Covered versus bare-metal stenting of the mesenteric arteries in patients with chronic mesenteric ischaemia (CoBaGI): a multicentre, patient-blinded and investigator-blinded, randomised controlled trial.

BACKGROUND: Mesenteric artery stenting with a bare-metal stent is the current treatment for atherosclerotic chronic mesenteric ischaemia. Long-term patency of bare-metal stents is unsatisfactory due to in-stent intimal hyperplasia. Use of covered stents might improve long-term patency. We aimed to compare the patency of covered stents and bare-metal stents in patients with chronic mesenteric ischaemia. METHODS: We conducted a multicentre, patient-blinded and investigator-blinded, randomised controlled trial including patients with chronic mesenteric ischaemia undergoing mesenteric artery stenting. Six centres in the Netherlands participated in this study, including two national chronic mesenteric ischaemia expert centres. Patients aged 18 years or older were eligible for inclusion when an endovascular mesenteric artery revascularisation was scheduled and a consensus diagnosis of chronic mesenteric ischaemia was made by a multidisciplinary team of gastroenterologists, interventional radiologists, and vascular surgeons. Exclusion criteria were stenosis length of 25 mm or greater, stenosis caused by median arcuate ligament syndrome or vasculitis, contraindication for CT angiography, or previous target vessel revascularisation. Digital 1:1 block randomisation with block sizes of four or six and stratification by inclusion centre was used to allocate patients to undergo stenting with bare-metal stents or covered stents at the start of the procedure. Patients, physicians performing follow-up, investigators, and radiologists were masked to treatment allocation. Interventionalists performing the procedure were not masked. The primary study outcome was the primary patency of covered stents and bare-metal stents at 24 months of follow-up, evaluated in the modified intention-to-treat population, in which stents with missing data for the outcome were excluded. Loss of primary patency was defined as the performance of a re-intervention to preserve patency, or 75% or greater luminal surface area reduction of the target vessel. CT angiography was performed at 6 months, 12 months, and 24 months post intervention to assess patency. The study is registered with ClinicalTrials.gov (NCT02428582) and is complete. FINDINGS: Between April 6, 2015, and March 11, 2019, 158 eligible patients underwent mesenteric artery stenting procedures, of whom 94 patients (with 128 stents) provided consent and were included in the study. 47 patients (62 stents) were assigned to the covered stents group (median age 69·0 years [IQR 63·0-76·5], 28 [60%] female) and 47 patients (66 stents) were assigned to the bare-metal stents group (median age 70·0 years [63·5-76·5], 33 [70%] female). At 24 months, the primary patency of covered stents (42 [81%] of 52 stents) was superior to that of bare-metal stents (26 [49%] of 53; odds ratio [OR] 4·4 [95% CI 1·8-10·5]; p<0·0001). A procedure-related adverse event occurred in 17 (36%) of 47 patients in the covered stents group versus nine (19%) of 47 in the bare-metal stent group (OR 2·4 [95% CI 0·9-6·3]; p=0·065). Most adverse events were related to the access site, including haematoma (five [11%] in the covered stents group vs six [13%] in the bare-metal stents group), pseudoaneurysm (five [11%] vs two [4%]), radial artery thrombosis (one [2%] vs none), and intravascular closure device (none vs one [2%]). Six (13%) patients in the covered stent group versus one (2%) in the bare-metal stent group had procedure-related adverse events not related to the access site, including stent luxation (three [6%] vs none), major bleeding (two (4%) vs none), mesenteric artery perforation (one [2%] vs one [2%]), mesenteric artery dissection (one [2%] vs one [2%]), and death (one [2%] vs none). INTERPRETATION: The findings of this trial support the use of covered stents for mesenteric artery stenting in patients with chronic mesenteric ischaemia. FUNDING: Atrium Maquet Getinge Group.

Biomarkers of sustained systemic inflammation and microvascular dysfunction associated with post-COVID-19 condition symptoms at 24 months after SARS-CoV-2-infection.

