALS. OBJECTIVE: To investigate the value of CA peak systolic velocity (PSV) in the workup of patients with suspected MALS. METHODS: Patients with diagnosis of MALS between 2009 and 2019 were referred by Department of Visceral Surgery after clinical and gastroenterological workup. Diagnosis was confirmed by surgery or further cross-sectional imaging. B-mode US findings and PSV in the CA during various respiratory states were compared between patients with a final MALS diagnosis and patients not meeting the diagnostic criteria. RESULTS: Patients with proven MALS (nâ=â10) had higher median CA PSV during normal inspiratory breath-hold (239 [IQR, 159-327] vs. 138 [IQR, 116-152] cm/s; pâ<â#x003C;<â#x200A;0.001), and expiratory breath-hold (287 [IQR, 191-412] vs. 133 [IQR, 115-194] cm/s; pâ<â#x003C;<â#x200A;0.001) compared to patients without MALS (nâ=â26). CA PSV in both inspiratory breath-hold (AUC 0.88, 95% CI 0.77-1.00) and expiratory breath-hold (AUC 0.89, 95% CI 0.78-1.00) was of diagnostic value for confirming MALS. The best diagnostic performance (100% sensitivity, 80% specificity) was found for the combination of CA PSVexpiration + 2.4 · PSVinspiration > 550 cm/s . CONCLUSIONS: Since results on optimal cutoff values are inconsistent, a combination of CA PSVs during breathing maneuvers may help to diagnose or rule out MALS.
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Arteriopatías Oclusivas/diagnóstico por imagen , Arteria Celíaca/diagnóstico por imagen , Síndrome del Ligamento Arcuato Medio/diagnóstico por imagen , Síndrome del Ligamento Arcuato Medio/diagnóstico , Ultrasonografía Doppler Dúplex/métodos , Adulto , Arteria Celíaca/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.
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Gastroenterología/normas , Isquemia Mesentérica/diagnóstico , Grupo de Atención al Paciente/normas , Radiología/normas , Sociedades Médicas/normas , Enfermedad Crónica/epidemiología , Enfermedad Crónica/terapia , Angiografía por Tomografía Computarizada , Medios de Contraste/administración & dosificación , Europa (Continente) , Medicina Basada en la Evidencia/métodos , Medicina Basada en la Evidencia/normas , Gastroenterología/métodos , Comunicación Interdisciplinaria , Angiografía por Resonancia Magnética/métodos , Arterias Mesentéricas/diagnóstico por imagen , Isquemia Mesentérica/epidemiología , Isquemia Mesentérica/terapia , Radiología/métodos , Medición de Riesgo/métodos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
OBJECTIVE: Spontaneous Isolated Coeliac Artery Dissection (SICAD) is a rare disease with few reports of management strategies. This study reports the mid- to long-term outcomes of conservative management and endovascular intervention of SICAD treatment. METHODS: Sixteen patients presenting with symptomatic SICAD from September 2006 to October 2018 were reviewed retrospectively. The clinical manifestations, initial radiological findings, methods of treatment, and serial follow up studies were analysed. RESULTS: The mean age of the patients was 51.2 ± 7.9 years, with a median follow up of 33.3 (range 1.0-118.9) months. Four patients received early intervention because of aneurysmal dilatation or distal hypoperfusion. Four patients who received conservative management showed progression of disease and were recommended for delayed intervention. Although collaterals prevented further hepatic ischaemia, one of these four patients failed in delayed intervention because of extensive thrombi completely occluding the hepatic artery. In the remaining eight patients who were managed conservatively, three (37.5%) showed regression of disease, one (12.5%) showed partial regression, and five (62.5%) showed no change in intimal flap or thrombosis, but all had symptomatic improvement. The median follow up duration for the seven patients who underwent successful intervention was 77.3 (range 34.3-118.9) months, and all stenting remained patent during the follow up period. CONCLUSION: Early intervention in symptomatic SICAD patients may be necessary in over 50% of patients, and endovascular stenting has durable long term outcomes.
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Disección Aórtica/terapia , Arteriopatías Oclusivas/prevención & control , Arteria Celíaca/cirugía , Tratamiento Conservador/métodos , Procedimientos Endovasculares/métodos , Adulto , Disección Aórtica/complicaciones , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Arteria Celíaca/patología , Tratamiento Conservador/efectos adversos , Tratamiento Conservador/normas , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/normas , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Arteria Hepática/diagnóstico por imagen , Arteria Hepática/patología , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Stents , Factores de Tiempo , Tiempo de Tratamiento , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Isquemia Mesentérica/cirugía , Enfermedad Crónica , Humanos , Stents , Procedimientos Quirúrgicos VascularesRESUMEN
To investigate the clinical diagnostic value of ultrasonographic superb micro‐vascular imaging ( SM I) for abdominal branch arteries′involvement in Stanford B aortic dissection ( AD ) . Methods A total of 34 AD patients underwent conventional ultrasound ,SMI and CTA . The characteristics of the ultrasonographic images of branch artery involvement including coeliac artery ,superior mesenteric artery ,left and right renal artery were analyzed . T he diagnostic performance of conventional ultrasound and SM I were compared and CT A was used as the reference standard . Results Among the 34 patients with AD ,according to the ultrasonographic images′characteristics ,136 branch arteries were categorized into four classes :Class Ⅰ (81/136) ,branch artery perfusion supplied from the aortic true lumen ; Class Ⅱ ( 27/136) , dissection extending into the branch ; Class Ⅲ ( 16/136 ) ,branch artery perfusion supplied from the aortic false lumen ; Class Ⅳ ( 12/136) ,branch artery perfusion supplied from the aortic true and false lumens . T he diagnostic accordance rate of the conventional ultrasound and SM I were 76 .5% ( 104/136 ) and 92 .6%( 126/136) and had significant differences ( P ＜0 .001) . Conclusions SMI can be used to evaluate branch artery involvement in AD patients w hich will guide the practice of pre‐operation and post‐operation .