Totally thoracoscopic atrial fibrillation surgery following massive small bowel resection due to superior mesenteric artery embolization: report of two cases.

BACKGROUND: Thromboembolic occlusion of the superior mesenteric artery (SMA) is a grave complication in individuals diagnosed with atrial fibrillation (AF). This condition often necessitates extensive bowel resection, culminating in short bowel syndrome, which presents challenges for anticoagulant administration and/or antiarrhythmic therapy. CASE PRESENTATION: Presented here are findings of two patients, aged 78 and 72 years, respectively, who underwent comprehensive thoracoscopic AF surgery subsequent to extensive small bowel resection following SMA embolization. In each, onset of AF precipitated an embolic event, while the concurrent presence of short bowel syndrome complicated anticoagulation management. Total thoracoscopic AF surgery, comprised stapler-closure of the left atrial appendage (LAA) and bilateral epicardial clamp-isolation of the pulmonary veins, an operative modality aimed at addressing AF rhythm control and mitigating embolic events such as cerebral infarction, led to favorable outcomes in both cases. Additionally, computed tomography (CT) conducted one month post-surgery revealed the absence of residual tissue in the LAA, with the left atrium demonstrating a well-rounded, spherical shape. At the time of writing, the patients have remained asymptomatic following surgery regarding thromboembolic and arrhythmic manifestations for 29 and 10 months, respectively, notwithstanding the absence of anticoagulant or antiarrhythmic pharmacotherapy. Additionally, electrocardiographic surveillance has revealed persistent sinus rhythm. CONCLUSIONS: The present findings underscore the feasibility and efficacy of a total thoracoscopic AF surgery procedure for patients presented with short bowel syndrome complicating SMA embolization, thus warranting consideration for its broader clinical application.

Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database.

BACKGROUND: Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection. METHODS AND RESULTS: Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization. CONCLUSIONS: EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained. REGISTRATION: URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.

A Rare Case of Transient Mesenteric Ischemia After Atrial Fibrillation With Rapid Ventricular Response Rate.

Mesenteric ischemia is an urgent event and requires prompt recognition and treatment, in order to reduce the risk of mortality. It results from the sudden onset of small intestinal hypoperfusion, from a reduction or cessation of arterial perfusion, which can occur from an embolic obstruction at the superior mesenteric artery. We present a case of transient mesenteric ischemia from an episode of atrial fibrillation with a rapid ventricular response rate. Despite being on chronic anticoagulation therapy, the patient developed transient mesenteric ischemia from an embolic clot. The patient's heart rate was controlled and no surgical intervention was required, a rare finding; however, it is very important to recognize and treat promptly.

Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery.

OBJECTIVES: The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment. METHODS: The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group. RESULTS: Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency. CONCLUSIONS: Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.

Ischemic hepatitis due to an occlusion of visceral arteries: a case report.

Ischemic hepatitis due to mesenteric artery occlusion is extremely rare. This is due to the function of the collateral network of the celiac-mesenteric arterial system and portal venous flow. A 64-year-old male presented with abdominal pain, a significantly reduced general condition, a weight loss of 20 kg in 4 months. Computed tomography showed occlusion of the celiac trunk and the superior mesenteric artery and hypodense lesions in the liver. We performed an antegrade visceral reconstruction with a bifurcated 12-6 mm Dacron graft from the supra-celiac aortic donor to the superior mesenteric and celiac arteries. The postoperative course and follow-up were uneventful.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion.

BACKGROUND: Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion. METHODS: We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN. CONCLUSION: The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor. LEVEL OF EVIDENCE: III.

Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases.

This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.

White gastric mucosa during endoscopy as a new endoscopic feature of chronic ischemic gastritis: A case report.

Chronic ischemic gastritis (CIG) requires early diagnosis and treatment as complications of thromboembolism can be fatal. Although computed tomography (CT) is useful in the diagnosis of CIG, it is difficult to diagnose from a patient's history, endoscopic findings, and tissue biopsy. Identification of the key findings that motivate computed tomography is an important issue. We report a case of CIG diagnosed by endoscopic findings of white patches of mucosa over time. A 63-year-old man presented with epigastric pain. He had a history of repeated gastric ulcers of an undetermined cause. We performed upper endoscopy and observed the appearance of multiple white patches on the gastric mucosa. Central vessel stenosis was considered, and aortic computed tomography revealed complete occlusion of the superior mesenteric artery and stenosis of the celiac artery. We carried out a surgical bypass and found no postoperative endoscopic mucosal changes or abdominal pain. White patch changes in the gastric mucosa over time during endoscopy may indicate CIG. This finding may help in the future diagnosis of CIG.