Introduction: Comprehensive studies investigating sustained hypercoagulability, endothelial function, and/or inflammation in relation to post-COVID-19 (PCC) symptoms with a prolonged follow-up are currently lacking. Therefore, the aim of this single-centre cohort study was to investigate serum biomarkers of coagulation activation, microvascular dysfunction, and inflammation in relation to persisting symptoms two years after acute COVID-19. Methods: Patients diagnosed with acute SARS-CoV-2 infection between February and June 2020 were recruited. Outcome measures included the CORona Follow-Up (CORFU) questionnaire, which is based on an internationally developed and partially validated basic questionnaire on persistent PCC symptoms. Additionally, plasma biomarkers reflecting coagulation activation, endothelial dysfunction and systemic inflammation were measured. Results: 167 individuals were approached of which 148 (89%) completed the CORFU questionnaire. At 24 months after acute infection, fatigue was the most prevalent PCC symptom (84.5%). Over 50% of the patients experienced symptoms related to breathing, cognition, sleep or mobility; 30.3% still experienced at least one severe or extreme (4 or 5 on a 5-point scale) PCC symptom. Multiple correlations were found between several PCC symptoms and markers of endothelial dysfunction (endothelin-1 and von Willebrand factor) and systemic inflammation (Interleukin-1 Receptor antagonist). No positive correlations were found between PCC symptoms and coagulation complexes. Discussion: In conclusion, this study shows that at 24 months after acute COVID-19 infection patients experience a high prevalence of PCC symptoms which correlate with inflammatory cytokine IL-1Ra and markers of endothelial dysfunction, especially endothelin-1. Our data may provide a rationale for the selection of treatment strategies for further clinical studies. Trial registration: This study was performed in collaboration with the CORona Follow-Up (CORFU) study (NCT05240742, https://clinicaltrials.gov/ct2/show/ NCT05240742).

Vascular Function, Systemic Inflammation, and Coagulation Activation 18 Months after COVID-19 Infection: An Observational Cohort Study.

INTRODUCTION: Among its effect on virtually all other organs, COVID-19 affects the cardiovascular system, potentially jeopardizing the cardiovascular health of millions. Previous research has shown no indication of macrovascular dysfunction as reflected by carotid artery reactivity, but has shown sustained microvascular dysfunction, systemic inflammation, and coagulation activation at 3 months after acute COVID-19. The long-term effects of COVID-19 on vascular function remain unknown. MATERIALS AND METHODS: This cohort study involved 167 patients who participated in the COVAS trial. At 3 months and 18 months after acute COVID-19, macrovascular dysfunction was evaluated by measuring the carotid artery diameter in response to cold pressor testing. Additionally, plasma endothelin-1, von Willebrand factor, Interleukin(IL)-1ra, IL-6, IL-18, and coagulation factor complexes were measured using ELISA techniques. RESULTS: The prevalence of macrovascular dysfunction did not differ between 3 months (14.5%) and 18 months (11.7%) after COVID-19 infection (p = 0.585). However, there was a significant decrease in absolute carotid artery diameter change, 3.5% ± 4.7 vs. 2.7% ± 2.5, p-0.001, respectively. Additionally, levels of vWF:Ag were persistently high in 80% of COVID-19 survivors, reflecting endothelial cell damage and possibly attenuated endothelial function. Furthermore, while levels of the inflammatory cytokines interleukin(IL)-1RA and IL-18 were normalized and evidence of contact pathway activation was no longer present, the concentrations of IL-6 and thrombin:antithrombin complexes were further increased at 18 months versus 3 months (2.5 pg/mL ± 2.6 vs. 4.0 pg/mL ± 4.6, p = 0.006 and 4.9 µg/L ± 4.4 vs. 18.2 µg/L ± 11.4, p < 0.001, respectively). DISCUSSION: This study shows that 18 months after COVID-19 infection, the incidence of macrovascular dysfunction as defined by a constrictive response during carotid artery reactivity testing is not increased. Nonetheless, plasma biomarkers indicate sustained endothelial cell activation (vWF), systemic inflammation (IL-6), and extrinsic/common pathway coagulation activation (FVII:AT, TAT) 18 months after COVID-19 infection.

Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort.

OBJECTIVE: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Mesenteric occlusive disease of the inferior mesenteric artery is associated with anastomotic leak after left-sided colon and rectal cancer surgery: a retrospective cohort study.

