In-stent Restenosis After Stenting for Superior Mesenteric Artery Dissection Is Associated With Stent Landing Zone: From Clinical Prediction to Hemodynamic Mechanisms.

OBJECTIVE: To identify risk factors for in-stent restenosis (ISR) in patients undergoing stent placement for superior mesenteric artery dissection (SMAD) and to determine the hemodynamic mechanism underlying ISR. METHODS: For this retrospective study, patients with SMAD who had ISR after stent placement were included in the ISR group, and age- and sex-matched patients with SMAD who did not experience ISR after stent placement were included in the control group. Clinical, imaging, and hemodynamic data were assessed. Multivariable regression was used to identify independent ISR risk factors. Structural and fluid dynamics simulations were applied to determine the hemodynamic mechanism underlying the occurrence of ISR. RESULTS: The study population included 26 patients with ISR and 26 control patients. Multivariate analysis demonstrated that stent-to-vascular (S/V) ratio (odds ratio [OR], 1.14; 95% confidence interval [CI]: 1.00-1.29; p=0.045), stent proximal position >10 mm away from the SMA root (OR, 108.67; 95% CI: 3.09-3816.42; p=0.010), and high oscillatory shear index (OSI) area (OR, 1.25; 95% CI: 1.02-1.52; p=0.029) were predictors of ISR. In structural and fluid dynamics simulations, a stent proximal position near the abdominal aorta (AA) or entering into the AA reduced the contact area between the proximal struts of the stent and the vascular wall, and alleviated the distal lumen overdilation. CONCLUSION: The S/V ratio, stent proximal position away from the SMA root (>10 mm), and high OSI area are independent risk factors for ISR in patients with SMAD undergoing stent placement. Deploying the proximal end of the stent near the AA or entering into the AA appears to improve the hemodynamic environment in the SMA lumen and ultimately reduce the risk of ISR. CLINICAL IMPACT: In-stent restenosis is an uncommon but potentially catastrophic complication after stent placement for the management of superior mesenteric artery dissection. This study identified risk factors for in-stent restenosis and demonstrated that, as long as the stent can fully cover the dissection range, deploying the proximal end of the stent near the abdominal aorta or less entering into the abdominal aorta may reduce the risk of in-stent restenosis in this patient population.

MFAP4-Deficiency Aggravates Age-Induced Changes in Resistance Artery Structure, While Ameliorating Hypertension.

BACKGROUND: Abnormalities of resistance arteries may play essential roles in the pathophysiology of aging and hypertension. Deficiency of the vascular extracellular matrix protein MFAP4 (microfibrillar-associated protein 4) has previously been observed as protective against aberrant arterial remodeling. We hypothesized that MFAP4-deficiency would reduce age- and hypertension-dependent arterial changes in extracellular matrix composition and stiffening. METHODS: Mesenteric arteries were isolated from old (20-23 months) littermate Mfap4+/+ and Mfap4-/- mice, and 2-photon excitation microscopy imaging was used to quantify elastin and collagen volumes and dimensions in the vascular wall. Ten-week-old littermate Mfap4+/+ and Mfap4-/- mice were subjected to 20 days of continuous Ang II (angiotensin II) infusion and hypertension was monitored using invasive blood pressure measurements. Arterial stiffness, responses to vascular constrictors, and myogenic tone were monitored using wire- or pressure myography. Collagen contents were assessed by Western blotting. RESULTS: MFAP4 deficiency significantly increased collagen volume and elastin fragmentation in aged mesenteric arteries without affecting arterial stiffness. MFAP4-deficient mice exhibited reduced diastolic pressure in Ang II-induced hypertension. There was no significant effect of MFAP4-deficiency on mesenteric artery structural remodeling or myogenic tone, although collagen content in mesenteric arteries was tendentially increased in hypertensive Mfap4+/+ mice relative to Mfap4-/- mice. Increased efficacy of vasoconstrictors (phenylephrine, thromboxane) and reduced stiffness were observed in Ang II-treated Mfap4-/- mouse mesenteric arteries in ex vivo myography recordings. CONCLUSIONS: MFAP4 deficiency reduces the elastin/collagen ratio in the aging resistance artery without affecting arterial stiffness. In contrast, MFAP4-deficiency reduces the stiffness of resistance arteries and ameliorates Ang II-induced hypertension.

Comprehensive management of challenging recurrent aortoiliac and lower extremity occlusive disease with simultaneous modified-covered endovascular reconstruction of the aortic bifurcation, inferior mesenteric artery snorkel, and lower extremity bypass.

