Traumatic Aortic and Celiac Pseudoaneurysm with Aortocaval Fistula Managed with Endovascular Aortic Cuff Deployment and Open Hepatic Revascularization.

We present the case of a young patient who sustained a gunshot wound to the abdomen initially treated with laparotomy and repair of small bowel, splenic vein and diaphragmatic injuries. Subsequent computed tomography (CT) performed for hemodynamic instability demonstrated a pseudoaneurysm involving the aorta and proximal celiac artery, with an associated aortocaval fistula. An attempt at transperitoneal repair of these injuries was aborted due to extensive inflammatory changes in the region encountered during exposure. Subsequently, a hybrid repair was performed. This consisted of exclusion of the aortic and celiac artery pseudoaneurysm using an endovascular aortic cuff (22 × 39 mm, Cook Medical) via infrarenal aortic access, surgical ligation of the celiac artery branches, and revascularization via bypass from the infrarenal aortic access site arteriotomy to the common hepatic artery.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery.

BACKGROUND: Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes. METHODS: Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com. RESULTS: Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid. CONCLUSIONS: Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications. LEVEL OF EVIDENCE: III (Retrospective therapeutic study and systematic literature review).

Incidence and management of arterial injuries during pancreatectomy.

PURPOSE: The incidence of intraoperative arterial injury during pancreatectomy is not well described. This study aims to evaluate the incidence, management, and outcome of arterial injuries during pancreatectomy. METHODS: This is a retrospective study of 1535 consecutive patients undergoing pancreatectomy between 2006 and 2016 at Oslo University Hospital. The type of arterial injury and potential contributing factors were analyzed. Short-term outcomes were compared between patients with arterial injury and patients undergoing a planned arterial resection due to tumor involvement. RESULTS: Arterial injury was diagnosed in 14 patients (incidence 0.91%), while planned arterial resection was performed in 22 patients. The injuries were located in the superior mesenteric artery (n = 5), right hepatic artery (n = 5), common hepatic artery (n = 2), left hepatic artery (n = 1), and celiac trunk (n = 2). The artery was reconstructed in all except one patient. In 11 patients with injury, peripancreatic inflammation, aberrant arterial anatomy, close relationship between tumor and injured artery, or a combination of the three were found. Median estimated blood loss was 1100 ml in both groups. Rate of severe complications (≥ Clavien grade IIIa), comprehensive complication index, and 90-day mortality for patients with intraoperative arterial injury vs planned arterial resection were 43 vs 45% (p = 0.879), median 35.9 vs 21.8 (p = 0.287), and 14.3 vs 4.5% (p = 0.551), respectively. CONCLUSION: Arterial injury during pancreatectomy is an infrequent and manageable complication. Early recognition and primary repair in order to restore arterial liver perfusion may improve outcome. However, the morbidity is high and comparable to patients undergoing a planned arterial resection.

Celiac Artery Avulsion Secondary to Blunt Trauma: A Case Report.

Celiac artery (CA) injuries are very rare and are often associated with high mortality. These injuries are associated more often with penetrating trauma rather than blunt trauma injury. Our case highlights a blunt trauma injury of CA in a hemodynamically stable patient without any symptoms that was treated conservatively.

Revascularization of the celiac and superior mesenteric arteries after operative injury using both splenic artery and saphenous graft.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.

Traumatic Blunt Injuries to the Celiac Artery: A 5-Year Review From a Level I Trauma Center.