PURPOSE: Anastomotic leak (AL) is a serious complication following colorectal surgery. Atherosclerosis causes inadequate anastomotic perfusion and is suggested to be a risk factor for AL. The aim of this study was to investigate the association of mesenteric occlusive disease on preoperative computed tomography (CT) scan with AL after left-sided colon or rectal cancer surgery. METHODS: This was a retrospective, multicenter cohort study including 1273 patients that underwent left-sided or rectal cancer resection between 2009 and 2018 from three hospitals in the Netherlands. AL patients were 1:1 matched with non-leak patients and preoperative contrast-enhanced CT-scans were retrospectively analyzed for mesenteric atherosclerotic lesions. The main outcome measure was the presence of mesenteric occlusive disease on the preoperative CT-scan. RESULTS: Anastomotic leak developed in 6% of 1273 patients (N = 76). Low anterior resection and stage I-III disease were statistically significant associated with AL (p = 0.01, p = 0.04). No other statistically significant differences in patient characteristics between AL and non-leak patients were found. A clinically significant stenosis (≥ 70-100%) of the inferior mesenteric artery was statistically significant more frequent present in AL patients, compared to non-leak patients (p < 0.01). No statistically significant differences in the presence of mesenteric occlusive disease of the celiac artery and superior mesenteric artery between AL patients and non-leak patients were found. CONCLUSION: Mesenteric occlusive disease of the IMA on preoperative CT-scan is associated with AL after left-sided colon or rectal resection for cancer. Preoperative identification of high-risk patients with a preoperative CT-scan of the mesenteric vasculature might be useful to reduce the risk of AL.

Long-term serological follow-up after primary Coxiella burnetii infection in patients with vascular risk factors for chronic Q fever.

We evaluated the long-term serological follow-up of patients with vascular risk factors for chronic Q fever that were previously Coxiella burnetii seropositive. C. burnetii phase I IgG titers were reevaluated in patients that gave informed consent or retrospectively collected in patients already deceased or lost to follow-up. Of 107 patients, 25 (23.4%) became seronegative, 77 (72.0%) retained a profile of past resolved Q fever infection, and five (4.7%) developed chronic Q fever. We urge clinicians to stay vigilant for chronic Q fever beyond two years after primary infection and perform serological testing based on clinical presentation.

Medical therapy and intervention do not improve uncomplicated isolated mesenteric artery dissection outcomes over observation alone.

OBJECTIVE: Isolated dissection of the mesenteric vessels is rare but increasingly recognized. This study aimed to evaluate patient characteristics, primary treatment, and subsequent outcomes of mesenteric dissection using multi-institutional data. METHODS: All patients at participant hospitals between January 2003 and December 2015 with dissection of the celiac artery (or its branches) or dissection of the superior mesenteric artery (SMA) were included. Patients with an aortic dissection were excluded. Demographic, treatment, and follow-up data were collected. The primary outcomes included late vessel thrombosis (LVT) and aneurysmal degeneration (AD). RESULTS: Twelve institutions identified 227 patients (220 with complete treatment records) with a mean age of 55 ± 12.5 years. Median time to last follow up was 15 months (interquartile range, 3.8-32). Most patients were men (82% vs 18% women) and symptomatic at presentation (162 vs 65 asymptomatic). Isolated SMA dissection was more common than celiac artery dissection (n = 158 and 81, respectively). Concomitant dissection of both arteries was rare (n = 12). The mean dissection length was significantly longer in symptomatic patients than in asymptomatic patients in both the celiac artery (27 vs 18 mm; P = .01) and the SMA (64 vs 40 mm; P < .001). Primary treatment was medical in 146 patients with oral anticoagulation or antiplatelet therapy (n = 76 and 70, respectively), whereas 56 patients were observed. LVT occurred in six patients, and 16 patients developed AD (3% and 8%, respectively). For symptomatic patients without evidence of ischemia (n = 134), there was no difference in occurrence of LVT with medical therapy compared with observation alone (9% vs 0%; P = .35). No asymptomatic patient (n = 64) had an episode of LVT at 5 years. AD rates did not differ among symptomatic patients without ischemia treated with medical therapy or observed (9% vs 5%; P = .95). Surgical or endovascular intervention was performed in 18 patients (3 ischemia, 13 pain, 1 AD, 1 asymptomatic). Excluding the patients treated for ischemia, there was no difference in LVT with surgical intervention vs medical management (one vs five; P = .57). CONCLUSIONS: Asymptomatic patients with isolated mesenteric artery dissection may be observed and followed up with intermittent imaging. Symptomatic patients tend to have longer dissections than asymptomatic patients. Symptomatic isolated mesenteric artery dissection without evidence of ischemia does not require anticoagulation and may be treated with antiplatelet therapy or observation alone.

Vascular imaging of the mesenteric vasculature.

Imaging of the mesenteric vasculature is crucial in diagnosing vascular disease of the gastro-intestinal tract such as acute or chronic mesenteric ischemia caused by arterial stenosis, embolism or thrombosis, mesenteric vein thrombosis and mesenteric aneurysm or dissection. The reference standard for imaging of the mesenteric vasculature is digital subtraction angiography. However, modalities as duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are developing rapidly and may provide accurate imaging non-invasively. This review provides an up-to-date overview of the anatomic resolution, clinical application, emerging techniques and future perspectives of these four radiological modalities for imaging of the mesenteric vasculature.

