Chronic Mesenteric Ischemia (CMI) is a rare cause of abdominal pain as vascular disorders tend to be last of the differential diagnoses considered in patients presenting with gastrointestinal symptoms. This is a case of a 58-year-old male who presented with a 2-year history of intermittent abdominal pain associated with sitophobia and undocumented weight loss. He had several in-hospital admissions and after a series of unremarkable diagnostic tests he was diagnosed with chronic mesenteric ischemia secondary to superior mesenteric artery stenosis as evidenced through computed tomography angiography. He underwent an aorto-SMA bypass with an 8mm Dacron graft. The main goals for revascularization of CMI are improving quality of life and prevention of bowel infarction. As CMI is a rare cause of abdominal pain, the patients tend to be victims of diagnostic delays. Early recognition and timely intervention are key in the management of this condition.
Mesenteric Ischemia ; Abdominal Pain ; Vascular Diseases

Objective: To investigate the factors influencing small intestinal ischemia in elderly patients with incarcerated hernia. Methods: The clinical data of 105 elderly patients admitted for surgical procedures of incarcerated hernia at Department of General Surgery, Huadong Hospital between January 2014 and December 2021 were retrospectively analyzed. There were 60 males and 45 females, aged (86.1±4.3) years (range: 80 to 96 years). They were divided into normal group (n=55) and ischemic group (n=50) according to intraoperative intestinal canal condition. The t test, χ² test and Fisher's exact probability method were used for the univariate analysis of the factors that influence intestinal ischemia in patients, and Logistic regression was used for multifactorial analysis. Results: In all patients, 18 patients (17.1%) had irreversible intestinal ischemia with bowel resection. Six patients died within 30 days, 3 cases from severe abdominal infection, 2 cases from postoperative exacerbation of underlying cardiac disease, and 1 case from respiratory failure due to severe pulmonary infection. The results of the univariate analysis showed that there were differences in gender, history of intussusception, duration of previous hernia, white blood cell count, neutrophil percentage, C-reactive protein, type of incarcerated hernia, and preoperative intestinal obstruction between the two groups (all P<0.05). The Logistic regression results showed that the short time to the previous hernia (OR=0.892, 95%CI 0.872 to 0.962, P=0.003), high C-reactive protein (OR=1.022, 95%CI 1.007 to 1.037, P=0.003), non-indirect incarcerated hernia (OR=10.571, 95%CI 3.711 to 30.114, P<0.01) and preoperative intestinal obstruction (OR=6.438, 95%CI 1.762 to 23.522, P=0.005) were independent risk factors for the development of intestinal ischemia in elderly patients with incarcerated hernia. Conclusions: The short duration of the previous hernia, the high values of C-reactive proteins, the non-indirect incarcerated hernia, and the preoperative bowel obstruction are influencing factors for bowel ischemia in elderly patients with incarcerated hernia. A timely operation is necessary to reduce the incidence of intestinal necrosis and improve the prognosis.
Male ; Aged ; Female ; Humans ; Retrospective Studies ; C-Reactive Protein ; Intestinal Obstruction/etiology* ; Hernia, Inguinal/surgery* ; Mesenteric Ischemia/surgery* ; Ischemia/surgery* ; Herniorrhaphy/adverse effects*

