Embolization for ruptured superior mesenteric artery aneurysms

Superior mesenteric artery (SMA) aneurysms are very uncommon. They are difficult to detect until they rupture and cause hypovolaemic shock. We performed embolization in four cases of aneurysm of branches of the superior mesenteric artery, succeeding in three cases without the need for surgical treatment. In the first case, the aneurysm was excised because of migration of a microcoil into the left hepatic artery. It was not retrieved because sufficient blood flow to the liver was shown on angiography after migration and no ischaemic change of liver was detected on laparotomy. In the second case, the aneurysm arose from the anterior pancreaticoduodenal artery. In the third case, the patient had two SMA aneurysms; one had been resected at surgery, another was revealed on follow-up angiography and embolized with microcoils. The fourth patient had a jejunal artery aneurysm with extravasation; haemostasis was achieved by packing it. In all four cases, no major complications were observed in the clinical course after embolization. Microcoils were considered to be the desirable embolic material, in order to prevent post-therapeutic ischaemic change. Embolization should be the treatment of choice for SMA aneurysms, because it is less invasive and takes less time than surgical treatment.     

Fibromuscular dysplasia of the internal carotid artery as a cause of transient cerebral ischemia episodes

A person's susceptibility to onychomycosis and the course of the disease once the nails are infected are functions of the interaction of the fungal agent, the host, and environmental factors. The disease is reported to have an overall prevalence of 2% to 13%, but the prevalence is much higher in certain populations, such as older people and those with immunosuppressive conditions. Although onychomycosis may be merely a nuisance and an embarrassment for healthy individuals, some morbidity is seen with all population groups, but especially high-risk patients: diabetics, patients infected with human immunodeficiency virus (HIV), patients with acquired immunodeficiency syndrome (AIDS), and patients with other types of immunosuppression (eg, transplant recipients and patients on long-term corticosteroid therapy). Whether the increased prevalence of onychomycosis in the elderly (up to 30% by age 60) is related to changes in immune function is not known.     

Fibromuscular dysplasia of the internal carotid artery: long-term surgical results

Fifty-eight patients underwent 72 operations for symptomatic fibromuscular dysplasia (FMD) between 1970 and 1986. There were 35 females and 23 males aged between 36 and 76 years (average 56). Among the 72 operated on lesions (11 bilateral) FMD stenotic lesions (string of beads, tubular, focal) were isolated (32) or associated with elongation (tortuosity, coiling, kink) in 24 cases, FDM aneurysms (7), and dissecting pseudoaneurysms (9). The surgical techniques included graduated or balloon intra-luminal dilatation either isolated (29) or associated with resection-anastomosis (35), saphenous graft (4) and reconstructive aneurysmorrhaphy (4). Bifurcation endarterectomy was combined in 14 patients. There was no hospital death. There were 2 neurologic deficits after operation (1 transient) and 12 transient nervous disorders due to dissection near the base of the skull required in one third of the cases. The follow-up period extends from 6 to 22 years. Five patients were lost to follow-up. Out of the 53 remaining patients, 44 (83%) are living and asymptomatic. Nine patients died: 4 from myocardial infarction, 3 from cancer, 2 from neurologic disease. Three late successful reoperations were observed: 1 aneurysm formation following graduated dilatation, 2 anastomotic stenosis. Surgical intraluminal dilatation either isolated or combined with reconstructive techniques is a safe and durable operation relieving symptoms. The benefits of repair are long lasting and should be offered to patients with symptomatic FMD carotid lesions. The medical management of asymptomatic cases allows to study the natural history of the disease whose causes are not so far fully known.     

