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

OBJECTIVE: The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. METHODS: This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI). RESULTS: Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups. CONCLUSION: Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.

Vascular Calcifications are Associated with Increased Mortality in Patients with Acute Mesenteric Ischemia.

BACKGROUND: Vascular calcifications have been identified as predictors of mortality in several cardiovascular diseases but have not been investigated in context of acute mesenteric ischemia. The aim of this study was to investigate the impact of vascular calcifications in patients with acute mesenteric ischemia. METHODS: Patients admitted for an acute mesenteric ischemia were retrospectively included. The presence of calcifications in the visceral aorta, the celiac trunk, the superior mesenteric artery, and the renal arteries was assessed on computed tomography scan images at the arterial phase. The calcification volumes were measured using the software Aquarius iNtuition Edition®. RESULTS: The all-cause mortality was 55 out of 86 patients (63.9%) for a median follow-up of 3.5 days (1-243). The survival rate of patients with calcification in the superior mesenteric artery was significantly lower than that of those without calcification (22% vs. 55.6%, P = 0.019). Patients who died had significantly a higher frequency of calcifications in the superior mesenteric artery, the visceral aorta, the celiac trunk, and the renal arteries. CONCLUSIONS: The presence of vascular calcifications in the superior mesenteric artery is associated with increased mortality in patients diagnosed with acute mesenteric ischemia. Further studies are required to identify the mechanisms underlying this association.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Are Effective Predictors of Prognosis in Patients with Acute Mesenteric Arterial Embolism and Thrombosis.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been shown to be valuable prognostic markers for a variety of pathological conditions including solid tumors, sepsis, and others. However, the prognostic values of the NLR and PLR in patients with acute mesenteric arterial embolism (AMAE) and acute mesenteric arterial thrombosis (AMAT) have not been elucidated. The aim of this study was to determine the predictive value of the NLR and PLR for poor prognosis in patients with AMAE and AMAT. METHODS: A total of 137 patients with AMAE (n = 77) or AMAT (n = 60) were divided into a poor outcome group (cases of intestinal necrosis or death) and a better outcome group (cases without intestinal necrosis who survived successfully), according to prognosis. Neutrophil, platelet, and lymphocyte counts were recorded before pharmacotherapy or surgery. The NLR and PLR were calculated, and logistic regression analysis was performed to test their prognostic values. RESULTS: The cutoff values for NLR and PLR were 11.05 and 156.26, respectively. The PLR was linearly associated with the NLR (R = 0.769, P < 0.001). NLR (odds ratio [OR] = 6.835, 95% confidence interval [CI] = 2.282-20.469, P = 0.001), PLR (OR = 4.871, 95% CI = 1.627-14.587, P = 0.005), and coronary heart disease (OR = 3.388, 95% CI = 1.156-9.929, P = 0.026) were found to be independent prognostic factors for the patients. CONCLUSIONS: NLR ≥ 11.05, PLR ≥ 156.26, and coronary heart disease were shown to be risk factors for poor prognosis in patients with AMAE and AMAT. According to these factors, patients can be divided into 3 prognostic groups: good, NLR < 11.05 with PLR < 156.26; moderate, NLR < 11.05 with PLR ≥ 156.26 or NLR ≥ 11.05 with PLR < 156.26; and poor, NLR ≥ 11.05 with PLR ≥ 156.26.

Endothelial Cell-Derived von Willebrand Factor Is the Major Determinant That Mediates von Willebrand Factor-Dependent Acute Ischemic Stroke by Promoting Postischemic Thrombo-Inflammation.

