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Superior mesenteric artery (SMA) syndrome causes duodenal obstruction between the SMA and aorta, which culminates into bowel obstruction. Meanwhile, nutcracker syndrome (NCS) involves left renal vein compression between the aorta and SMA, categorized by the compression site. We present a 15-year-old female with no prior medical or surgical history who displayed early signs of the rarely coexisting SMA and nutcracker phenomena, which were managed symptomatically along with nutritional support to reach her optimal body mass index.

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BACKGROUND: Transcatheter radiofrequency ablation is one of the main treatments for atrial fibrillation, but related complications of this surgery are uncommon. CASE PRESENTATION: Here, we report a 70-year-old elderly male patient with atrial fibrillation who experienced severe abdominal pain early after undergoing radiofrequency ablation; related imaging examinations suggested that the patient had intestinal edema and thickening, combined with hepatic portal vein gas accumulation. The reason was that the patient experienced intestinal necrosis due to superior mesenteric artery embolism related to radiofrequency surgery. The surgeon suggested laparotomy for exploration. However, after multidisciplinary consideration, we ultimately chose conservative treatment. After fasting, gastrointestinal decompression, spasmolysis, pain relief, somatostatin inhibition of intestinal edema, antiinfection, and anticoagulation, the patient's condition improved, and he was discharged. We followed the patient for 1 month after discharge, and there was no special discomfort. CONCLUSION: Hepatoportal vein gas accumulation after radiofrequency ablation of atrial fibrillation is rare, and imaging findings have important guiding significance for the diagnosis and treatment of the disease.

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OBJECTIVES: Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies. METHODS: Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist. RESULTS: The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery. CONCLUSION: This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.

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PURPOSE: Chronic mesenteric ischemia (CMI) is a rare disease that progresses with acute mesenteric ischemia, along with high mortality. How to choose the appropriate surgical method and the artery which should be opened first is the key to the treatment. CASE REPORT: In this study, we successively used vascular bypass and endovascular therapy to treat a case of complex chronic mesenteric ischemia. CONCLUSION: For mesenteric ischemic disease, the superior mesenteric artery (SMA) should be opened preferentially. Arterial bypass or interventional therapy can be used, or both can be combined, to finally achieve the purpose of treatment.

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Objective: Arteritis refers to all infectious and non-infectious conditions that lead to inflammation of the arterial wall. However, little is known about its presence in patients with coronavirus disease 2019 (COVID-19). Most patients improved with steroids along with conservative treatments in a few studies. We report our experience with superior mesenteric artery (SMA) arteritis causing an aneurysm following COVID-19 infection. Case presentation: A 66-year-old female patient who was infected with COVID-19 1 month prior presented with abdominal pain. A computed tomography scan revealed proximal SMA arteritis. Although preliminary antibacterial treatment was initiated, the follow-up CT revealed an aggressive and fast-growing 5.7-cm SMA aneurysm. Subsequently, an open interposition bypass of the SMA aneurysm was performed successfully. As the specimens retrieved during surgery showed no bacterial colonization in the tissue or blood cultures, the patient was discharged without complications. Conclusions: The mechanism of arteritis in patients with COVID-19 has not been elucidated. In the absence of evidence of bacterial infection in arteritis, it is necessary to consider the possibility of viral infection caused by COVID-19 during the COVID-19 pandemic era and start with high-dose steroid therapy promptly.

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INTRODUCTION: Nutcracker syndrome results from the compression of the left renal vein between the aorta and the superior mesenteric artery. The Nutcracker syndrome is rare and occurs in specific contexts such in patients who have lost significant weight. Our case presents an infrequent instance of nutcracker syndrome following a complicated biliary surgery. CASE PRESENTATION: A 32-year-old patient presented with symptomatic cholelithiasis. Laparoscopic cholecystectomy was complicated by an injury in the right hepatic artery necessitating a biliary reconstruction. After three months, the BMI was 18 Kg/m2.The patient was operated on, he had a hepaticojejunal anastomosis on the left hepatic duct. Right hepatectomy was unnecessary due to complete atrophy of the right liver. Postoperatively, persistent low back pain prompted a CT scan. It revealed compression of the left renal vein in the aortomesenteric clamp indicating a nutcracker syndrome. The patient was put on anticoagulants with a good evolution. DISCUSSION: The Nutcracker syndrome is categorized into three types: the anterior form, the posterior form and the posterolateral form. The aortomesenteric angle could be subject to variation depending on the body mass index (BMI). Significant weight loss could induce nutcracker syndrome by decreasing the Aorto- superior mesenteric artery angle due to reduced retroperitoneal and perivascular fat (D'Souza et al., n.d.). In our case, the patient's BMI dropped from 25 to 18 kg/m2 contributing to the syndrome. Radiological examinations should assess not only the anatomy of the aorto-mesenteric angle but to identify an eventual associated thrombosis. Conservative treatment is sufficient in most cases with a resolution of symptoms in 60 to 80 % of cases. CONCLUSION: We aimed to bring attention to Nutcracker syndrome, especially in patients who have experienced significant weight loss after a complicated surgery.

