Endovascular treatment of traumatic pseudoaneurysm of the ileal branch of the superior mesenteric artery in a 9-year-old girl: Case report and literature review.

RATIONALE: Visceral artery aneurysm is a rare and potentially fatal vascular condition that typically affects the superior mesenteric or inferior mesenteric arteries, the splenic, hepatic, and celiac arteries, as well as their branches. Visceral artery aneurysms can usually be treated using endovascular intervention, open surgery, or percutaneous thrombin injection. PATIENT CONCERNS: A 9-year-old girl was admitted to our trauma center with abdominal and bilateral leg pain after a car accident involving a head-on collision. DIAGNOSIS: Abdominal computed tomography (CT) showed bowel herniation through a muscle defect in the left lateral abdominal wall. There was a small amount of fluid around the liver and spleen, mild thickening of the small bowel wall, and infiltration in the small bowel mesentery, indicating the possibility of small bowel injury. INTERVENTIONS: Emergent exploratory laparotomy was performed. After resection of the ischemic parts of the terminal ileum and sigmoid colon, intestinal continuity was reestablished. Primary repair was performed on a traumatic left lateral abdominal wall hernia. She recovered well postoperatively without any complications. A follow-up abdominal CT scan after 2 months showed a pseudoaneurysm of the ileal branch of the superior mesenteric artery. Despite the absence of any gastrointestinal symptoms, the pseudoaneurysm was treated by endovascular intervention using numerous coils because of the significant risk of delayed rupture or massive bleeding. OUTCOMES: Follow-up abdominal CT scan after 6 months showed complete occlusion and resorption of the pseudoaneurysm. LESSONS: Although it is technically challenging, endovascular coil embolization may be a feasible technique in children with traumatic visceral artery pseudoaneurysms without complications.

A rare iatrogenic mesenteric laceration and hemorrhagic shock after colonoscopy. Case report and literature review.

AIM: We report a particular case study of the unexpected death of a 70-year-old caucasian man (affected by crohn's disease) due to the laceration of the ileocolic mesentery and its blood vessels following a colonoscopy procedure carried out only a few hours previously. MATERIAL OF THE STUDY: The autopsy showed that the lacerated blood vessels (i.e. the collateral and terminal branches of the superior mesenteric artery), which run along the section of the intestines between the end of the ileum and the ascending cecum, had led to a severe intra-abdominal hemorrhage and, consequently, fatal hemorrhagic shock. RESULTS: In such cases, both an autopsy and complete histological analysis are essential in order to determine the exact point responsible for the intestinal hemorrhage and to better understand the pathological mechanism involved. DISCUSSION: The unexpected death due to severe peritoneal hemorrhaging following a minimally invasive diagnostic clinical procedure, such as a colonoscopy, is particularly rare in Literature. In fact, amongst the several endoscopy procedures commonly used today, it is one of the safest procedures with the lowest recorded rate of complications. Furthermore, it is an even rarer event that a routine diagnostic colonoscopy can result in a fatality, with only two cases reported. CONCLUSIONS: In the case of sudden death following such a routine diagnostic clinical procedure, the forensic scientist should not disregard the fact that also damage, which appears negligible (caused by the normal procedures used in carrying out a colonoscopy) can actually also result in severe and fatal hemorrhaging. KEY WORDS: Colonoscopy, Fatal hemorrhage, Forensic pathology.

Mesenteric Vascular Injury in Trauma: An NTDB Study.

BACKGROUND: Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries. METHODS: A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating). RESULTS: Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001). CONCLUSIONS: The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.

A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy-6-year Follow-up.

OBJECTIVE: To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature. MATERIALS AND METHODS: The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump. RESULTS: At the 6-year follow-up, the patient had no intestine-related sequelae. CONCLUSION: Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

Glutamine protects intestine against ischemia-reperfusion injury by alleviating endoplasmic reticulum stress induced apoptosis in rats