Trends in population-based incidence, diagnostics, and mortality of acute superior mesenteric artery occlusion.

Acute occlusion of the superior mesenteric artery (SMA) results in lethal intestinal ischemia. Results from two previous population-based studies in Malmö, Sweden, suggest a decreasing incidence of acute SMA occlusion. This study aimed to evaluate trends in the epidemiology of acute SMA occlusion in Malmö. The report was a retrospective population-based study conducted from 2014 to 2019 on patients with acute SMA occlusion residing in Malmö municipality. Patient data were retrieved from Skåne University Hospital and postmortem examinations. Epidemiological data were compared to those of the two earlier studies, in particular to the one conducted from 2000 to 2006. Sixteen patients with acute SMA occlusion resided in Malmö municipality. The incidence of acute SMA occlusion significantly decreased from 5.4/100,000 person-years to 0.8/100,000 person-years. The ratio of acute SMA occlusion to non-occlusive mesenteric ischemia (NOMI) decreased from 12.5:1 to 0.9:1 (p < 0.0001), the proportion of inhabitants aged 80 years or above in the population decreased from 6.0% to 4.3% (p < 0.0001), and the autopsy rate decreased from 25% to 14% (p < 0.0001). The in-hospital mortality rate decreased from 63% to 44% (p = 0.14). The incidence of acute SMA occlusion seems to have decreased significantly in Malmö, probably due to high-resolution computed tomography angiographies being available around the clock to distinguish acute SMA occlusion from NOMI, a reduced proportion of elderly individuals, improved control of medical risk factors, and a decrease in autopsy rates.

Intraoperative Indocyanine Green Imaging for the Evaluation of Blood Perfusion Area in Cancer of the Splenic Flexure With an Occluded Inferior Mesenteric Artery: A Report of Two Cases.

Radical resection for cancer of the splenic flexure requires careful consideration of the dissection line so that blood flow in the remnant bowel is maintained, particularly when the root of the inferior mesenteric artery (IMA) is already occluded. Intraoperative indocyanine green (ICG) imaging is a promising method for evaluating blood perfusion of organs and vessels. However, there are few reports on the use of ICG to determine the dissection line in patients with altered blood flow. In this article, we describe two cases of successful resection of splenic flexure cancer (SFC) in patients with an occluded IMA under ICG guidance. Case one was a 76-year-old man with a diagnosis of stage III SFC who had previously undergone endovascular aortic repair without reimplantation of the IMA. Intraoperative ICG imaging revealed that the left side of the colon was perfused mainly by the left branch of the middle colic artery (MCA). We performed a hemicolectomy with preservation of the MCA-left colic artery (LCA) arcade and resected an enlarged lymph node en bloc. Case two was a 77-year-old man with a diagnosis of stage II SFC in whom the root of the IMA appeared to be occluded by arteriosclerosis. Computed tomography showed that the LCA was anastomosed to the accessory middle colic artery (AMCA) while the left branch of the MCA was joined to the marginal artery. Intraoperative ICG imaging revealed that the left side of the colon was perfused by the AMCA and not the MCA. By preserving the AMCA-LCA arcade, we were able to safely divide the left branch of the MCA. Both patients were discharged with no symptoms of bowel ischemia or recurrence of cancer during follow-up. Interindividual variation in vessel branching patterns and dominant vessels in the descending and distal transverse colon may result from congenital factors or acquired disease. Detailed information on blood perfusion is required to avoid postoperative bowel ischemia. This report is the first to focus on patients with SFC and altered blood flow. We show that ICG imaging might be a reasonable option for determining an adequate surgical dissection area.

Acute superior mesenteric artery occlusion associated with COVID-19 pneumonia: a case report.