OBJECTIVE: von Willebrand factor (VWF), which is synthesized in endothelial cells and megakaryocytes, is known to worsen stroke outcome. In vitro studies suggest that platelet-derived VWF (Plt-VWF) is biochemically different from the endothelial cell-derived VWF (EC-VWF). However, little is known about relative contribution of different pools of VWF in stroke. APPROACH AND RESULTS: Using bone marrow transplantation, we generated chimeric Plt-VWF mice, Plt-VWF mice that lack ADAMTS13 in platelets and plasma (Plt-VWF/Adamts13(-/-)), and EC-VWF mice to determine relative contribution of different pools of VWF in stroke. In brain ischemia/reperfusion injury model, we found that infarct size and postischemic intracerebral thrombo-inflammation (fibrin(ogen) deposition, neutrophil infiltration, interleukin-1ß, and tumor necrosis factor-α levels) within lesions were comparable between EC-VWF and wild-type mice. Infarct size and postischemic thrombo-inflammation were comparable between Plt-VWF and Plt-VWF/Adamts13(-/-) mice, but decreased compared with EC-VWF and wild-type mice (P<0.05) and increased compared with Vwf(-/-) mice (P<0.05). Susceptibility to FeCl3 injury-induced carotid artery thrombosis was comparable between wild-type and EC-VWF mice, whereas Plt-VWF and Plt-VWF/Adamts13(-/-) mice exhibited defective thrombosis. Although most of the injured vessels did not occlude, slope over time showed that thrombus growth rate was increased in both Plt-VWF and Plt-VWF/Adamts13(-/-) mice compared with Vwf(-/-) mice (P<0.05), but decreased compared with wild-type or EC-VWF mice. CONCLUSIONS: Plt-VWF, either in presence or absence of ADAMTS13, partially contributes to VWF-dependent injury and postischemic thrombo-inflammation after stroke. EC-VWF is the major determinant that mediates VWF-dependent ischemic stroke by promoting postischemic thrombo-inflammation.

[THROMBOANGIITIS OBLITERANS OVERLAPPING WITH ATHEROSCLEROTIC OCCLUSIVE ARTERIAL DISEASE: SMALL MESENTERIC ARTERY INVOLVEMENT BY THROMBOANGIITIS OBLITERANS].

INTRODUCTION: Thromboangiitis obliterans is an inflammatory occlusive vascular disease of young smokers that commonly involves the small and medium sized arteries and veins of the extremities. An important differential diagnosis of thromboangiitis obliterans is atherosclerotic arterial disease. An atypical presentation of thromboangiitis obliterans by involvement of mesenteric arteries has been described sporadically. CASE PRESENTATION: We report the case of a patient presenting with Raynaud's phenomenon, ischemia of the upper and lower extremities, as well as mesenteric ischemia. The dramatic course of the disease advanced to gangrene of the calves and intestinal infarction. In this patient, angiographic and histologic features were consistent with thromboangiitis obliterans associated with atherosclerotic arteriopathy. DISCUSSION: A review of the literature revealed 31 reported cases of mesenteric artery involvement by thromboangiitis obliterans. The overlap between thromboangiitis obliterans and atherosclerotic arteriopathy is rare but has recently focused attention in the literature. CONCLUSION: In the differential diagnosis of mesenteric ischemia, thromboangiitis obliterans is a rare but important diagnosis that should be considered. In view of shared features of thromboangiitis obliterans and peripheral artery disease, awareness of their possible coexistence is needed in order to make the right diagnosis and offer proper treatment.

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

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

[SURGICAL TREATMENT OF AN ACUTE MESENTERIAL ISCHEMIA].

Experience of surgical treatment of 143 patients, suffering an acute mesenterial ischemia, was summarized. Isolated intestinal resection was performed in 41 patients (lethality 65.9%), intestinal resection with the mesenterial vessels thrombembolectomy--in 9 (lethality 33.3%). After performance of the combined intervention postoperative lethality was in two times lower, than after isolated intestinal resection.

Mesenteric inflammatory veno-occlusive disease: radiographic and histopathologic evaluation of 2 cases.

Mesenteric inflammatory veno-occlusive disease (MIVOD) is a rare cause of inflammatory enterocolitis whose clinical and imaging presentation can be confused with mesenteric venous thrombosis and inflammatory bowel disease. We report two cases of histologically proven MIVOD in patients presenting with abdominal pain and describe potentially useful distinguishing features at contrast-enhanced CT, including prominent small pericolonic arteries and veins but a diminutive or absent inferior mesenteric vein. Alerting referring clinicians to the possibility of this diagnosis may help avoid unnecessary anticoagulation and reduce diagnostic delay. Treatment of MIVOD is surgical resection, which is typically curative.