Fibromuscular dysplasia of the internal carotid artery: a clinicopathological study

A combination of Southern blot analysis on a panel of tumor-derived somatic cell hybrids and fluorescence in situ hybridization techniques was used to map YACs, cosmids and DNA markers from the Xp11.2 region relative to the X chromosome breakpoint of the renal cell carcinoma-associated t(X;1)(p11;q21). The position of the breakpoint could be determined as follows: Xcen-OATL2-DXS146-DXS255-SYP-t(X;1)-TFE 3-OATL1-Xpter. Fluorescence in situ hybridization experiments using TFE3-containing YACs and cosmids revealed split signals indicating that the corresponding DNA inserts span the breakpoint region. Subsequent Southern blot analysis showed that a 2.3-kb EcoRI fragment which is present in all TFE3 cosmids identified, hybridizes to aberrant restriction fragments in three independent t(X;1)-positive renal cell carcinoma DNAs. The breakpoints in these tumors are not the same, but map within a region of approximately 6.5 kb. Through preparative gel electrophoresis an (X;1) chimaeric 4.4-kb EcoRI fragment could be isolated which encompasses the breakpoint region present on der(X). Preliminary characterization of this fragment revealed the presence of a 150-bp region with a strong homology to the 5' end of the mouse TFE3 cDNA in the X-chromosome part, and a 48-bp segment in the chromosome 1-derived part identical to the 5' end of a known EST (accession number R93849). These observations suggest that a fusion gene is formed between the two corresponding genes in t(X;1)(p11;q21)-positive papillary renal cell carcinomas.     

Fibromuscular dysplasia of the renal arteries

Thirty-two cases of fibrous-muscular dysplasial of renal arteries (including one autopsy case) were studied. Sections of renal arteries removed at reconstructive operations from patients suffering from renovascular hypertension were examined. Two morphological variants of the process were distinguished: medial dysplasia (perimedial fibroplasia, medial fibroplasia, and dissecting aneurysm) and intimal proliferation. Morphologically, fibrous-muscular dysplasia is a manifestation of proliferation of smooth muscle cell which appears to have various forms and stages. Diagnostically, fibrous-muscular dysplasia should be differentiated from atherosclerosis, nonspecific arteritis, proliferation of the intima due to hypovolemia, and perivascular sclerosis of different etiologies.     

CT angiography of superior mesenteric artery syndrome

OBJECTIVE: Our purpose was to describe the use of CT angiography and three-dimensional (3D) reconstruction in the diagnosis of superior mesenteric artery syndrome in three patients. CONCLUSION: CT angiography combined with 3D reconstructions is a noninvasive technique that may have a complementary diagnostic role similar to that of angiography in patients with a classic clinical presentation suggestive of superior mesenteric artery syndrome. CT angiography combined with 3D reconstructions should be considered in patients who might otherwise require angiography.     

Laparoscopic management of superior mesenteric artery syndrome

Superior mesenteric artery syndrome (SMAS) is a rare clinical condition that should be considered in patients with long-standing abdominal complaints where endoscopic and conventional roentgenographical findings are often negative. It has been claimed that SMAS is caused by intermittent obstruction of the horizontal portion of the duodenum between the superior mesenteric artery and the spine and the aorta. The main target of this presentation is to present our experience in the laparoscopic management of 4 cases of documented SMAS after failure of medical treatment. The laparoscopic severing of the ligament of Treitz is a feasible and safe technique. It could bring about total relief of symptoms in three out of the four patients. The operative time rapidly decreased with the acquaintance of the field. The visualization (exposure) is quite satisfactory. the technique offers added precision and accuracy to the dissection manoeuvres. Recovery was uneventful and rapid with minimal needs for postoperative analgesia. We recommend the use of mini-endoshear (pediatric). Phases of dissection from the mesocolon and retro-pancreatically are presented. We stress the finding of the drainage of the inferior mesenteric vein into the superior mesenteric vein instead of the splenic vein. This could put the inferior mesenteric vein (looking as a fibrous band) in jeopardy. Also it reduces the area of access to the retropancreatic dissection. We raise the possibility of an etiological role of this anatomical variation to the duodenal compression and call upon the study of such a possibility. The importance to attain the proper retropancreatic space has been shown by the possibility of dissecting between the uncinate process and the rest of the pancreas. The psychological impact of a minimal invasive approach together with symptoms relief was quite rewarding.     