BACKGROUND: The novel 2019 coronavirus disease (COVID-19), which is caused by infection with the severe acute respiratory syndrome coronavirus 2, has spread rapidly around the world and has caused many deaths. COVID-19 involves a systemic hypercoagulable state and arterial/venous thrombosis which induces unfavorable prognosis. Herein, we present a first case in East Asia where an acute superior mesenteric artery (SMA) occlusion associated with COVID-19 pneumonia was successfully treated by surgical intervention. CASE PRESENTATION: A 70-year-old man presented to his local physician with a 3-day history of cough and diarrhea. A real-time reverse transcriptase-polymerase chain reaction test showed positive for COVID-19, and he was admitted to the source hospital with the diagnosis of moderate COVID-19 pneumonia. Eight days later, acute onset of severe abdominal pain appeared with worsening respiratory condition. Contrast CT showed that bilateral lower lobe/middle lobe and lingula ground glass opacification with distribution suggestive of COVID-19 pneumonia and right renal infarction. In addition, it demonstrated SMA occlusion with intestinal ischemia suggesting extensive necrosis from the jejunum to the transverse colon. The patient underwent an emergency exploratory laparotomy with implementing institutional COVID-19 precaution guideline. Upon exploration, the intestine from jejunum at 100 cm from Treitz ligament to middle of transverse colon appeared necrotic. Necrotic bowel resection was performed with constructing jejunostomy and transverse colon mucous fistula. We performed second surgery to close the jejunostomy and transverse colon mucous fistula with end-to-end anastomosis on postoperative day 22. The postoperative course was uneventful and he moved to another hospital for rehabilitation to improve activities of daily living (ADLs) on postoperative day 45. As of 6 months after the surgery, his ADLs have completely improved and he has returned to social life without any intravenous nutritional supports. CONCLUSIONS: Intensive treatment including surgical procedures allowed the patient with SMA occlusion in COVID-19 pneumonia to return to social life with completely independent ADLs. Although treatment for COVID-19 involves many challenges, including securing medical resources and controlling the spread of infection, when severe abdominal pain occurs in patients with COVID-19, physicians should consider SMA occlusion and treat promptly for life-saving from this deadly combination.

Deficiency of AMPKα1 Exacerbates Intestinal Injury and Remote Acute Lung Injury in Mesenteric Ischemia and Reperfusion in Mice.

Mesenteric ischemia and reperfusion (I/R) injury can ensue from a variety of vascular diseases and represents a major cause of morbidity and mortality in intensive care units. It causes an inflammatory response associated with local gut dysfunction and remote organ injury. Adenosine monophosphate-activated protein kinase (AMPK) is a crucial regulator of metabolic homeostasis. The catalytic α1 subunit is highly expressed in the intestine and vascular system. In loss-of-function studies, we investigated the biological role of AMPKα1 in affecting the gastrointestinal barrier function. Male knock-out (KO) mice with a systemic deficiency of AMPKα1 and wild-type (WT) mice were subjected to a 30 min occlusion of the superior mesenteric artery. Four hours after reperfusion, AMPKα1 KO mice exhibited exaggerated histological gut injury and impairment of intestinal permeability associated with marked tissue lipid peroxidation and a lower apical expression of the junction proteins occludin and E-cadherin when compared to WT mice. Lung injury with neutrophil sequestration was higher in AMPKα1 KO mice than WT mice and paralleled with higher plasma levels of syndecan-1, a biomarker of endothelial injury. Thus, the data demonstrate that AMPKα1 is an important requisite for epithelial and endothelial integrity and has a protective role in remote organ injury after acute ischemic events.

Occlusion of the Superior Mesenteric Artery in Rats Reversed by Collateral Pathways Activation: Gastric Pentadecapeptide BPC 157 Therapy Counteracts Multiple Organ Dysfunction Syndrome; Intracranial, Portal, and Caval Hypertension; and Aortal Hypotension.