Phlebosclerotic colitis: three cases and literature review.

Three cases of phlebosclerotic colitis (PC) are presented and all in males. The etiology of the PC still remains unknown. The characteristic manifestations of PC were transmural calcifications on CT and dark purple mucosa on endoscopy. Cases 1 and 2 underwent computed tomography (CT), magnetic resonance imaging (MRI), and endoscopy while case 3 underwent CT and endoscopy. Cases 1 and 2 were admitted to our hospital for ileus. Case 3 had been diagnosed as ischemic colitis and came to our hospital for re-examination. Calcifications could be found within the colon wall and adjacent mesenteric vein from cecum to transverse colon in case 1 and from cecum to descending colon in cases 2 and 3. Extensive mural thickening of the colon could be seen on CT imaging and MRI, while dark purple mucosa was found on endoscopy in all three patients. However, their extents were more than those of calcifications. The literature is limited to a few case reports. Clinicians should be familiar with the imaging and endoscopy features of PC and radiologists should pay attention to the thickening of colon wall beside the calcifications.

Mesenteric artery complications during angioplasty and stent placement for atherosclerotic chronic mesenteric ischemia.

OBJECTIVE: The purpose of this study was to describe the incidence, management, and outcomes of mesenteric artery complications (MACs) during angioplasty and stent placement (MAS) for chronic mesenteric ischemia (CMI). METHODS: We retrospectively reviewed the clinical data of 156 patients treated with 173 MAS for CMI (1998-2010). MACs were defined as procedure-related mesenteric artery dissection, stent dislodgement, embolization, thrombosis, or perforation. End points were procedure-related morbidity and death. RESULTS: There were 113 women and 43 men (mean age, 73 ± 14 years). Eleven patients (7%) developed 14 MACs, including distal mesenteric embolization in six, branch perforation in three, dissection in two, stent dislodgement in two, and stent thrombosis in one. Five patients required adjunctive endovascular procedures, including in two patients each, catheter-directed thrombolysis or aspiration, retrieval of dislodged stents, and placement of additional stents for dissection. Five patients (45%) required conversion to open repair: two required evacuation of mesenteric hematoma, two required mesenteric revascularization, and one required bowel resection. There were four early deaths (2.5%) due to mesenteric embolization or myocardial infarction in two patients each. Patients with MACs had higher rates of mortality (18% vs 1.5%) and morbidity (64% vs 19%; P <.05) and a longer hospital length of stay (6.3 ± 4.2 vs 1.6 ± 1.2 days) than those without MACs. Periprocedural use of antiplatelet therapy was associated with lower risk of distal embolization or vessel thrombosis (odds ratio, 0.2; 95% confidence interval, 0.06-0.90). Patients treated by a large-profile system had a trend toward more MACs (odds ratio, 1.8; 95% confidence interval, 0.7-26.5; P = .07). CONCLUSIONS: MACs occurred in 7% of patients who underwent MAS for CMI and resulted in higher mortality, morbidity, and longer hospital length of stay. Use of antiplatelet therapy reduced the risk of distal embolization or vessel thrombosis. There was a trend toward more MACs in patients who underwent interventions performed with a large-profile system.

Progression of apoptic signaling from mesenteric ischemia-reperfusion injury to lungs: correlation in the level of ER chaperones expression.

Multiple organ dysfunction syndrome (MODS) is characterized by the development of probably reversible, progressive dysfunction of vital systems in two or more organs, directly undamaged by surgery or other trauma. The organs which have the most common potential dysfunction are lungs, liver, kidneys, heart and gastrointestinal tract. The small intestine is the source of production of proinflammatory mediators leading and contributing to multiorgan failure. The endoplasmic reticulum (ER), after ischemia and post-ischemic reperfusion, is significantly involved in the activation of enterocyte apoptosis. The purpose of this study was to determine the stage of apoptosis in the lungs, initiated through inflammatory response from the small intestine. We analyzed changes in mRNA levels of pro-apoptotic genes Gadd153 (Chop) and anti-apoptotic genes Grp78 (Bip) in the small intestine wall and lung parenchyma. During experimental procedure the rats underwent 60 min of ischemia, caused by complete occlusion of the mesenteric arteria cranialis, with subsequent reperfusion and evaluation after 1 h, 24 h and 30 days (from R1, R24 to R30, respectively, each group n = 8). The gene expression levels were measured using RT-PCR followed by electrophoresis and visualization under UV. In the lungs we detected significantly lower level of expression Grp78 by 45 ± 6.9%. This suggests that ischemic attack and subsequent reperfusion did not promote ER stress in the lungs through induction of Gadd153 expression in the small intestine. There is still no effective approach to the treatment of affected ischemic intestine tissue, to stop the processes with could eventually lead to MODS. Therefore it is necessary to study changes in the damaged tissue at the molecular level and try to suggest possible therapeutic defined routes to the protection of tissue.

Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization.

A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

Diamine oxidase as a marker for diagnosis of superior mesenteric arterial occlusion.

BACKGROUND/AIMS: We investigated changes in serum diamine oxidase (DAO) activity during superior mesenteric arterial occlusion. We aimed to evaluate its value in the early diagnosis of superior mesenteric arterial occlusion. METHODOLOGY: Seventy mature male Sprague-Dawley rats were used in the study. These were divided into 7 groups of 10 rats each: 10min, 15min, 30min, 45min, 60min and 90min superior mesenteric arterial occlusion (SMA-O) groups, and a sham group. Blood samples were taken at the indicated time points for measuring serum DAO activity. Simultaneously, the small-intestinal segments were assessed histologically and graded according to Chiu's score. RESULTS: In the 15min group, SMA-O resulted in a rapid increase in DAO activity. Serum DAO activity and the mucosal injury score fitted well with the cubic model (r2=0.985, p<0.01). There was a positive correlation between ischemic duration and small-intestinal mucosal injury (r=0.909, p<0.01). Taking DAO=29.81U/L as a early diagnostic standard for superior mesenteric arterial occlusion, the sensitivity, accuracy and specificity were 94.34% (50/53), 95.71% (67/70), 100% (17/17), respectively. CONCLUSIONS: Serum DAO activity is a sensitive predictor of small-intestinal injury. Our finding suggests that measurement of serum DAO levels might provide a marker for early diagnosis of superior mesenteric arterial occlusion.

Enterocolic lymphocytic phlebitis: an unusual cause of abdominal complaints.

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

Sudden death from superior mesenteric artery thrombosis in a cocaine user.

Cocaine-mediated tissue injury is well established, particularly myocardial ischemia and infarction. Gastrointestinal complications including mesenteric ischemia, ischemic colitis and intestinal perforation occur less frequently. Cocaine-induced visceral arterial thrombosis is a rare finding. We report a case of a 49-year-old chronic cocaine user with superior mesenteric artery (SMA) thrombosis. The patient presented with a 24-h history of abdominal pain, nausea and vomiting. Physical examination documented tachycardia and a soft, non-rigid abdomen with voluntary guarding. Abdominal X-ray did not show any evidence of peritoneal free air or bowel obstruction. Laboratory investigations revealed elevated white blood cells and a high anion gap; a blood gas analysis was not done. Three hours after initial presentation, the patient had a cardiac arrest and died. At autopsy, the jejunum was ischemic, without obvious infarction. The SMA was occluded at its origin by significant atherosclerosis with superimposed thrombus. The myocardium had fibrosis, without acute infarction, and severe triple coronary artery atherosclerosis. Toxicological blood analysis confirmed cocaine use. This report emphasizes the need to consider chronic stimulant drug abuse in accelerated atheroma and thrombosis of visceral arteries.

[The treatment process optimization in patients suffering from acute disorder of mesenteric blood circulation].

The results of treatment of 253 patients, suffering an acute disorder of mesenteric blood circulation, were analyzed; the treatment program, applied in 55 patients, was optimized. Timely diagnosis in the tissues the ischemia stage as well as during restoration of blood circulation in a. mesenterica superior, while its proximal occlusion, application of a "second-look" tactics have had secured beneficial results of treatment in patients, the lethality was 33%. Intraoperative application of redoxmetry for estimation of the intestine life capacity have had promoted prophylaxis of the sutures insufficiency in interintestinal anastomoses. Optimization of the treatment tactics (two-staged surgical treatment with retrograde jejunal intubation, the postponed formation of anastomosis) gave possibility to reduce lethality in patients, suffering arterial occlusion from 75 to 60% (P<0.05).