Cast syndrome: the superior mesenteric artery syndrome

Cast syndrome, clinically known as superior mesenteric artery syndrome (SMAS), is gastric dilatation with partial or complete obstruction of the duodenum. Although rare, it is most frequently seen in orthopaedic patients who have had spinal surgery or who are in hip spica or body casts. Obstruction occurs when there is compression of the duodenum between the superior mesenteric artery anteriorly and the aorta and spinal column posteriorly. Obstruction can occur within days of surgery or casting or may not develop for several weeks. Treatment for SMAS varies from conservative nonoperative to operative procedures. Complications can be severe if symptoms are not quickly recognized and treatment instituted in a timely manner.     

Fibromuscular dysplasia of the internal carotid artery associated with alpha1-antitrypsin deficiency

OBJECTIVE: A deficiency of alpha1-antitrypsin has been implicated in the development of various disorders affecting medium-sized arteries, including intracranial aneurysms, cervicocephalic arterial dissections, and fibromuscular dysplasia (FMD). We performed alpha1-antitrypsin phenotyping in three consecutive patients who underwent bypass surgery for FMD of the extracranial internal carotid artery to test the hypothesis that alpha1-antitrypsin deficiency is a genetic risk factor for the development of FMD. METHODS: The study population consisted of three women (aged 37, 49, and 53 years, respectively) who had bilateral internal carotid artery stenosis caused by FMD. The indications for surgery included ocular or cerebral ischemic symptoms in two patients and progressive stenosis in one patient. The diagnosis of FMD was confirmed by histological examination of the resected segment of artery. The alpha1-antitrypsin phenotype was determined by isoelectric focusing in polyacrylamide gels. RESULTS: Two of the three patients had a heterozygous alpha1-antitrypsin deficiency (PiMZ phenotype). Pathological examination of the resected arterial segment showed typical medial FMD with focal intimal fibroplasia in both patients with the PiMZ phenotype. CONCLUSION: These findings suggest that a heterozygous alpha1-antitrypsin deficiency may be a genetic risk factor for the development of FMD of the internal carotid artery.     

Fibromuscular dysplasia and multiple dissecting aneurysms of intracranial arteries. A further cause of Moyamoya syndrome

A 16-year-old boy, who had sudden left-sided hemiplegia, died two weeks following onset of symptoms. A right carotid angiogram showed stenosis at the termination of the internal carotid artery. The middle cerebral artery had a beaded appearance and some of its branches were occluded. A basal "moyamoya" syndrome and transdural anastomoses were present. At autopsy, multiple intracranial dissecting aneurysms were found. Arteries of the body displayed fibromuscular dysplasia (FMD). The relevance of dysplastic changes of intracranial arteries and the relationship to moyamoya syndrome are discussed.     

Duodenal trichobezoar caused by compression of the superior mesenteric artery

Trichobezoars can occur in young women who have a history of trichotillomania, trichophagia, gastric dysmotility, and psychiatric dysfunction. A 6-year-old anorexic girl presented with a fixed right-upper-quadrant abdominal mass. Exploratory celiotomy for a duodenal trichobezoar led to removal of the large foreign body, via a duodenotomy, and prompted a Ladd procedure, in which the duodenum was moved from beneath the compressing superior mesenteric artery to relieve underlying duodenal narrowing.     

Left gastric artery arising from the superior mesenteric artery--case reports

The release profile of chlorhexidine from the PerioChip (Chip), a biodegradable local delivery system that contains 2.5 mg of chlorhexidine gluconate (CHX) in a cross-linked hydrolyzed gelatin matrix, into the gingival crevice, was evaluated in an in vivo, open label, single-center, 10-day pharmacokinetic study conducted on 19 volunteers with chronic adult periodontitis. Each volunteer had a single chip inserted into each of 4 selected pockets, with probing pocket depths of between 5-8 mm, at time 0. Gingival crevicular fluid (GCF) samples were collected using filter paper strips prior to Chip placement and at 2 h, 4 h, 24 h and 2, 3, 4, 5, 6, 8, and 9 days post-Chip placement. The GCF volume was measured using a calibrated Periotron 6000. Blood samples were collected at times 0, 1, 4, 8, 12 h and 5 days post-dosing. Urine was collected as a total 24-h specimen immediately post-dosing and 2 single samples at time 0, prior to dosing, and 5 days. The CHX was eluted from the paper strips and the CHX levels in GCF, blood and urine quantified using HPLC. The results indicate an initial peak concentration of CHX in the GCF at 2 h post-Chip insertion (2007 microg/ml) with slightly lower concentrations of between 1300-1900 microg/ml being maintained over the next 96 h. The CHX concentration then progressively decreased until study conclusion with significant CHX concentrations (mean=57 microg/ml) still being detectable at study termination. CHX was not detectable in any of the plasma or urine samples at any time point during the study. These results indicate that the PerioChip can maintain clinically effective levels of CHX in the GCF of periodontal pockets for over 1 week with no detectable systemic absorption.     