Abstract Purpose Glutamine, as an essential part of enteral nutrition and parenteral nutrition agent, has been widely recognized to be a kind of important intestinal mucosa protectant in clinical practice and experimental research. However, the mechanisms of its protective effects are still not fully understand. Consequently, this study aimed to explore the potential mechanism of glutamine on ischemia-reperfusion (I/R) injury induced endoplasmic reticulum (ER) stress in intestine. Methods An experimental model of intestinal I/R in rats was established by 1 hour occlusion of the superior mesenteric artery followed by 3 hours of reperfusion. Morphologic changes of intestinal mucosa, apoptosis of epithelial cells, and expression of intestinal Grp78, Gadd153, Caspase-12, ATF4, PERK phosphorylation (P-PERK) and elF2αphosphorylation(P-elF2α) were determined. Results After I/R, the apoptotic index of intestinal mucosa epithelial cells observably increased with notable necrosis of intestinal mucosa, and the expressions of Grp78, Gadd153, Caspase-12, ATF4, P-PERK and P-elF2αall were increased. However, treatment with glutamine could significantly relieve intestinal I/R injury and apoptosis index. Moreover, glutamine could clearly up-regulate the expression of Grp78, restrain P-PERK and P-elF2α, and reduce ATF4, Gadd153 and Caspase-12 expressions. Conclusion Glutamine may be involved in alleviating ER stress induced intestinal mucosa cells apoptosis.

The consequences of major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis.

BACKGROUND: Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. METHOD: A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured. RESULTS: The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026). CONCLUSION: This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.

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.

Endovascular Treatment of Post-traumatic Superior Mesenteric Arteriovenous Fistula: A Case Report.

Superior mesenteric arteriovenous fistulae (SMAVFs) are extremely rare with no consensus about therapeutic indications and optimal approach. Here, we present a case of a symptomatic SMAVF found in a young patient a few years after a penetrating abdominal injury. Following a complex clinical management of the acute status, we successfully managed the fistula with 3 covered stents in 2 consecutive endovascular procedures. Technical details of the performed procedures, including the main pitfalls and chosen solutions, have been explored and discussed.

Trauma to the Superior Mesenteric Artery and Superior Mesenteric Vein: A Narrative Review of Rare but Lethal Injuries.

Mesenteric vessels, including the superior mesenteric artery (SMA) and vein (SMV), provide and drain the rich blood supply of the midgut and hindgut. SMA and SMV injuries are rare and often lethal. Clinical management of these injuries is not well established, but treatment options include operative, non-operative, and endovascular strategies. A narrative review of the literature was conducted using MEDLINE Complete-EBSCO. Relevant studies, specifically those focusing on diagnosis and management of SMA and SMV injuries, were selected. Only original reports and collected series were selected to prevent duplication of cases. A search of the literature for mesenteric arterial injuries yielded 87 studies. Vessel-specific breakdown of the studies yielded 40 with SMA injuries and 41 with SMV injuries. These searches were winnowed to 26 individual studies, which were included in this collective review. Limitations of this study are similar to all narrative literature reviews: the dependence on previously published research and availability of references as outlined in our methodology. Although historically rare, mesenteric vessel injuries are seen with increasing incidence and continue to present a challenge to trauma surgeons due to their daunting mortality rates. Currently, universal treatment guidelines do not exist, but the various options for their management have been extensively reviewed in the literature.

Percutaneous Endoscopic Gastrostomy Tube Insertion-induced Superior Mesenteric Artery Injury Treated with Angiography.

Percutaneous endoscopic gastrostomy (PEG) is widely used to provide nutritional support for patients with dysphagia and/or disturbed consciousness preventing oral ingestion, and PEG tube placement is a relatively safe and convenient non-surgical procedure performed under local anesthesia. However, the prevention of PEG-insertion-related complications is important. A 64-year-old man with recurrent pneumonia underwent tracheostomy and nasogastric tube placement for nutritional support and opted for PEG tube insertion for long-term nutrition. However, during the insertion procedure, needle puncture had to be attempted twice before successful PEG tube placement was achieved, and a day after the procedure his hemoglobin had fallen and he developed hypotension. Abdominal computed tomography revealed injury to a pancreatic branch of the superior mesenteric artery (SMA) associated with bleeding, hemoperitoneum, and pancreatitis. Transarterial embolization was performed using a microcatheter to treat hemorrhage from the injured branch of the SMA, and the acute pancreatitis was treated using antibiotics and supportive care. The patient was discharged after an uneventful recovery. Clinicians should be mindful of possible pancreatic injury and bleeding after PEG tube insertion. Possible complications, such as visceral injuries or bleeding, should be considered in patients requiring multiple puncture attempts during a PEG procedure.