Clinical significance of mesenteric arterial collateral circulation in patients with celiac artery compression syndrome.

OBJECTIVE: Although extensive collateral arterial circulation will prevent ischemia in most patients with stenosis of a single mesenteric artery, mesenteric ischemia may occur in these patients, for example, in patients with celiac artery compression syndrome (CACS). Variation in the extent of collateral circulation may explain the difference in clinical symptoms and variability in response to therapy; however, evidence is lacking. The objective of the study was to classify the presence of mesenteric arterial collateral circulation in patients with CACS and to evaluate the relation with clinical improvement after treatment. METHODS: Collateral mesenteric circulation was classified on the basis of angiographic findings. Collaterals were categorized in three groups: no visible collaterals (grade 0), collaterals seen on selective angiography only (grade 1), and collaterals visible on nonselective angiography (grade 2). Surgical release of the celiac artery in patients with suspected CACS was performed by arcuate ligament release. Clinical success after surgical revascularization was defined as an improvement in abdominal pain. RESULTS: Between 2002 and 2013, there were 135 consecutive patients with suspected CACS who were operated on. In 129 patients, preoperative angiograms allowed classification of collateral circulation. Primary assisted anatomic success was 93% (120/129). In patients with grade 0 collaterals, clinical success was 81% (39 of 48 patients); with grade 1 collaterals, 89% (25 of 28 patients); and with grade 2 collaterals, 52% (23 of 44 patients; P < .001). CONCLUSIONS: Patients with CACS and with extensive collateral mesenteric arterial circulation are less likely to benefit from arcuate ligament release than are patients without this type of collateral circulation. The classification of the extent of mesenteric collateral circulation may predict and guide shared decision-making in patients with CACS.

Estimated prevalence of chronic Q fever among Coxiella burnetii seropositive patients with an abdominal aortic/iliac aneurysm or aorto-iliac reconstruction after a large Dutch Q fever outbreak.

OBJECTIVES: The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007-2010 in the Netherlands. METHODS: In November 2009, an ongoing screening program for Q fever was initiated. Patients with abdominal aortic and/or iliac disease were screened for presence of IgM and IgG antibodies to phase I and II antigens of Coxiella burnetii using immunofluorescence assay and presence of C. burnetii DNA in sera and/or vascular wall tissue using polymerase chain reaction (PCR). RESULTS: A total of 770 patients with abdominal aortic and/or iliac disease were screened. Antibodies against C. burnetii were detected in 130 patients (16.9%), of which 40 (30.8%) patients showed a serological profile of chronic Q fever. Three patients presented with acute Q fever, one of which developed to chronic Q fever over time. The number of aneurysm-related acute complications in patients with chronic Q fever was significantly higher compared to patients negative for Q fever (p = 0.013); 9.0% (30/333) vs. 30.0% (6/20). Eight out of 46 patients with past resolved Q fever (8/46, 17.4%) presented with aneurysm-related acute complications (no significant difference). CONCLUSION: The prevalence of chronic Q fever in C. burnetii seropositive patients with abdominal aortic and/or iliac disease living in an epidemic area in the Netherlands is remarkably high (30.8%). Patients with an aneurysm and chronic Q fever present more often with an aneurysm-related acute complication compared to patients without evidence of Q fever infection.

Mesenteric stenosis, collaterals, and compensatory blood flow.

BACKGROUND: The mesenteric circulation has an extensive collateral network. Therefore, stenosis in one or more mesenteric arteries does not necessarily lead to symptoms. The objective of this study was to determine the effect of collateral flow on celiac artery (CA) and superior mesenteric artery (SMA) duplex parameters. METHODS: Between 1999 and 2007, a cohort of 228 patients analyzed for suspected chronic mesenteric syndrome was studied. Stenosis of the mesenteric vessels and collateral flow patterns were identified on angiography and categorized. The effect of stenosis in one mesenteric vessel and the presence of collaterals from the other unaffected vessel was examined in both the CA and SMA. RESULTS: Stenosis of the CA resulted in a significantly higher peak systolic velocity (PSV) and end-diastolic velocity in the normal SMA without stenosis. This was also found for the CA without stenosis in the presence of a stenosis of the SMA. An incremental effect of the severity of the CA stenosis was found with a mean SMA PSV of 158 cm/s when normal and 259 cm/s when occluded. The presence of collaterals had a clear effect on duplex parameters of the angiographically normal SMA. In the presence of collaterals and a 70% CA stenosis, the PSV in the normal SMA was significantly higher (P = .025). CONCLUSIONS: This study shows that stenosis in either the CA or SMA increases flow velocities in the other unaffected mesenteric artery. This increase was correlated with the presence of collaterals. Collaterals and stenoses in one of the mesenteric arteries may lead to mimicking or overgrading of stenosis in the other mesenteric artery.

