THE MESENTERIC CIRCULATION: Anatomy and Physiology

Mesenteric artery stenosis leads to inadequate blood flow toward various parts of the gastrointestinal tract. Revascularization is the primary aim of treatment regardless of its approach. During the last decades, open revascularization has been replaced by endovascular-first approach. Mesenteric artery in-stent restenosis occurs in a considerable number of patients that need reintervention in up to half of them using redo endovascular revascularization or open surgery. Here, we reported a case of SMA and celiac artery stenoses treated by aortic reimplantation of the SMA.

A 62-year-old man with history of previous stenting of CA and SMA was referred due to chronic intermittent abdominal. CT angiography of the abdomen showed restenosis of both arteries. A transection distal part of the occlusions SMA and reimplantation of it into the SMA on the anterolateral face of the infrarenal aorta as the end-to-side anastomosis were performed resulting in resolving the patient problem.

Chronic mesenteric ischemia can result from various medical conditions. Mesenteric vascular surgical revascularization through open laparotomy had been considered the standard of care. However, minimally invasive surgery such as endovascular therapy has attracted attention in the recent decades. There are some concerns about the difficulties of further surgery in case of re-occlusion. The end-to-side anastomosis and aortic reimplantation can be considered in patients with appropriate runoff in the remaining parts of corresponding vessels.

Aortic reimplantation of the superior mesenteric artery in patients with restenosis of stents is a viable option especially in case of inappropriate iliac artery to perform retrograde mesenteric bypass.

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

This article describes a chimney technique (ChEVAR) to preserve the patency of the inferior mesenteric artery (IMA) in a patient with abdominal aortic aneurysm (AAA) and bilateral internal iliac artery obstruction. In addition, a review of the literature is performed.

This article describes a male in his 70s with multiple comorbidities and a 5.6 cm infrarenal aortic aneurysm. CT scan showed bilateral iliac internal artery obstruction with compensatory hypertrophy of lumbar arteries along with a 6 mm inferior mesenteric artery. We planned a staged treatment: embolization of lumbar arteries to prevent type 2 endoleak as a first step, followed two months later by standard EVAR with chimney graft to maintain patency of IMA. The postoperative course was uneventful. The endograft was widely patent on CT scan at his 6-month follow-up visit.

ChEVAR to preserve the patency of IMA is a feasible and valid technique that could be considered in the case of bilateral hypogastric obstruction.

The marginal artery of Drummond (MA) is an anatomically variable blood vessel that forms a major anastomotic network between the superior and inferior mesenteric arteries. It vascularizes the transverse and descending colons and is a major contributor to the collateral circulation of left-colic structures.

To conduct a systematic review of the MA and highlight the current understanding of its anatomy and role in physiological and pathological vascularization.

The major online databases (Pubmed, Google Scholar, Embase, and Web of Science) were systematically assessed to reveal all available literature pertaining to the MA. Articles judged relevant by the authors were used for the final review.

The MA is a key player in the collateral circulation of left-colic structures in the setting of pathological processes affecting their normal vascularization. It helps to maintain perfusion in the event of obstructions and atherosclerosis, and in the cases of obliteration or congenital absence of the mesenteric vessels, it sustains adequate vascularization of the left-colon. The MA has come into increasing prominence as surgeons have become more aware of both iatrogenic injuries to it and its value in mitigating the effects of reduced patency of the mesenteric vessels.

The MA continues to become more important to surgeons as both an obstacle and an opportunity in abdominal procedures. Further exploration of its anatomical variability, for example through embryological and dissection studies, will further improve treatment outcomes during abdominal surgery.