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Henoch-Schönlein purpura (HSP) is a systemic vasculitis characterized by palpable purpura, arthralgia or arthritis, GI symptoms, and renal involvement. Superior mesenteric artery (SMA) syndrome, a rare condition, occurs when the third part of the duodenum is compressed between the aorta and the SMA, leading to upper intestinal obstruction. This case report describes the clinical presentation, diagnostic process, and management of an eight-year-old girl with HSP complicated by SMA syndrome. The patient initially presented with abdominal pain and vomiting, eventually developing the characteristic rash of HSP. While initial management was supportive, her condition deteriorated. Treatment with intravenous methylprednisolone resulted in significant symptom improvement and resolution of both SMA syndrome and HSP manifestations. This case highlights the need to recognize SMA syndrome as a potential complication of HSP and demonstrates the effectiveness of steroid therapy in managing this condition. Further research is needed to develop comprehensive treatment guidelines for HSP patients with SMA syndrome.

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Superior mesenteric artery syndrome, or Wilkie's syndrome, is one of the rarest gastrointestinal disorders known to medical science. It is characterized by the vascular clamp of the third portion of the duodenum, between the superior mesenteric artery and the aorta. It presents as an uncommon cause of upper intestinal obstruction. Imaging is required, preferably with a contrast-enhanced CT or an MRI; conservative management is preferred, leaving surgery for the most complex cases. We present the case of a 34-year-old man with Duchenne's muscular dystrophy and a history of substantial weight loss after hospital admission for aspiration pneumonia. He underwent an abdominal CT scan that showed enlargement of the stomach, the second and third parts of the duodenum; without observing masses, the patient received conservative management with a nasojejunal feeding tube. At the outpatient reevaluation, 1 month postdischarge, he became asymptomatic and had progressive weight gain.

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Ureteropelvic junction obstruction (UPJO) is a pathological condition characterized by obstruction of the junction between the renal pelvis and ureter, often resulting in dilatation of the renal collecting system. Aberrant accessory vessels or early branching of the inferior pole vessels are the most common causes of extrinsic UPJO. The inferior mesenteric artery has not been reported as a common cause of UPJO. Here, we report the case of a 7-year-old patient with UPJO and an anomalous inferior mesenteric artery. The patient was initially diagnosed with congenital uropathy during the evaluation for primary enuresis.

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Superior mesenteric artery (SMA) invasion by a malignant tumour is a serious condition leading to intestinal ischaemia. Although SMA stenting has been reported to be useful for SMA dissection and stenosis caused by atherosclerotic plaque, SMA stenting for stenosis caused by malignant tumour invasion is rarely reported and uncertain. A 75-year-old woman presented intestinal ulcer and melena caused by SMA invasion of unresectable pancreatic cancer. The bare metal stent was implanted for the vessel stenosis, and a small intestinal ulcer was markedly improved after stenting. However, one and a half months after stenting the stent was occluded and a thrombectomy was performed. After thrombectomy, residual stenosis caused by tumour invasion was observed in the stent. The patient suddenly died 2 days after thrombectomy before additional covered stenting for residual stenosis. Stent implantation may be a treatment option for intestinal ischaemia caused by vessel invasion of malignant tumours. On the other hand, re-stenosis of the stent due to tumour ingrowth is a problem, and covered stenting is considered for long-term stent patency.

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Laparoscopic total mesorectal excision is the main surgical approach for treating rectal cancer, but there is still no clear consensus on the issue of low ligation of the inferior mesenteric artery during the procedure. Robotic surgery has been shown to have certain advantages over laparoscopic surgery in multiple studies, but further research is needed to better understand the outcomes of robotic surgery in the context of low ligation procedures. In this study, we included 1590 patients with mid-low rectal cancer. Among them, 942 patients underwent low ligation surgery (LL), divided into 138 in the robotic group and 804 in the laparoscopic group. The high ligation surgery (HL) group consisted of 648 patients. The results of LL vs HL showed that the LL group had faster bowel movement recovery (P = 0.003), lower anastomotic leak rate (P = 0.032), and lower International Prostate Symptom Score (IPSS) at 6 months postoperatively (P < 0.001). The results of Rob-LL vs Lap-LL showed that the Rob-LL group had longer operative time (P < 0.001), less blood loss (P = 0.001), more lymph nodes retrieved (P = 0.045), and lower Wexner score at 2 weeks postoperatively (P = 0.029). The concept of low ligation of the inferior mesenteric artery is a promising surgical approach that can accelerate the patient's functional recovery. When combined with robotic technology, it may offer more benefits than laparoscopic techniques.