Gastric pentadecapeptide BPC 157 therapy counteracts multiple organ dysfunction syndrome in rats, which have permanent occlusion of the superior mesenteric artery close to the abdominal aorta. Previously, when confronted with major vessel occlusion, its effect would rapidly activate collateral vessel pathways and resolve major venous occlusion syndromes (Pringle maneuver ischemia, reperfusion, Budd-Chiari syndrome) in rats. This would overwhelm superior mesenteric artery permanent occlusion, and result in local, peripheral, and central disturbances. Methods: Assessments, for 30 min (gross recording, angiography, ECG, pressure, microscopy, biochemistry, and oxidative stress), included the portal hypertension, caval hypertension, and aortal hypotension, and centrally, the superior sagittal sinus hypertension; systemic arterial and venous thrombosis; ECG disturbances; MDA-tissue increase; and multiple organ lesions and disturbances, including the heart, lung, liver, kidney, and gastrointestinal tract, in particular, as well as brain (cortex (cerebral, cerebellar), hypothalamus/thalamus, hippocampus). BPC 157 therapy (/kg, abdominal bath) (10 µg, 10 ng) was given for a 1-min ligation time. Results: BPC 157 rapidly recruits collateral vessels (inferior anterior pancreaticoduodenal artery and inferior mesenteric artery) that circumvent occlusion and ascertains blood flow distant from the occlusion in the superior mesenteric artery. Portal and caval hypertension, aortal hypotension, and, centrally, superior sagittal sinus hypertension were attenuated or eliminated, and ECG disturbances markedly mitigated. BPC 157 therapy almost annihilated venous and arterial thrombosis. Multiple organ lesions and disturbances (i.e., heart, lung, liver, and gastrointestinal tract, in particular, as well as brain) were largely attenuated. Conclusions: Rats with superior mesenteric artery occlusion may additionally undergo BPC 157 therapy as full counteraction of vascular occlusion-induced multiple organ dysfunction syndrome.

Superior Mesenteric Arterial and Venous Thrombosis in COVID-19.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 has been reported in literature, combined superior mesenteric arterial and venous thrombosis is rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection. CASE REPORT: We report a case of a 45-year-old man who was a health care worker who presented to the emergency department with severe abdominal pain. The clinical examination was unremarkable, but imaging revealed acute mesenteric ischemia caused by superior mesenteric artery and superior mesenteric vein occlusion. Imaging of the chest was suggestive of COVID-19 infection, which was later confirmed with reverse transcription polymerase chain reaction of his nasopharyngeal swab. To date, only 1 case of combined superior mesenteric artery and superior mesenteric vein thrombosis caused by COVID-19 has been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding high-resolution computed tomography of the chest to abdominal imaging should be considered in patients with acute abdomen because it can help to identify COVID-19 immediately. © 2020 Elsevier Inc.

Short-term experience with aspiration embolectomy using a ACE68 reperfusion catheter to treat embolic superior mesenteric artery occlusion.

We report the short-term results with aspiration embolectomy using an ACE68 reperfusion catheter to treat patients with acute embolic superior mesenteric artery (SMA) occlusion. Our study included 4 consecutive male patients ranging in age from 72 to 86 years (mean age 79 years). In all patients, the main trunk of the SMA was occluded. The technical success rate was 100% for all procedures. There were no major procedure-related complications. One patient underwent laparotomy with intestinal resection after successful recanalization. No patient reported clinical symptoms of abdominal ischemia at follow-up. Our short-term experience shows that percutaneous aspiration embolectomy using an ACE68 reperfusion catheter is an effective treatment for acute mesenteric ischemia.

Naturally shrunk visceral artery aneurysms by stenting for the superior mesenteric artery occlusion.

A 77-year-old woman who had experienced postprandial abdominal pain for four years was admitted to our institution presenting sudden and severe abdominal pain. Contrast-enhanced computed tomography (CECT) demonstrated complete short-segmented occlusion in the orifice of the superior mesenteric artery (SMA), and saccular aneurysms in the right hepatic artery and the anterior superior pancreaticoduodenal artery. She was diagnosed with abdominal angina due to occlusion of the SMA. The SMA was recanalized by stenting, and a CECT scan confirmed naturally shrunk aneurysms after eight months. The patency of the SMA was maintained at five years after endovascular treatment.

Superior Mesenteric Artery Thrombosis Following Severe COVID-19 Pneumonia.