Effects of glucagon on superior mesenteric artery and femoral artery haemodynamics in humans

OBJECTIVE: It remains unclear whether glucagon is a localized splanchnic arterial vasodilator in humans. This study examined this issue by assessing the haemodynamic effect of exogenous glucagon on splanchnic and extrasplanchnic arteries. METHODS: After an overnight fast, flow velocity of superior mesenteric artery and femoral artery was recorded by means of echo-Doppler in 10 controls and 10 patients with cirrhosis. Mean arterial pressure, heart rate and plasma glucagon level were also determined. These measurements were repeated after intramuscular injection of glucagon (1 mg) at 15 min and 30 min. RESULTS: Patients with cirrhosis had much higher glucagon levels than controls (P < 0.01). Plasma glucagon level rose following glucagon administration in controls (P < 0.01) and patients with cirrhosis (P < 0.01). Glucagon administration had no effect on mean arterial pressure, heart rate and femoral artery velocity in controls and patients with cirrhosis. In contrast, superior mesenteric artery velocity significantly increased after glucagon administration in both groups (P < 0.01, P < 0.01), although the effect was less pronounced in patients with cirrhosis than in controls (P < 0.05). CONCLUSION: These data suggest that glucagon might be a localized splanchnic arterial vasodilator. Thus, glucagon may be one of the factors contributing to the pathogenesis of the splanchnic hyperdynamic circulation seen in patients with cirrhosis.     

A new case of false aneurysm of the superior mesenteric artery

The sensitizing capacity of brewer's yeast (Saccharomyces cerevisiae) was studied with the skin prick test method in 449 subjects, including 226 atopic dermatitis (AD) patients, 50 patients with allergic rhinitis (AR) and/or asthma (A), and 173 nonatopic controls. A positive SPT reaction (> or = + +) was seen in 94% of patients with severe AD, in 76% with moderate AD, and in 25% with mild AD or no history of AD. Patients with AR and/or A and nonatopic controls displayed a positive reaction in only 8 and 2% of cases, respectively. There was also a parallel skin prick test reactivity with other yeasts including Pityrosporum ovale and Candida albicans, suggesting cross-reactivity. Parallel skin reactivity was observed also with molds and animal dander but not with pollen or house-dust mite. A significant correlation was also found between total serum IgE level and skin prick test (SPT) results with S. cerevisiae.     

Fibromuscular dysplasia of the internal carotid artery in a child with alpha-1-antitrypsin deficiency

Fibromuscular dysplasia (FMD) is a non-inflammatory segmental arteriopathy of unknown origin. Most often the renal arteries are affected, however, also mesenteric, lumbar, vertebral, or carotid arteries may be involved. FMD has frequently been reported as a cause of stroke in adults, but very rarely in children. We report the case of an 11-year-old boy who presented with an ischaemic infarction in the anterior part of the territory of the left middle cerebral artery. Angiography demonstrated a 'string of beads' lesion suggestive of FMD causing occlusion at the origin of the middle artery. Laboratory analyses revealed the protease inhibitor (Pi) phenotype SZ (PiSZ) of alpha-1-antitrypsin deficiency as well as decreased antioxidants and signs of enhanced lipid peroxidation. Such an imbalance may be associated with diminished resistance to oxidation, possibly causing direct cellular and tissue injury. Whether alpha-1-antitrypsin deficiency and an impaired status of antioxidants, as seen in our patient, might play a role in the pathogenesis of FMD is presently unclear.