Two cases with acute abdominal aneurysm and evidence of acute Q fever infection.

We report 2 patients with symptomatic aortic aneurysm and serologic evidence of acute Q fever with positive Coxiella burnetii PCR in blood/tissue. This suggests a role for acute Q fever in aneurysm progression. Diagnostic testing for Q fever infection in patients with symptomatic aneurysms in Q fever areas is recommended.

The influence of respiration on criteria for transabdominal duplex examination of the splanchnic arteries in patients with suspected chronic splanchnic ischemia.

BACKGROUND: Duplex ultrasound imaging of the mesenteric vessels is often used as a first diagnostic tool to evaluate the mesenteric circulation in patients with unexplained chronic abdominal symptoms. Several studies on duplex criteria have been published; however, most studies are small and included not exclusively patients with symptoms suggestive of chronic mesenteric syndrome (CMS). This study evaluated the contribution of respiration-monitored duplex ultrasound imaging in the diagnosis of stenosis or occlusion of the mesenteric arteries in patients suspected of CMS and thereby improves the definition of the criteria for stenosis. METHODS: Between 1999 and 2007, 779 consecutive patients presented to our tertiary referral center for evaluation and treatment of CMS. Mesenteric artery duplex ultrasound imaging and angiography of the abdominal aorta and its branches were performed in 324 patients. Angiography was considered the gold standard for verifying the presence or absence of arterial pathology. Results from duplex imaging and angiography were compared to determine the optimal duplex criteria for stenosis. In addition, the contribution of expiration and inspiration on duplex imaging and angiography were established. RESULTS: Significantly higher peak systolic and end-diastolic velocities were found in the celiac artery (CA) and superior mesenteric artery (SMA) during expiration than during inspiration. Receiver operating characteristic curve analyses found respiration-dependent cutoff values for CA and SMA stenosis. The values corresponding with the highest accuracy (minimal false-negative and false-positive results) were determined. Peak systolic velocities cutoff points during expiration and inspiration were 280 and 272 cm/s, respectively, for the CA and 268 and 205 cm/s for the SMA. The end-diastolic velocity cutoff points during expiration and inspiration were 57 and 84 cm/s, respectively, for the CA and 101 and 52 cm/s for the SMA. Sensitivity for different duplex parameters in detecting mesenteric stenosis was 66% to 78% and specificity was 77% to 86%. CONCLUSIONS: This study proposes new criteria related to respiration for duplex ultrasound imaging of the mesenteric arteries in patients with symptoms suggestive of CMS. It emphasizes the importance of taking into account the effect of respiration on duplex parameters. The lower sensitivity and specificity in our study compared with other studies puts into perspective the position of duplex imaging in the work-up of patients with suspected CMS. Duplex results should be used as a guide, with a low threshold giving a higher negative predictive value and, consequently, a lower positive predictive value.

Open or percutaneous revascularization for chronic splanchnic syndrome.

BACKGROUND: Treatment of chronic splanchnic syndrome remains controversial. In the past 10 years, endovascular repair (ER) has replaced open repair (OR) to some extent. This evidence summary reviews the available evidence for ER or OR of chronic splanchnic syndrome. METHODS: A systematic literature search of MEDLINE database was performed to identify all studies that evaluated treatment of chronic splanchnic syndrome between 1988 and 2009. RESULTS: The best available evidence consists of prospectively accumulated but retrospectively analyzed data with a high risk for confounding. Only a few of these studies incorporated functional tests to assess splanchnic ischemia before or after treatment. ER has the advantage of low short-term morbidity but the disadvantage of decreased long-term primary patency compared with OR. ER and OR have similar rates of secondary patency, although the reintervention rate after ER is higher. CONCLUSION: ER appears to be preferential in the treatment of elderly patients and in patients with comorbidity, severe cachexia, or hostile abdomen. Long-term results after OR are excellent. OR can still be proposed as the preferred option for relatively young and fit patients.