OBJECTIVES: Despite recent advancements in endovascular technology and proven durability of open surgeries, managing extensive aortoiliac occlusive disease (AIOD) with concurrent severe lower extremity (LE) arterial occlusion remains a formidable challenge. This paper introduces a comprehensive approach to addressing recurrent AIOD and LE occlusive diseases by employing modified-CERAB, inferior mesenteric artery (IMA) snorkel, and LE bypass in a challenging case. METHODS: A 56-year-old male patient presented with subacute bilateral lower extremity rest pain with dry gangrene in the left great toe and a complex medical history. His history included a hostile abdomen stemming from past ischemic bowel episodes and multiple bowel resections through laparotomies. Furthermore, the patient had a persistent left ventricular thrombus (LVT), stage-2 chronic kidney disease (CKD), diabetes, and was currently experiencing bilateral LE rest pain and dry gangrene in the left great toe, accompanied by severe dermatitis in both LEs. RESULTS: He successfully underwent modified-CERAB with a concurrent snorkel technique for IMA preservation, along with an LE bypass to resolve bilateral LE critical ischemia. CONCLUSION: This comprehensive management approach, combining simultaneous modified-CERAB, IMA snorkel, and LE bypass, provides an effective alternative for addressing complex AIOD and LE occlusive disease patients with hostile abdomen.

Vasorelaxant and hypotensive effects of an ethanolic extract of Nymphaea pubescens and its main compound quercetin 3-methyl ether 3'-O-ß-xylopyranoside.

Aim: Nymphaea plants were traditionally used to treat diseases associated with endothelial dysfunction. The present study investigated the effects of an ethanolic extract of Nymphaea pubescens Willd. (commonly named water lily, WL) and its main compound 1 (quercetin 3-methyl ether 3'-O-ß-xylopyranoside) on vascular function in rats. Materials and methods: The vasorelaxant effects of the WL extract and its main compound 1 and their underlying mechanisms of action were evaluated on isolated mesenteric arteries from Wistar rats. Blood pressure and heart rate were measured in anesthetized rats after infusion (i.v) of vehicle, WL extract, and compound 1 (at 0.01, 0.025, 0.05, 0.1, 0.5, and 1 mg/kg). Nifedipine was used as a positive control. Results: Both WL extract and compound 1 induced vasorelaxant effects (with EC50 of 0.08 ± 0.01 mg/mL and 42.8 ± 6.3 µM, respectively) that were reduced by endothelium removal. A significant decrease in these relaxations was observed with L-NAME but not with apamin-charybdotoxin or indomethacin. In the endothelium-denuded condition, WL extract-induced relaxation was enhanced by 4-aminopyridine and glibenclamide, while iberiotoxin and ODQ (1H-[1,2,4]oxadiazolo[4,3-a]quinoxaline-1-one) had no effect. In contrast, compound 1-induced relaxation was not changed by any of these inhibitors. Both WL extract and compound 1 enhanced sodium nitroprusside-induced relaxation and inhibited receptor-operated Ca2+ channels. Only the WL extract was able to reduce PE-induced contraction (p < 0.001). As compared to the vehicle, the infusion of WL extract and compound 1 lowered systolic and diastolic blood pressure. Interestingly, the hypotensive effect of the compound was similar to that of nifedipine. The rebound tachycardia found at the highest dose of nifedipine was not observed with the WL extract or compound 1 (p < 0.05). Conclusion and discussion: Our study demonstrated a vasorelaxant effect of the WL extract and its main compound quercetin 3-methyl ether 3'-O-ß-xylopyranoside, relying on the potentiation of the NO-cGMP pathway and calcium inhibitory effects. These vasorelaxant effects were associated with a potent hypotensive effect, providing pharmacological evidence for the traditional use of this plant.

Post-traumatic jejunal branch of superior mesenteric artery pseudoaneurysm in paediatrics: a compelling case report highlighting early diagnosis and successful endovascular embolization.

Introduction and importance: This manuscript underscores the critical significance of prompt diagnosis and intervention in cases of post-traumatic gastroduodenal artery pseudoaneurysms. Such occurrences, particularly in the paediatric population, are rare but potentially life-threatening complications following abdominal trauma, necessitating heightened clinical awareness. Despite their rarity, the devastating consequences of delayed recognition and management emphasize the necessity for advanced imaging modalities and individualized treatment strategies. Case presentation: A 17-year-old male presented with severe epigastric pain following a football fall. Despite initial stability, persistent symptoms prompted further investigation. Conventional screening methods proved inconclusive, leading to a contrast-enhanced computed tomography (CT) scan that revealed a jejunal branch of superior mesenteric artery (SMA) pseudoaneurysm. The subsequent fluoroscopy-guided angiography and successful embolization using glue exemplify the importance of timely intervention in such cases. Conclusion: This case highlights the importance of early recognition and appropriate intervention in post-traumatic jejunal branch of SMA pseudoaneurysms. The successful outcome achieved through endovascular embolization underscores the necessity for vigilant monitoring and tailored management strategies in similar clinical scenarios.