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Abdominopelvic vascular compression syndromes (VCS) refer to conditions where blood vessels in the abdomen or pelvis are compressed by nearby structures, leading to various symptoms and complications. These conditions include superior mesenteric artery syndrome (SMAS), nutcracker syndrome (NCS), May-Thurner syndrome (MTS), and median arcuate ligament syndrome (MALS). Each syndrome is characterized by specific compressions of blood vessels, resulting in symptoms such as pain, nausea, vomiting, weight loss, leg swelling, and other related issues. Ehlers-Danlos syndrome (EDS), characterized by hyperelasticity, altered collagen, and mobility of the viscera, has been associated with VCS, although the exact prevalence is unknown. We report a case of a patient with EDS who presented with multiple VCS, including NCS, MTS, SMAS, and MALS.

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Superior mesenteric artery (SMA) syndrome is a rare disease in which the third part of the duodenum between the SMA and the abdominal aorta is compressed, leading to small bowel obstruction. Treatment is usually conservative, such as parenteral and nasojejunal nutrition. The pathophysiology includes loss of the retroperitoneal fat layer and subsequent duodenal compression. We present a 53-year-old malnourished female patient who came with complaints of vomiting, constipation, abdominal pain, and distension for four days. This article highlights the diagnostic challenges associated with SMA syndrome and emphasizes the importance of early diagnosis and intervention.

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Nutcracker syndrome (NCS), a rare but impactful vascular condition, emerges from the compression of the left renal vein by adjacent major arteries, leading to a diverse array of symptoms such as hematuria, flank pain, and renal challenges. Highlighting the case of a 30-year-old male with an atypical presentation of NCS, this report explores the diagnostic complexities arising from its varied presentations and therapeutic options. It emphasizes the critical role of computed tomography (CT) in unveiling the underlying vascular constriction. Through this lens, the case underscores the necessity of considering NCS in the differential diagnosis of abdominal pain, advocating for a prompt and accurate diagnosis to guide effective management strategies, ranging from conservative approaches to surgical intervention. This stresses the importance of heightened awareness and ongoing research for optimizing patient outcomes in the face of this elusive condition.

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BACKGROUND: Superior mesenteric artery syndrome (SMAS) is a rare condition, for which laparoscopic surgery was successfully performed safely and with long-term efficacy. METHODS: This single center retrospective clinical study comprised 66 patients with SMAS, surgically treated between January 2010 and January 2020, who were allocated to three different surgical groups according to their medical history and symptoms (Laparoscopic duodenojejunostomy, n = 35; Gastrojejunostomy, n = 16; Duodenojejunostomy plus gastrojejunostomy, n = 15). Patient demographics, surgical data and postoperative outcomes were retrieved from the medical records. RESULTS: All operations were successfully completed laparoscopically, and with a median follow-up of 65 months, the overall symptom score was significantly reduced from 32 to 8 (p < 0.0001) and the BMI was increased from 17.2 kg/m2 to 21.8 kg/m2 (p < 0.0001). CONCLUSIONS: When conservative measures failed in the treatment of SMAS, laparoscopic surgery proved to be a safe and effective method. The specific surgical technique was selected according to the history and symptoms of each individual patient. To our knowledge, this study represents the largest number of laparoscopic procedures at a single center for the treatment of superior mesenteric artery syndrome.

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PURPOSE: This study aims to evaluate outcomes in patients with mesenteric artery embolism (MAE) who received primary endovascular therapy (EVT) or laparotomy, and investigate risk factors for 30-day mortality. METHODS: A retrospective analysis of 94 MAE patients who underwent two different treatment strategies was undertaken. An inverse probability of treatment weighting (IPTW) method was used to balance the confounding effects of baseline clinical data. Logistic regression analysis was performed to compare the outcomes according to type of treatment regimens before and after IPTW. Univariate and multivariable analysis were conducted to determine the risk factors for 30-day mortality. RESULTS: Twenty-eight MAE patients received primary EVT, and 66 Open Surgery (OS). Logistic regression analysis showed that there was no significant difference between the EVT and OS group in 30-day mortality rate before (odds ratio [OR] 0.477, 95% confidence interval [CI] 0.170 to 1.340, P = 0.160), and after IPTW (OR 0.647, 95% CI 0.210 to 1.993, P = 0.449). After IPTW, it revealed that the rates of second-look surgery (OR 36.727, 95% CI 5.407 to 249.458, P < 0.001) and hospital stay [> 30 days] (OR 0.006, 95% CI 0.000 to 0.363, P = 0.014) were different in the two groups. D-dimer (> 4 mg/L) and procalcitonin (> 0.5 ng/mL) were the independent risk factors for 30-day mortality in MAE patients postoperatively (P < 0.05). CONCLUSION: In this retrospective study, MAE patients who performed primary EVT had no obvious difference in 30-day mortality rate compared to those who received OS; but it was conducive to reducing prolonged hospital stays. An increase in procalcitonin level and higher D-dimer were associated with short-term poor prognosis in patients with MAE.