BACKGROUND: Injury to the celiac artery secondary to a blunt mechanism of trauma is an extremely rare injury that accounts for only 1%-2% of all visceral vascular lesions. Although rare, this injury is associated with significant mortality. Despite this high mortality, there are currently only a few published case series of blunt celiac artery injuries in the literature. This study sought to review all cases of blunt celiac artery injuries that presented to our Level I trauma center over a 5-year period. METHODS: This was a retrospective chart review of all patients who presented with a traumatic blunt celiac artery injury between January 2012 and March 2017. RESULTS: A total of 10 patients met the inclusion criteria for this study. The majority of patients were male (7/10, 70%), the average age was 38.3 ± 16.1 years, and overall mortality was 20% (2/10). On average, patients spent 10.2 ± 6.5 days in the hospital, 4.4 ± 4.5 days in the ICU, and 1.6 ± 2.0 days on the ventilator. The majority of patients presented with either an intimal dissection (3/10, 30%) or an intraluminal thrombus (3/10, 30%). Other injuries included pseudoaneurysms (2/10, 20%), complete avulsion (1/10, 10%), and an intimal dissection with thrombus (1/10, 10%). Of these injuries, 2 (20%) were noted to have retrograde flow on imaging studies including computed tomography angiography and a visceral angiogram. The majority of patients (8/10, 80%) were managed nonoperatively, and 5 (50%) patients were discharged home on aspirin. One patient who was initially managed nonoperatively required an unplanned return to the operating room for ischemic bowel, liver, and stomach. There were no other complications noted. DISCUSSION: Traumatic blunt injury to the celiac artery is rare. Although there are multiple treatment options, there is currently no consensus in regard to management guidelines. In this case series, the majority of patients were successfully managed nonoperatively suggesting that a selective approach for intervention on patients with a blunt celiac artery injury should be considered.

[A rare cause of pneumoperitoneum]. / Pneumoperitoneu de cauza rara.

We provide the description of a 77 year old patient, admitted into the IC unit, with whom the surgical intervention was required by the presence of a massive pneumoperitoneum observed during abdominal CT. Anamnestic and clinical information was scarce; the patient had been admitted into the gastroenterology unit with the following diagnosis: acute pancreatitis, renal failure, atrioventricular block, while the hemodynamic instability made hospitalisation into the IC unit mandatory. Anatomopathological lesions secondary to a major vascular damage at the level of the celiac trunk and at the superior mesenteric level were noticed intraoperatively: total gastric necrosis with perforation, splenic infarction, entero-mesenteric infarction, abdominal wall necrosis. The patient did not allow for a surgical solution. The anatomopathological examination of the gastric tissue fragment enabled the diagnosis of extensive gangrene of the gastric wall. The relevance of the case consists in the presence of an abdominal vascular damage detected in full development, where the pneumoperitoneum required surgical exploration. The intricacy of the anatomopathological lesions accounts for the acute painful abdominal onset, accompanied by quick hemodynamic, clinical, and biochemical deterioration. Thus, gastric perforation through rupture secondary to total gastric gangrene of vascular origin joins the many causes of pneumoperitoneum.

Traumatic dissection of the coeliac artery and splenic injury following blunt trauma.

An 18-year-old male patient presented to our regional referral hospital postcollapse at home. This was about 48 hours following a 2 m fall from a mountain bike. CT scan at presentation showed a grade 3/4 laceration at the splenic lower pole with some haemoperitoneum. He was managed conservatively. However, on day 4 he developed increasing abdominal pain which prompted repeat CT abdominal angiography. This scan did not show any further active bleeding from the spleen, however, a coeliac artery dissection was discovered, which was not evident on the first scan. After liaison with the vascular surgery team at a tertiary hospital, this was treated conservatively. Coeliac artery dissection following blunt trauma is an extremely rare occurrence, with fewer than 10 cases described in the literature. To our knowledge, this is the first case of concurrent splenic injury and coeliac artery dissection following blunt trauma to be reported.

Iatrogenic celiac and hepatic artery dissections during intra-arterial regional tumor therapies: a 16-year retrospective review.