Robotic management of superior mesenteric artery syndrome.

Wilkie's syndrome is an unusual cause of upper intestinal obstruction due to mechanical compression of the superior mesenteric artery (SMA) to the duodenum, with nonspecific symptoms, whose diagnosis is confirmed by angiotomography. Initially, the treatment is conservative to regain weight and restore mesenteric adipose tissue, associated with postural changes of the patient. If this fails, surgical treatment is indicated, being laparoscopic duodenojejunostomy described as the gold standard. Robotics' assistance is feasible and safe to carry out the procedure. We present the case of a 21-year-old male patient who comes with stabbing abdominal pain and persistent postprandial vomiting that has caused weight loss of 11 kilograms in the last 2 years without apparent cause, associated with gastroesophageal reflux. During the procedure, we evidenced open diaphragmatic pillars and duodenal compression due to SMA, and robotic-assisted laparoscopic hyatoplasty + Nissen fundoplication + duodenojejunostomy were performed without complications, with excellent post-surgical results.

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.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study.

PURPOSE: To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS: Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS: Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION: This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

A Case of Successful Hybrid Treatment of Dual Arterial Bypass Using Indocyanine Green Fluorescence Angiography and Endovascular Treatment for Recurrent Superior Mesenteric Artery Aneurysm.

A 54-year-old woman with a mycotic superior mesenteric artery (SMA) aneurysm underwent emergent aneurysm resection with a great saphenous vein bypass. Follow-up computed tomography revealed a rapidly growing recurrent SMA aneurysm at the stump. Under the diagnosis of recurrent pseudoaneurysm of SMA with a fragile stump, we performed an open dual arterial bypass using indocyanine green fluorescence angiography and endovascular coil embolization. Subsequently, the patient's recurrent mycotic SMA aneurysm was successfully managed without mesenteric ischemic complications. This method may help prevent fatal mesenteric ischemia during SMA aneurysm surgery.

Delayed presentation of Wilkie's syndrome after scoliotic curve correction surgery: a case report.

BACKGROUND: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare but serious complication following scoliosis correction surgery. It occurs as a result of mechanical compression of third part of duodenum between the SMA and aorta. This condition occurs most commonly in significantly underweight patients with deformities, and usually during the first week following spinal deformity corrective surgeries. The angle between the abdominal aorta and the SMA gets reduced following spinal lengthening during deformity correction surgery causing compression of third part of duodenum resulting in development of SMA syndrome. CASE PRESENTATION: We present a case of 17-year-old male with congenital scoliosis with a 70-degree scoliotic curve who underwent spinal deformity correction surgery with posterior instrumented fusion. Post-operative course was uneventful and the patient was discharged after suture removal on post-operative day 15. The patient presented after 21-days of symptom onset on post-operative-day 51, with a 3 week history of post-prandial vomiting, abdominal pain and distension which resulted in rapid weight loss of 11 kg. A CT-angiogram showed obstruction at third part of duodenum. After reviewing clinical and radiological profile of the patient, a diagnosis of SMA syndrome was made. Conservative management was tried, but due to rapid deterioration of patient condition and symptoms of complete intestinal obstruction, the patient was treated surgically by gastro-jejunostomy and side-to-side jejuno-jejunostomy, which improved his condition. CONCLUSION: SMA syndrome can occur much later than previously reported cases and with potentially life-threatening symptoms following scoliosis correction. Having a high index of suspicion, early recognition of condition and institution of appropriate treatment are essential to prevent occurrence of severe complications including risk of intestinal perforation and mortality. This case highlights management of delayed onset of SMA syndrome, with presentation further delayed after symptom onset, as is common in developing parts of the world, due to limited availability and accessibility of resources, and low socio-economic status of large segments of the population.

Spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma: a rare case.

BACKGROUND: Gastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. CASE PRESENTATION: A 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma. CONCLUSION: A gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review.

Background: Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach. Methods: A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies. Results: After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively. Conclusions: The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach's distinct advantages and indications.