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There is no definitive approach for assessing mesenteric ischemia and determining the optimal timing for endovascular intervention in the management of spontaneous isolated dissection of the superior mesenteric artery (SISMAD). A 56-year-old male with acute abdominal pain was diagnosed with SISMAD. After evaluating mesenteric ischemia through mesenteric fractional flow reserve (FFR), FFR was 0.72, and the patient was recommended conservative treatment for SISMAD, which involves fasting, total parenteral nutrition, and anticoagulation. The patient's syndrome was relieved after conservative treatment for 14 days without stent implantation. Over the next 5 years, no recurrence of abdominal pain or worsening of SISMAD was observed in the patient. Assessing the severity of mesenteric ischemia can be done through mesenteric FFR. Upon confirmation of the exclusion of risks related to dilatation or rupture of SISMAD aneurysm, an approach in favor of conservative management for SISMAD may indeed be considered pragmatic when the FFR exceeds 0.72.

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BACKGROUND AND OBJECTIVE: The isolated superior mesenteric artery dissection (ISMAD) is a rare but potentially fatal vascular disorder. Classifications for ISMAD were previously proposed based on morphometric features. However, the classification systems were not standardized and verified yet. This study conducted computational flow analysis to validate the latest classification system of ISMAD and aid clinical decision-making based on hemodynamic parameters. METHODS: 62 patients with ISMAD were included and classified into different types according to false lumen structures (five types, Type I-V) and true lumen patency (two types, Type P and Type S) according to Qiu classification system. Computational fluid dynamics and three-dimensional structural analyses were conducted on the basis of computed tomography angiography datasets. Quantitative and qualitative functional analyses were performed via parameters of interest including volume flow of each minute, pressure drop, pressure gradient, the derivative parameters of wall shear stress such as time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), and the relative residence time (RRT). Statistical analyses were conducted among different ISMAD types. RESULTS: TAWSS, OSI and RRT showed significant difference among different types when classified using false lumen structures. In detail, Type IV showed significantly higher TAWSS than other types (p = 0.007). OSI was obviously higher in Type II (p = 0.015). Type IV also presented the lowest RRT (p = 0.005). The pressure drop, pressure gradient, OSI and RRT showed higher value in Type S than that in Type P, demonstrating a statistical significance with p values of 0.017, 0.041, 0.001 and 0.012, respectively. While Type P had larger volume flow than Type S (p = 0.041). CONCLUSIONS: The notable differences in hemodynamic features among different types demonstrated the feasibility of Qiu classification system. The evaluation based on hemodynamic simulation might also provide insights into risk identification and guide therapeutic decisions for ISMAD.

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PURPOSE: Nutcracker syndrome (NCS) can be caused by narrowness of the superior mesenteric artery (SMA) angle. Nevertheless, the cut-off value of the SMA angle is controversial and variable. Therefore, the present study evaluated the optimal SMA angle to maximize diagnostic performance for NCS diagnosis by conducting a meta-analysis. METHODS: We comprehensively searched the English literature related to the diagnosis of NCS from the perspective of SMA (from the date of database inception to June 2022). The accuracy of an SMA angle less than 41° in the diagnosis of NCS was evaluated by calculating the pooled sensitivity (SEN), pooled specificity (SPE), positive likelihood ratio (LR+), negative likelihood ratio (LR-), summary receiver operating characteristic (SROC) curve and area under the curve (AUC) value. The I2 test and meta-regression analysis were used to assess heterogeneity and sources of heterogeneity, respectively. Publication bias was assessed using Deeks' funnel plot asymmetry test. RESULTS: Six studies (526 patients) met the inclusion criteria. SEN and SPE were 0.94 (95% confidence interval (CI) 0.80-0.99) and 0.85 (95% CI 0.65-0.94), respectively. The LR + value was 6.0, and the LR- value was 0.07, revealing that SMA angles less than 41° exhibited an excellent ability to help confirm or exclude NCS. Additionally, SROC curves showed that the AUC of SMA angles less than 41° for the diagnosis of NCS was 0.96, indicating that SMA angles less than 41° have good efficacy for helping to diagnose NCS. CONCLUSION: This study explored the diagnostic efficacy of the cut-off value of the SMA angle by meta-analysis. According to the high SPE and SEN results, SMA angles less than 41° have good efficacy in facilitating NCS diagnosis.