Superior mesenteric artery dissection as a complication of an endovascular attempt to treat aneurysms of the pancreaticoduodenal arteries.

A case of iatrogenic dissection of the superior mesenteric artery (SMA) in a 42-year old woman during an attempt of endovascular treatment of aneurysms of the pancreaticoduodenal arteries coexisting with a stenosis of the coeliac trunk is presented. The dissection occurred most probably during insertion of an introducer sheath into the SMA. The patient at that moment reported a short-lasting abdominal pain and after that remained asymptomatic. Due to technical difficulties, the attempt of endovascular management of pancreaticoduodenal aneurysms was abandoned. The completion angiography revealed the occlusion of the SMA. The patient underwent an emergency laparotomy; pancreaticoduodenal aneurysms were excised and SMA dissection was repaired with endarterectomy and a patch closure. Postoperative recovery was uneventful and the patient remained asymptomatic during a 30-month follow-up. The case underscores the importance of completion angiography after endovascular interventions in the SMA since the early period of its occlusion may be asymptomatic.

A randomized, controlled animal trial demonstrating the feasibility and safety of the Magellan™ endovascular robotic system.

BACKGROUND: The success of remotely steerable catheters designed for cardiac ablation procedures in the peripheral vasculature (in the laboratory and in highly select live cases) has led to the development of a vascular robotic system designed specifically for use in the arterial and venous systems. Limited bench-top and animal testing has been successful, but no randomized, controlled study of the system's safety has been performed. METHODS: In a 3-phase study, we performed a randomized, controlled trial comparing standard manual catheterization and balloon angioplasty of visceral, renal, and contralateral lower extremity vessels in a porcine model. We also demonstrated feasibility of standard device deployment through the system. RESULTS: There was 100% technical success in test (robotic) and control (manual) arm cannulation and balloon angioplasty of all target vessels, without complications. Pathologic analysis at 7 days revealed significantly fewer traumatic lesions in the test animal arm as compared with the control arm (P < 0.001) and, by 30 days, all lesions had healed in both groups. There was 100% success in delivery of standard devices (balloons and stents) without complications. CONCLUSIONS: Remotely steerable robotic catheters are at least as safe as manual catheter techniques, and may prove less traumatic to peripheral vessels. Standard devices can be deployed through the system, and the stability of the platform may aid in ease of device delivery in difficult vascular segments.

Portal vein thrombosis secondary to embolization of superior mesenteric arteriovenous fistula.

Superior mesenteric arteriovenous fistula is a rare vascular disorder. Endovascular embolization has been widely used to treat this disease. Patients receiving successful fistula embolization generally have good prognoses. We present a man with iatrogenic superior mesenteric arteriovenous fistula who received endovascular embolization. Portal thrombus was detected on postoperative day 2, and the patient eventually died of multiple organ failure on postoperative day 13 despite having received antithrombotic and antiplatelet therapy. We identified portal thrombosis as a serious complication of transcatheter superior mesenteric arteriovenous fistula embolization.

Protective effects of montelukast and Hypericum perforatum against intestinal ischemia-reperfusion injury in hamsters.

AIM: To evaluate the effects of montelukast and Hypericum perforatum against ischemia/reperfusion (I/R)-induced intestinal damage. MATERIALS AND METHODS: Twenty-eight hamsters were divided into 4 groups following midline abdominal laparotomy: control group (n = 7), I/R group (n = 7), montelukast and I/R (MIR) group (n = 7), and Hypericum perforatum and I/R (HPIR) group (n = 7). After 60 min of ischemia through obstruction of the superior mesenteric artery, 24 h of reperfusion was maintained. Ten minutes prior to the reperfusion period, the MIR group received 7 mg/kg of intraperitoneal montelukast and the HPIR group received 7 mg/kg of intraperitoneal Hypericum perforatum. Malondialdehyde, glutathione, myeloperoxidase, and cardiotrophin-1 levels were measured from blood samples. A semiquantitative histological evaluation was performed. RESULTS: Montelukast and Hypericum perforatum significantly reduced malondialdehyde levels and increased glutathione levels compared to the I/R group (P < 0.008). A statistically significant difference was also found between the I/R group and MIR and HPIR groups in terms of myelqperoxidase levels (P < 0.008). The MIR and HPIR groups showed increased cardiotrophin- 1 levels compared to the control and I/R groups (P < 0.008 for all). The MIR and HPIR groups showed significantly lower histological scores compared to the I/R group (P = 0.03 and P = 0.007, respectively). CONCLUSION: This study demonstrated the preventive effects of montelukast and Hypericum perforatum on I/R-induced intestinal injury.