PURPOSE: To identify the incidence and outcomes of iatrogenic celiac and hepatic artery dissections during transarterial therapies, including bland embolization, chemoembolization, radioembolization (TARE), and pre-TARE scintigraphic mapping. METHODS: The institution's quality assessment database, electronic medical record, and picture archiving and communication system were reviewed to identify all patients who underwent transarterial locoregional therapy from 1/2001 to 7/2017 and to determine the incidence of iatrogenic dissection, to assess patency of the arteries after dissection, and to assess the ability to complete therapy. RESULTS: 2253 patients underwent 3776 transarterial hepatic oncology procedures. Among 3776 procedures, 40 (1.1%) were associated with dissection of the visceral vasculature, affecting 39 patients (1.7%). The incidence of flow-limiting dissections was 0.3% (13/3776) and non-flow-limiting dissections was 0.7% (27/3776). After dissection, 68% (27/40) of treatments were completed the same day. Among the 13 aborted treatments, 8 (62%) were completed on a subsequent encounter. Follow-up imaging was obtained in 26 of 40 cases at median time of 63 days. Complete resolution of the dissection was seen in 15/26 cases (58%), near complete resolution (< 30% luminal narrowing) in 3/26 (12%), unchanged appearance of a non-flow-limiting dissection in 4/26 (15%), progressive luminal narrowing in 3/26 (12%), and complete occlusion in 1/26 (4%). CONCLUSION: Iatrogenic dissections of visceral arteries rarely occur during tumor embolization procedures. 35/39 (90%) of patients underwent successful treatment despite the dissection.

Successful conservative treatment of acute traumatic occlusions of the celiac artery and superior mesenteric artery: A case report emphasizing the importance of the visceral collateral circulations.

RATIONALE: Blunt injury of major visceral arteries such as celiac artery (CA) and superior mesenteric artery (SMA) are very rare but fatal, therefore, these injuries are challenging to trauma surgeons. The patient with occlusion of CA or SMA is theoretically viable by visceral collateral circulation. However, there are very rare cases in clinics. To date, there have been few reports of both CA and SMA occlusions after blunt trauma. Herein we describe our successful conservative treatment of patients with both CA and SMA occlusions. PATIENT CONCERNS: Fifteen-year-old girl suffering from schizophrenia was transferred to our hospital after a fall from 3-floor-height with a purpose of suicide. DIAGNOSES: An abdominal computed tomography (CT) scan with contrast enhancement showed proximal CA and proximal SMA occlusions with surrounding retroperitoneal hematoma, however, distal parts of occlusion were supplied by the collateral vessels (enlarged marginal artery of left colon from inferior mesenteric artery and pancreaticoduodenal arcade). INTERVENTIONS: She was treated by only supportive care without anticoagulant due to retroperitoneal hematoma. OUTCOMES: The patient was discharged 25 days after admission without complications. LESSONS: We think that our patient could survive because her vascular status was healthy and collateral circulations were plenty according to the young age. We believe that this case can provide a basis for ligation in these forbidding and handless major visceral arterial injuries such as CA or SMA.

Tratamiento quirúrgico de un aneurisma micótico roto de la arteria hepática / Surgical treatment of ruptured mycotic hepatic artery aneurysm

No disponible

Injuries to the visceral arteries.

Injuries of the major visceral arteries are among the more difficult to manage and rarely occur without serious associated injuries. Sixty-six patients are presented with injuries to the celiac, superior, and inferior mesenteric arteries. Fifty-three injuries resulted from gunshot wounds, nine from stab wounds, and four from blunt trauma. Operative management included vessel ligation in 11 patients, arteriorrhaphy in 43, resection and end-to-end anastomosis in six, Dacron graft interposition in four, and aortic reimplantation in two. Twenty-three patients died, 16 from failure to control hemorrhage. In two patients failure to restore adequate visceral circulation resulted in bowel ischemia and infarction. The successful management of patients with visceral arterial injuries is dependent upon rapid and adequate exposure followed by primary repair or revascularization utilizing available surgical techniques.

Visceral vascular injuries.

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Importance of brain-gut axis in the gastroprotection induced by gastric and remote preconditioning.