Retroperitoneal endoscopic release in the management of celiac artery compression syndrome.

INTRODUCTION: Celiac artery compression syndrome (CACS) can be treated successfully by division of the median arcuate ligament and celiac plexus fibers. The standard technique is the open approach by an upper midline or left subcostal incision. Only six single cases in which a laparoscopic transabdominal approach for CACS was used have been reported. We prospectively evaluated the feasibility of the endoscopic retroperitoneal approach for treatment of CACS. METHODS: All patients with symptoms suggestive of CACS were evaluated using splanchnic duplex ultrasound scanning, gastric exercise tonometry (GET), and multiplane selective splanchnic angiography. The criteria for treatment were chronic abdominal symptoms, respiratory-dependent CA stenosis, and abnormal GET result. The release was performed by a retroperitoneal endoscopic approach. Anatomic success of the procedure was confirmed by angiography. RESULTS: The endoscopic retroperitoneal approach was used to treat 46 patients with CACS. One patient (2%) required conversion to an open procedure due to suprarenal artery bleeding. Release was ended prematurely in one patient due to a pneumothorax resulting in loss of working space. A postoperative pneumothorax developed in two patients, of which one needed treatment. No other complications were observed. Postoperative angiography during inspiration and expiration showed normal vessel anatomy in 36 of 46 patients. Six of 10 patients with persisting intraluminal stenoses were treated endovascularly. Five of these were successful, which brings the primary-assisted anatomic patency for the total group to 89% (41 of 46 patients). Three patients are being observed, and endovascular treatment remains an option in case of insufficient improvement. On median follow-up of 20 months (range, 2-42 months) 41 patients were free of symptoms or showed significant improvement. CONCLUSIONS: The endoscopic retroperitoneal approach for the release of the CA in CACS, with additional endovascular treatment of persistent stenosis, is feasible and effective. Short-term results were comparable with the open procedure.

Gallstone formation after pancreas and/or kidney transplantation: an analysis of risk factors.

Pancreas and kidney transplantation (SPK) is the treatment of choice for patients with type 1 diabetes mellitus and end-stage renal failure. Gallstones are common after SPK transplantation but little is known about the true incidence and etiology of gallstones in this group. We therefore evaluated the incidence of gallstones and the presence of transplant-related risk factors in patients after SPK and kidney transplantation alone (KTA). Data were evaluated of 56 consecutive patients who underwent SPK transplantation and compared the results with those of 91 consecutive nondiabetic patients who underwent KTA transplantation at the Leiden University Medical Center between 1987 and 1994. Of the 58 evaluable KTA patients, 20.7% developed gallstones during 7.7 yr of follow-up and in the SPK group 43.9% of the 41 evaluable patients developed gallstones during 7.1 yr of follow-up. Postoperative weight loss and cyclosporin A-related hepatotoxicity correlated with gallstone formation both in SPK and KTA patients. In addition, the duration of postoperative fasting and autonomic neuropathy correlated with gallstones in SPK patients. It is concluded that both in patients after SPK transplantation and in patients after KTA transplantation, the risk to develop gallstones is significantly increased. Physicians should be aware of the high incidence of gallstones in SPK recipients.

Gastric exercise tonometry: the key investigation in patients with suspected celiac artery compression syndrome.

INTRODUCTION: Controversy continues about the mere existence of the celiac artery compression syndrome. Earlier results of treatment of unselected patients groups showed varying, mostly disappointing, results. The recently introduced gastric exercise tonometry test is able to identify patients with actual gastrointestinal ischemia. We prospectively studied the use of gastric exercise tonometry as a key criterion for revascularization treatment in patients with otherwise unexplained abdominal complaints and significant stenosis of the celiac artery by compression of the arcuate ligament. METHODS: Patients were prospectively selected using abdominal artery angiography and gastric exercise tonometry. Patients with a significant compression of the celiac artery, typical abdominal complaints, and abnormal tonometry were considered for revascularization. RESULTS: Over a 7-year period, 43 patients with significant celiac artery compression were included in this study, and 30 patients were diagnosed as ischemic. Twenty-nine patients had revascularization, 22 (76 %) had a trunk release only. After a median follow-up of 39 months, 83% of patients were free of symptoms. The repeated tonometry after treatment improved in 100% of patients free of symptoms, compared with 25% in patients with persistent complaints after revascularization. CONCLUSIONS: The results of this study suggest that the celiac axis compression syndrome exists and that the actual ischemia can be detected by gastric exercise tonometry and treated safely, with success.