The objective of this study was to analyze the three different management modalities for isolated superior mesenteric artery (SMA) dissection. We did a comprehensive literature search and found 703 articles on the initial search, out of which 111 articles consisting of 145 patients were selected for analysis. The mean age was 55.7 years (standard deviation,9.7;33–85) and 80.6% were male. These patients were managed conservatively (41.3%), endovascularly (28.1%) or surgically (30%). The median follow-up was 10 months (interquartile range [IQR], 4–18 months), 12 months (IQR, 6–19 months) and 14 months (IQR, 6–20 months) respectively. Contrast-enhanced computed tomography (CT) was the most commonly used diagnostic tool in the conservative group (43.8%), while conventional CT scan was the most widely used in endovascular (58.1%) and surgical group (50%). 17% percent of the conservative group had SMA angiography for diagnosis, while this was less than 3% in the other groups. Of these patients, 96.7%, 97.4%, and 100.0% recovered successfully in the conservative, endovascular, and surgical groups respectively. There was no significant difference in the mortality between the three groups (Pearson χ²=0.482). This suggests a conservative and endovascular approach could be used in most patients, which can reduce costs and surgery-related morbidity and mortality. Surgical management should be reserved for cases having infarction or widespread bowel ischemia and in cases where other treatment modalities fail.
Angiography ; Diagnosis ; Follow-Up Studies ; Humans ; Infarction ; Ischemia ; Male ; Mesenteric Artery, Superior ; Mortality ; Tomography, X-Ray Computed

Bowel ischemia is a life-threatening surgical emergency. We report a case of rapidly progressive bowel necrosis in a previously healthy child without proven mechanical small bowel obstruction. The definite diagnosis was established at the time of an exploratory operation. Of note, imaging studies and even a laparotomy did not reveal any evidence of acute appendicitis or mechanical obstruction such as intussusception or Meckel's diverticulum. During hospitalization, since we could not rule out surgical abdomen after inconclusive image findings, we closely followed the patient and repeated physical examinations carefully. Eventually surgical exploration was performed based on changes in clinical condition, which proved to be the right decision for the patient. We propose that in children with suspected strangulation of small bowel obstruction, especially when imaging findings do not provide a conclusive diagnosis, the timely exploratory surgical approach ought to be chosen based on carefully observed clinical findings and other evaluations.
Abdomen ; Appendicitis ; Child ; Diagnosis ; Emergencies ; Hospitalization ; Humans ; Intestine, Small ; Intussusception ; Ischemia ; Laparotomy ; Meckel Diverticulum ; Mesenteric Ischemia ; Necrosis ; Physical Examination

Supra-celiac aortic cross clamping is often utilized during aortic reconstruction for aneurysmal/occlusive disease involving the pararenal aorta. However, this may be accompanied a myriad of complications related to hemodynamic disturbances, cardiopulmonary compromise and hepatic ischemia. Supra-mesenteric aortic cross clamping may be an excellent option in selected patients with suitable anatomy to minimize or avoid these complications. Herein, the merits of and technical tips for supra-mesenteric aortic cross clamping are discussed.
Aorta ; Celiac Artery ; Constriction ; Hemodynamics ; Humans ; Ischemia ; Mesenteric Artery, Superior

We presented a challenging case of a patient diagnosed with abdominal aortic aneurysm (AAA), peripheral artery disease, and chronic mesenteric ischemia (CMI). Herein, we describe the treatment in this high-risk patient diagnosed with CMI who also had critical limb ischemia and his AAA had rapidly expanded. First we performed angioplasty and celiac arterial stenting. Afterwards, we proceeded to perform balloon angioplasty of the iliac arteries and chimney endovascular aneurysm repair (Ch-EVAR) preserving the inferior mesenteric artery (IMA). The patient was discharged three days later and his IMA remained patent eighteen months post-operation. A thorough pre-operative assessment is essential in such challenging cases. Minimally invasive procedures like endovascular therapy and the chimney technique extend the prognoses in high-risk patients.
Aneurysm ; Angioplasty ; Angioplasty, Balloon ; Aortic Aneurysm, Abdominal ; Extremities ; Humans ; Iliac Artery ; Ischemia ; Mesenteric Artery, Inferior ; Mesenteric Ischemia ; Peripheral Arterial Disease ; Prognosis ; Stents