Limitation of the damage to the organs such as heart, liver, intestine, stomach and brain by an earlier brief complete occlusion of their arteries is defined as ischemic preconditioning (IP). No study so for has been undertaken to check whether brain-gut axis is involved in the gastroprotection exhibited by gastric IP or in that induced by repeated brief episodes of ischemia of remote organs such as heart and liver. This study was designed to determine the possible involvement of vagal and sensory afferent nerves, in the mechanism of gastric and remote organ IP on the gastric mucosa in rats exposed to prolonged ischemia-reperfusion with or without functional ablation of sensory nerves by capsaicin or in those with removed vagal innervation by vagotomy. This gastric IP was induced by short ischemia episodes (occlusion of celiac artery 1-5 times for 5 min) applied 30 min before subsequent ischemia followed by 3 h of reperfusion (I/R) and compared with remote IP induced by occlusion of left descending coronary artery or hepatic artery plus portal vein. The area of gastric lesions was determined by planimetry, gastric blood flow (GBF) was measured by H(2)-gas clearance method and mucosal biopsy samples were taken for the assessment of calcitonin gene-related peptide (CGRP) by RIA. Exposure of gastric mucosa to standard 3 h of I/R produced numerous gastric lesions and significant fall in the GBF and mucosal CGRP content. Two 5 min short ischemic episodes by occlusion of coronary or hepatic arteries, significantly reduced gastric damage induced by I/R with the extent similar to that exhibited by two short (5 min) episodes of gastric ischemia. These protective effects of gastric and remote IPs were accompanied by a restoration of the fall in the CGRP content caused by I/R alone. Protection and hyperemia induced by gastric IP were significantly attenuated in capsaicin-denervated or vagotomized animals and completely removed in those exposed to the combination of vagotomy and capsaicin-denervation. The IP-induced protection and hyperemia were restored by the administration of exogenous CGRP to gastric IP in capsaicin-treated animals. Gastroprotective and hyperemic actions of remote IP were markedly diminished in capsaicin-denervated rats and in those subjected to vagotomy. We conclude that brief ischemia in remote organs such as heart and liver protects gastric mucosa against gastric injury induced by I/R as effectively as gastric IP via mechanism involving both vagal and sensory nerves releasing vasodilatatory mediators such as CGRP.

Liver trauma in children.

A review of our experience with urban children who sustained blunt abdominal trauma revealed that liver trauma occurred in one-third of all children. The cause of trauma, predominantly blunt in nature, led to a multitude of associated injuries which not only caused visceral and skeletal injury endangering the patient, but, more apparent even though less significant injuries delayed diagnosis and therapy of the underlying sever liver injury. Awareness of the possibility of liver injury in children with blunt abdominal trauma, prompt operative intervention wil injuries should significantly increase the salvage of these pediatric trauma victims.

Nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization.

We present our experience in the nonoperative management of iatrogenic lesions of celiac branches by using transcatheter arterial embolization. We treated 6 pseudoaneurysms (5 intrahepatic and 1 of the gastroduodenal artery), 6 vessel lacerations (1 common hepatic artery, 1 right hepatic artery, 1 gastroduodenal artery, 2 pancreatoduodenal, 1 polar intrasplenic artery), 1 arterioportal fistula, and 1 arteriobiliary fistula; all the bleeding lesions were secondary to surgical, endoscopic, or interventional radiologic procedures.

Acute intramural haematoma of the coeliac artery.

The report describes a previously healthy 24-year-old women presenting with acute abdominal pain following a hyperextension manoeuvre. The key finding of a continuous bruit with systolic and diastolic components in the epigastric region subsequently led to the diagnosis of an intramural haematoma of the coeliac artery, that caused a subtotal occlusion of the artery. The diagnosis was achieved by both colour-coded duplex sonography and magnetic resonance angiography. The case shows that a conservative management rather than operative reconstruction is justified in an oligo-symptomatic situation with no signs of end-organ damage as in this patient.