Ischemic bowel due to embolization from an isolated mobile thrombus of the ascending aorta: a case report and review of the literature.

Aortic thrombi are commonly present in atherosclerotic and aneurysmatic aortas. Thrombus formation in an aorta with or focal atherosclerosis in a patient without risk factors is rare. A 63-year-old woman with dementia and hypothyroidism presented with hypotension and respiratory distress. Work-up revealed leukocytosis, sinus tachycardia, and proximal small bowel obstruction. At emergent laparotomy, a superior mesenteric artery thomboembolus was identified with necrosis of surrounding bowel. The patient expired on hospital day five. Autopsy revealed a 1.4 cm thrombus overlying an isolated atherosclerotic plaque in the ascending aorta and infarctions of the spleen, liver, and right kidney as well as occlusive thromboembolism of the superior mesenteric artery. This case report illustrates lethal complications from an unsuspected aortic thrombus. Work-up for patients presenting with signs of peripheral embolization, or in this case, necrotic bowel, should include the aorta as a source of embolic thrombi.

Intestinal ischemia/reperfusion: microcirculatory pathology and functional consequences.

BACKGROUND: Intestinal ischemia and reperfusion (I/R) is a challenging and life-threatening clinical problem with diverse causes. The delay in diagnosis and treatment contributes to the continued high in-hospital mortality rate. RESULTS: Experimental research during the last decades could demonstrate that microcirculatory dysfunctions are determinants for the manifestation and propagation of intestinal I/R injury. Key features are nutritive perfusion failure, inflammatory cell response, mediator surge and breakdown of the epithelial barrier function with bacterial translocation, and development of a systemic inflammatory response. This review provides novel insight into the basic mechanisms of damaged intestinal microcirculation and covers therapeutic targets to attenuate intestinal I/R injury. CONCLUSION: The opportunity now exists to apply this insight into the translation of experimental data to clinical trial-based research. Understanding the basic events triggered by intestinal I/R may offer new diagnostic and therapeutic options in order to achieve improved outcome of patients with intestinal I/R injury.

Outcomes in mice with abdominal angiostrongyliasis treated with enoxaparin.

Abdominal angiostrongyliasis (AA) is caused by the nematode Angiostrongylus costaricensis. Parasite-associated thrombosis of mesenteric vessels may lead to intestinal infarction, which might be prevented with anti-thrombotic agents. This study assessed the effect of enoxaparin on survival and pathological findings in Swiss mice with AA. In this experiment, 24 mice were infected with A. costaricensis (10 L3 per animal) followed by treatment with subcutaneous enoxaparin (40 mg/kg/day) or water (sham), starting from 15 days post-infection (dpi) and continued until animal death. Animals were monitored until death or sacrifice at the 50th dpi. Ten mice (42%) were dead after 36 ± 8 dpi. Of these, five (50%) were treated with enoxaparin. Animals treated with enoxaparin and sham did not differ in terms of weight loss (median, 1.3 vs. 4.2 g; P = 0.303) and macroscopical findings. Microscopically, no difference was found in regard to vascular granuloma (median grade, 2 vs. 3; P = 0.293) and presence of either vasculitis (75% vs. 100%; P = 0.217), mesenteric thrombosis (33% vs. 50%; P = 0.680), or bowel necrosis (25% vs. 50%; P = 0.400). Mice dead before the 50th dpi showed more pneumonia (90% vs. 21%; P = 0.002), bowel infarction (40% vs. 0%; P = 0.02), and purulent peritonitis (60% vs. 7%; P = 0.008) compared to survivors. Prophylactic enoxaparin in mice did not prevent tissue damage and mortality related with AA. The lower prevalence of mesenteric thrombosis and bowel infarction regardless of treatment were notorious. Frequent septic complications suggest the need of studies addressing the effect of antibiotics in AA.