Thrombotic events are well-recognized complications of coronavirus disease 2019 (COVID-19). The incidence of such complications is highly related to the severity of COVID-19 pneumonia. Recent evidence suggests that the coagulopathy of COVID-19 may persist for some period even after the full recovery from pneumonia. We report the case of a 35-year-old man who presented with a 10-day history of fever and cough. His plain radiograph showed bilateral peripherally located opacities suggestive of COVID-19. The diagnosis was confirmed by the reverse transcriptase-polymerase chain reaction (RT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was placed on a non-invasive ventilator but it failed to maintain normal oxygen saturation. Hence, the decision for intubation was made. He was extubated after 10 days in the ICU. The patient had a complete recovery. One week after discharge, the patient presented with severe abdominal pain that was out of proportion to the physical examination findings. He had an abdominal CT scan, which demonstrated a large thrombus occluding the superior mesenteric artery. There was no bowel dilatation or focal mural thickening to suggest bowel ischemia. The patient was resuscitated with intravenous fluid hydration. Opioid analgesics were administered to control the pain. After stabilizing the patient, he underwent laparotomy with thrombectomy. The patient tolerated the operation with no complications and had an uneventful recovery. The patient was discharged in good condition with no active issues after four days of hospitalization. The superior mesenteric thrombosis is an unusual complication of COVID-19 pneumonia. This case provides further evidence on the possibility of thrombotic events following the recovery from COVID-19. There is a pressing need for future studies to investigate the role of prophylactic antithrombotic and anticoagulants in patients who recovered from severe COVID-19.

Impact of the collateral network on central-repair-first strategy in superior mesenteric artery occlusion with type A acute aortic dissection.

OBJECTIVES: Surgery for acute type A aortic dissection with mesenteric malperfusion is challenging. Although the peripheral-reperfusion-first strategy has shown good results, more discussion regarding indicated patients is needed. This study aimed to describe the imaging features and surgical outcomes of mesenteric malperfusion and to clarify which cases should be considered for the peripheral-reperfusion-first strategy. METHODS: A total of 200 patients underwent emergent aortic repair for acute type A aortic dissection at our institution between October 2011 and July 2019. Superior mesenteric artery occlusion on preoperative contrast-enhanced computed tomography was detected in 12 patients, who were categorized into two groups based on enhancement (n = 7) or non-enhancement (n = 5) of the superior mesenteric artery peripheral branches. Operative outcomes after central repair were compared between groups. RESULTS: Four patients in the enhanced group had no postoperative abdominal complications, and three patients required superior mesenteric artery bypass grafting with the central-repair-first strategy. However, all patients in the enhanced group survived and did not require intestinal resection. In contrast, four patients (80%) in the non-enhanced group had intestinal necrosis, three patients required intestinal resection, and one patient died from multiple organ failure. CONCLUSION: The presence or absence of an enhancement of the peripheral superior mesenteric artery by the collateral network could be helpful for decision-making. The central-repair-first strategy may be permitted in patients with enhanced peripheral branches. Conversely, in patients with non-enhanced peripheral branches, a more invasive assessment should be considered before central aortic repair, and peripheral-reperfusion-first strategy may be required.

Recanalization using direct stenting before bowel resection for acute-on-chronic superior mesenteric artery occlusion: A case report.

INTRODUCTION: Acute-on-chronic mesenteric ischemia (ACMI) refers to acute mesenteric ischemia (AMI) developing in a patient displaying typical symptoms of chronic mesenteric ischemia (CMI). Delayed treatment can cause short bowel syndrome and increased mortality. Intervention involves intestinal revascularization and resection of the necrotic intestine. However, the revascularization procedure must consider the chronic nature of the occlusion. PRESENTATION OF CASE: A 79-year-old man presented with periumbilical pain for 6 h. AMI was diagnosed, together with chronic superior mesenteric artery occlusion and suspected intestinal necrosis. The symptomatic CMI might have insufficient blood flow to intestines. Endovascular recanalization of the superior mesenteric artery using direct stenting was performed before laparotomy to improve blood flow to the intestines. Subsequent laparotomy revealed approximately 60 cm of ischemic small bowel extending from the jejunum (300 cm anal to the ligament of Treitz) to the ileum (30 cm oral to the terminal ileum). The necrotic bowel was resected without anastomosis. At the second-look operation, further resection was not required. DISCUSSION: Making a differential diagnosis between acute and acute-on-chronic occlusions is essential for determining the necessity of recanalization and the method of restoring the intestinal blood flow. Here, the patient with symptomatic CMI might have had insufficient blood flow to the intestines despite establishing collateral supply. We determined that recanalization was needed. Direct stenting without predilation could save time to recanalization and result in less risk of distal embolization. CONCLUSION: This case suggests prompt recanalization using direct stenting can minimize subsequent bowel resection in patients with ACMI.