The effects of luteolin on the intestinal ischemia/reperfusion injury in mice.

The purpose of this study is to investigate the potential protective effect of the flavonoid Luteolin on ischemia-reperfusion (IR) injury in mouse intestine, which has not previously been studied. Twenty-four female C57BL/6 mice were randomly assigned to four groups, each consisting of 6 mice: a sham group (laparotomy, but no IR injury), a sham + Luteolin group (no IR, and Luteolin was administered intraperitoneally 30 min after laparotomy), IR group (30 min occlusion of the superior mesenteric artery (SMA) then 2 hr' reperfusion), IR + Luteolin (30 min occlusion of the SMA then 2 hr' reperfusion; Luteolin was administered intraperitoneally before reperfusion). Intestine tissues were harvested from the mice for histopathological and biochemical analysis. Total oxidant status (TOS) and total antioxidant capacity (TAC) of the intestinal tissues were measured using Erel's method. Oxidative stress index (OSI) was calculated using the TOS/TAC ratio. Intestinal histological changes were significantly decreased in the IR + Luteolin group compared with the IR group (p = .037). TOS tissue levels were also significantly decreased in the IR + Luteolin group compared with the IR group (p = .005). TAC levels did not increase significantly in the IR treatment group and were not affected by Luteolin treatment (p > .05). The results of this study show that Luteolin administration provides considerable protection against IR injury in the mouse intestine.

Recanalization of iatrogenic dissection of the superior mesenteric artery: a case report.

We present a case of acute abdominal pain due to a long-segment iatrogenic superior mesenteric artery dissection, which was immediately treated successfully with balloon fenestration of the intimal flap, resulting in complete resolution of the symptoms without recurrence during the 2-year follow-up period.

Superior mesenteric artery pseudoaneurysm after blunt abdominal trauma.

True aneurysms and pseudoaneurysms of the visceral arteries are uncommon. Visceral artery aneurysms (VAAs) represent 0.1-0.2% of all vascular aneurysms and were also found in 0.1% of autopsies. VAAs most commonly affect the splenic (60%), hepatic (20%), and superior mesenteric (9%) arteries. Mesenteric injury caused by blunt abdominal trauma is relatively rare. A 30-year-old man arrived at our trauma hospital and was found to have a traumatic pseudoaneurysm of the superior mesenteric artery (SMA) after a motor vehicle collision. To date, only 10 visceral arterial pseudoaneurysms have been reported in the literature. We present an 11th case of a pseudoaneurysm involving the SMA after blunt abdominal trauma.

Superior mesenteric arteriovenous fistula: imaging findings and endovascular treatment.

Arteriovenous fistulae (AVF) of the superior mesenteric vasculature are rarely encountered. We present a case of an iatrogenic superior mesenteric AVF following subtotal colectomy, which was successfully treated with coil embolization. Cross-sectional imaging and angiographic findings are reviewed along with the options for endovascular therapy.

A rare cause of obstructive jaundice: superior mesenteric artery pseudoaneurysm.

Visceral arterial aneurysm and pseudoaneurysm are uncommon forms of vascular disease that have a significant potential for rupture or erosion into an adjacent viscera, resulting in life-threatening hemorrhage. Pseudoaneurysms related to the superior mesenteric artery are a recognized complication of trauma to the vessel, and successful treatment with stenting has been previously described. Percutaneous techniques offer an alternative form of therapy, and the number of reported cases treated with embolization has been rising steadily. We present the case of a 26-year-old patient with a large pseudoaneurysm of the superior mesenteric artery complicated with obstructive jaundice.

Prolonged indwelling time of temporary vascular shunts is associated with increased endothelial injury in the porcine mesenteric artery.

BACKGROUND: Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity. METHOD: After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4). RESULTS: Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58). CONCLUSION: When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.