Efficacy and safety analysis of AcoStream thrombus aspiration device in the treatment of acute superior mesenteric artery embolism.

OBJECTIVE: Acute superior mesenteric artery embolism is a life-threatening disease caused by the abrupt interruption of mesenteric blood circulation, and the prognosis is very poor. Several studies have confirmed the efficacy and safety of percutaneous mechanical thrombectomy in acute superior mesenteric artery embolism, however, there are currently no literature reports on the latest percutaneous mechanical thrombectomy device-AcoStream™. In the present report, we summarize a series of cases and share our surgical experiences. METHODS: The clinical data of 10 patients (six men and four women, mean age 77.6 ± 7.4 years) with acute superior mesenteric artery embolism treated by AcoStream™ in our center from December 2022 to December 2023 were retrospectively analyzed. Based on the literature, we summarized the diagnosis, therapy, and surgical experience of acute superior mesenteric artery embolism. RESULTS: Percutaneous mechanical thrombectomy was performed for all the patients. The success rate of surgery reached 100% and no perioperative complications occurred. Abdominal pain was significantly relieved and the abdominal signs gradually disappeared in eight patients, while the other two patients still complained of abdominal pain during hospitalization, and eventually, they underwent resection of necrotic bowel. All the patients' symptoms were significantly relieved and they were smoothly discharged from the hospital. CONCLUSIONS: As shown in the present study, percutaneous mechanical thrombectomy using AcoStream™ is minimally invasive, safe, and efficient in the initial stage of acute superior mesenteric artery embolism. We believe that percutaneous mechanical thrombectomy can be a promising alternative in selected cases.

An uncommon cause of sub-acute intestinal obstruction in young adult: Wilkie's syndrome.

Abstract: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare disease presenting as an acute abdomen. It has a clinical presentation similar to intestinal obstruction and is often missed during diagnosis. Reduced weight leading to loss of fat pad between SMA and aorta is the main pathophysiology. Diagnosis is made through barium meal and CT scan. Conservative management remains the treatment of choice; however, surgery is opted for in refractory cases. Key Clinical Message: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare disease presenting as an acute abdomen with clinical features similar to intestinal obstruction. This is a case of SMA syndrome in an adult male with a decrease in aortomesenteric angle, with no predisposing condition.

Safety of preoperative branch embolization in patients undergoing evar.

The purpose of this systematic review is to evaluate the safety of pre-endovascular abdominal aortic aneurysm repair (EVAR) embolization of aortic side branches - the inferior mesenteric artery and lumbar arteries. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. A search of MEDLINE and DIMENSION databases identified 9 studies published from 2011 to 2021 that satisfied the inclusion and exclusion criteria. These studies were analyzed to detect the incidence of embolization-related complications. A total of 482 patients underwent preoperative aortic side branch embolization, 30 (6.2%) of whom suffered some kind of minor complication. The only major complication observed was ischemic colitis in 4 (0.82%) patients, two (0.41%) of whom died after bowel resection surgery. Regarding these findings, aortic side branch embolization seems to be a safe procedure, with very low percentages of both minor and major complications.

O objetivo desta revisão sistemática foi avaliar a segurança da embolização de artéria mesentérica inferior (AMI) e artérias lombares (ALs) pré-correção endovascular de aneurisma da aorta abdominal. Foram realizadas pesquisas nas bases de dados MEDLINE e Dimensions. Foram encontrados 9 estudos publicados de 2011 a 2021 que atendiam aos critérios de inclusão e exclusão. Os estudos foram analisados ​​para definir a incidência de complicações relacionadas à embolização. No total, 482 pacientes foram submetidos a embolização de AMI e/ou ALs, dos quais 30 (6,2%) sofreram algum tipo de complicação menor. A única complicação importante observada foi colite isquêmica em 4 (0,82%) pacientes. Dois (0,41%) desses pacientes morreram após cirurgia de ressecção intestinal. Em relação a esses achados, a embolização de AMI e ALs parece ser um procedimento seguro, com um percentual muito baixo de complicações menores e importantes.

Systematic review and meta-analysis of current evidence in endograft therapy for spontaneous isolated superior mesenteric artery dissection.