Mesenteric venous thrombosis has a low prevalence and nonspecific clinical symptoms, and it may cause bowel infarction and death. Early diagnosis and prompt surgical intervention with anticoagulants are important to patients. We examined a 27-year-old woman complaining of diffuse abdominal pain and hematochezia, and diagnosed extensive mesenteric venous thrombosis with intestinal infarction and pulmonary thromboembolism. In light of the patient's symptoms, an operation seemed necessary. However, because of the high risk of mortality, we decided to look for another option. The patient was successfully treated with intensive medical care and a radiological procedure in spite of intestinal infarction.
Abdominal Pain ; Adult ; Anticoagulants ; Early Diagnosis ; Female ; Gastrointestinal Hemorrhage ; Humans ; Infarction ; Mesenteric Ischemia ; Mesenteric Vascular Occlusion ; Mortality ; Prevalence ; Pulmonary Embolism ; Thrombectomy ; Thrombolytic Therapy ; Thrombosis ; Urokinase-Type Plasminogen Activator

A 57-year-old woman presented to vascular surgery clinic with visceral artery aneurysms that were incidentally detected during regular check-up. Imaging studies revealed occlusion of the celiac axis and severe stenosis of the superior mesenteric artery and 3 aneurysms along the posterior and inferior pancreaticoduodenal arteries, as well as the right gastroepiploic artery. Endovascular embolization of all aneurysms was rejected because of the risk of hepatic ischemia. These complicated lesion caused by polyarteritis nodosa were successfully treated using a hybrid operation with coil embolization, aneurysm resection, and antegrade aorto-celiac-superior mesentery artery bypass.
Aneurysm ; Arterial Occlusive Diseases ; Arteries ; Constriction, Pathologic ; Embolization, Therapeutic ; Female ; Gastroepiploic Artery ; Humans ; Ischemia ; Mesenteric Artery, Superior ; Mesentery ; Middle Aged ; Polyarteritis Nodosa

PURPOSE: Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities. RESULTS: The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively). CONCLUSION: SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.
Anti-Bacterial Agents ; Appendicitis ; Classification ; Comorbidity ; Demography ; Disease Progression ; Diverticulitis ; Humans ; Ileus ; Inflammation ; Medical Records ; Mesenteric Ischemia ; Portal Vein ; Prognosis ; Retrospective Studies ; Thrombosis ; Venous Thrombosis

OBJECTIVE: This study was conducted to investigate the relationship between invasive treatments and computed tomographic (CT) classification or findings in symptomatic spontaneous isolated superior mesenteric artery dissection (SISMAD). METHODS: This retrospective observational study included 30 patients with SISMAD from Jan 2012 to Dec 2016. Demographic data, risk factor, treatment modalities, and CT findings including morphological classification, dissection length, and true lumen relative diameter (TLRD) were reviewed. The enrolled patients were classified into two groups (conservative management group, CG; invasive management group, IG). RESULTS: Based on CT classifications, one patient was type I (CG, n=1; IG, n=0), two were type IIa (CG, n=2; IG, n=0), five were type IIIa (CG, n=5; IG, n=0), 10 were type IIIb (CG, n=9; IG, n=1), and 12 were type IIIc (CG, n=1; IG, n=11). There was a high tendency to undergo invasive treatment among type IIIc (P < 0.001). The TLRD, distance from the aorta to dissection point, and dissection length were 18.3% (range, 0%–29.8%), 1.7 cm (range, 0–3.5 cm), and 7.3 cm (range, 4.9–10.0 cm), respectively. There TLRD (CG, 26.8% [range, 22.2%–48.8%]; IG, 0%; P < 0.001) and distance from the aorta to dissection point (CG, 1.0 cm [range, 0–2.1 cm]; IG, 3.5 cm [range, 0.8–5.4 cm]; P=0.024) differed significantly between groups. However, there was no significant difference in dissection length between CG and IG (P=0.527). CONCLUSION: The TLRD, distance from the aorta to dissection point, and CT classification such as type IIIc were associated with invasive management. Further studies on extended natural course of the disease from a larger number of subjects are necessary to draw a strong conclusion.
Abdominal Pain ; Aorta ; Classification ; Humans ; Mesenteric Arteries ; Mesenteric Artery, Superior* ; Mesenteric Ischemia ; Observational Study ; Retrospective Studies ; Risk Factors