The role of endovascular stent therapy (EST) in the treatment of spontaneous isolated superior mesenteric artery dissection (SISMAD) has gained momentum in recent years but remains controversial. We gathered research examining the advantages and disadvantages of EST for SISMAD patients. Primary outcomes involved both immediate and long-term results. Random or fixed effect models were used for effect size (ES) calculation with 95% confidence interval (CI) based on 50% heterogeneity threshold. Our analysis incorporated data from 21 studies including 611 SISMAD cases treated by EST. Our findings show a complication rate of approximately 1% following EST (95%CI 0.01-0.02, I2 = 0%, P = 0.97), with a bare minimum mortality rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P > 0.05) and a reintervention rate of < 1% (95%CI 0.00-0.01, I2 = 0%, P = 0.89). We also found technique success and symptom resolution approaching 94% and 99%, respectively, in the immediate postoperative phase. In the long run, we observed a recurrence of symptoms at 3% (95%CI 0.00-0.06, I2 = 58.6%, P < 0.01), creation of new dissections at 1% (95%CI 0.00-0.02, I2 = 0%, P = 0.73), aneurysm progression at 2% (95%CI 0.00-0.03, I2 = 42.7%, P = 0.12), reintervention due to complications at 3% (95%CI 0.00-0.05, I2 = 0%, P = 0.43) and stenotic stents at 12% (95%CI 0.04-0.23, I2 = 77.5%, P < 0.01). Nevertheless, high levels of stent patency 98% (95% CI 0.97-1.00, I2 = 0%, P = 0.51) and complete remodeling 88% (95% CI 0.82-0.94, I2 = 65.5%, P < 0.05) were observed postoperatively. Overall, EST presents minimal complications and promising long-term outcomes for SISMAD, although the prevalence of stent stenosis requires further attention.

A comparative study on the transbrachial and transfemoral approaches for the treatment of superior mesenteric artery lesions.

BACKGROUND: Superior Mesenteric Artery (SMA) lesions present a significant challenge in endovascular surgery. Both the transbrachial (TBA) and the transfemoral (TFA) approaches have been employed for the treatment of these lesions, but the comparative effectiveness of these methods remains unclear. MATERIALS AND METHODS: A retrospective analysis was conducted on patients who underwent TBA and TFA at a tertiary center between June 2020 and February 2023. Key parameters including technical success, procedural details, and complication rates were examined. RESULTS: In a study of 99 patients, 66 underwent Transfemoral Approach (TFA) and 33 underwent Transbrachial Approach (TBA). No significant age or gender differences were noted between groups. TFA procedures were longer (90.0 vs 63.5 min, p = 0.002) and had higher fluoroscopy times (59.0 vs 43.0 min, p = 0.02) and selective SMA times (366.0 vs 245.0 min, p = 0.038) compared to TBA, especially with a smaller aortomesenteric angle (<90°). Technical success rates were high in both groups (TFA 97%, TBA 93.9%, p = 0.60). Complication rates were similar between groups, with no significant predictors for access site complications identified. CONCLUSION: Both the TBA and the TFA are effective for the treatment of SMA lesions, with TBA potentially offering advantages in terms of efficiency and patient recovery, particularly in cases with certain anatomy. No significant differences in complication rates were found between the two groups. Further research, including prospective randomized trials, is needed to confirm these findings.

Misdiagnosed superior mesenteric artery syndrome due to diabetic gastroparesis. Case report and literature review.

INTRODUCTION: Superior mesenteric artery syndrome (SMAS) is a rare cause of upper intestinal obstruction. This occurs due to duodenal compression between the superior mesenteric artery and the aorta. Anatomical alterations, eating disorders, after some surgical procedures, and trauma are frequent causes of this rare syndrome. Diabetes is a highly prevalent disease that can cause gastroparesis in up to 12 %. Its association with SMAS is extremely rare and challenging to identify. CASE PRESENTATION: A 32-year-old man experienced nausea and vomiting after diagnosis and treatment for type II diabetes. He was treated for diabetic gastroparesis for 2 years without improvement until he lost 40 kg of weight. After imaging studies, a distance between the superior mesenteric artery and the aorta of 5.3 mm and an angle of 17 degrees were detected, corroborating the diagnosis of SMAS syndrome. Due to medical failure, surgical treatment via duodenojejunostomy was performed. DISCUSSION: Diabetes is a very prevalent disease in the world population that can cause gastrointestinal symptoms. In our patient, diabetic gastroparesis delayed the diagnosis of SMAS until severe symptoms of upper intestinal obstruction and significant weight loss occurred. In our patient, due to medical failure, surgical treatment significantly improved his symptoms and stopped his weight loss. CONCLUSION: Superior mesenteric artery syndrome is a rare syndrome, and challenging to differentiate from diabetic gastroparesis. Delays in management may result in excessive weight loss. Surgical treatment can improve symptoms and weight loss.