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Pathology of Arteriosclerotic, Fibrodysplastic, and Developmental Renal Artery Occlusive Disease

Renal artery occlusive disease is the most common cause of surgically correctable hypertension in adults and in some instances contributes to deterioration in kidney function. It is a less common cause of secondary hypertension in pediatric patients. Pathologic processes causing renovascular hypertension include arterial fibrodysplasia, developmental hypoplasia, and arteriosclerosis. These entities are distinctly different, and discussion of them must be individualized. Renal Artery Fibrodysplasia Fibrodysplastic stenoses…

Gastroduodenal and Pancreaticoduodenal Artery Aneurysms

Gastroduodenal artery aneurysms account for 1.5% and pancreatic and pancreaticoduodenal artery aneurysms account for 2% of all splanchnic artery aneurysms. These aneurysms are usually categorized as being either pseudoaneurysms or true aneurysms. It is important to acknowledge their differences regarding pathogenesis, clinical manifestations including risk to life, and the various means of their management. Arteriosclerosis is often present in both aneurysmal types and is considered a…

Mesenteric Artery Aneurysms

Mesenteric artery aneurysms are an uncommon disease within the splanchnic circulation. Although a considerable number of case reports and small series exist that describe the relevance and management of these aneurysms, our knowledge on this topic remains somewhat anecdotal. Nevertheless, clinicians are increasingly asked to make recommendations regarding their treatment. In that regard, it is important to separately discuss the aneurysms of the superior, inferior, jejunal,…

Celiac, Hepatic, and Splenic Artery Aneurysms

Although uncommon, splanchnic artery aneurysms are being recognized with increasing frequency with the widespread use of advanced imaging techniques. True aneurysms and pseudoaneurysms of the visceral branches of the aorta remain a potential source of significant vascular morbidity and mortality. Management of these aneurysms is evolving to include a more important role for endovascular therapy. Aneurysms involving the celiac, hepatic, and splenic arteries account for more…

Venous Thrombosis Within the Splanchnic Circulation

Mesenteric vein thrombosis was first recognized by Eliot a century ago and was more completely described by Warren and Eberhard as early as 1935. The underlying pathophysiology and treatment options have only been well delineated during the last few decades. Understanding has been confounded by the fact that clinical presentations range widely from acute life-threatening bowel ischemia to very subtle chronic symptoms, depending on the pace…

Nonocclusive Mesenteric Ischemia

Acute mesenteric ischemia and intestinal gangrene can result from arterial embolization, arterial or venous thrombosis, or nonocclusive mesenteric ischemia (NOMI). NOMI is a condition characterized by primary splanchnic vasoconstriction of a patent arterial tree and is commonly associated with low cardiac output and flow states. Paradoxically, NOMI has also been reported following successful mesenteric revascularization. Intestinal gangrene in association with heart failure was first described by…

Celiac Artery Compression Syndrome

Celiac artery compression syndrome was first described in the 1960s. It is a consequence of extrinsic compression by the median arcuate ligament of the celiac artery and surrounding neural tissues ( Figure 1 ). Several synonyms have been applied to this condition, including celiac axis syndrome, celiac band syndrome, Dunbar’s syndrome, and the median arcuate ligament syndrome. Controversy surrounds the existence of this syndrome because many…

Operative Treatment of Pediatric Splanchnic Arterial Occlusive Disease

Clinical Presentation Splanchnic arterial occlusive disease in children is a very uncommon pathologic entity and a rare cause of intestinal ischemic symptoms. This disease is usually recognized as an incidental finding during studies of hypertensive children having abdominal aortic coarctations or renal artery disease. In two earlier publications from our institution, splanchnic artery occlusive lesions were encountered in 22% of patients with abdominal aortic coarctations and…

Arterial Bypass for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is a relatively rare, potentially lethal, and often misdiagnosed condition caused by fixed stenosis or occlusion of the proximal splanchnic arteries. It is estimated to account for less than 1 in 100,000 hospital admissions in the United States. The earliest description of CMI as a clinical disorder dates to the early 20th century, but it was Dunphy who in 1936 recognized the…

Transaortic Splanchnic Endarterectomy for Chronic Mesenteric Ischemia

Management of chronic mesenteric ischemia remains a challenge because of the relative infrequency of this disease and the technical requirements of a successful mesenteric revascularization. The increase in endovascular treatment of visceral occlusive disease has also reduced the number of open surgical mesenteric artery reconstructions and diminished familiarity with this technique. Adequate exposure of the celiac artery (CA) and superior mesenteric artery (SMA), which arise from…

Endovascular Therapy for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is caused most often by ostial atherosclerotic disease. The typical patient is female, with median age of 65 years old. Most studies quote a 3:1 or 4:1 female-to-male ratio, with age ranging from 40 to 90 years old. The term intestinal angina has been coined to describe the chronic abdominal pain that occurs within a few minutes to 30 minutes after meals. Patients…

Acute Embolic and Thrombotic Mesenteric Ischemia

Embolism and thrombosis of the mesenteric arteries, mesenteric venous thrombosis, and nonocclusive mesenteric ischemia are the four major causes of acute intestinal ischemia. Mortality rates for patients with acute mesenteric arterial occlusion range between 50% and 90%, and the presence and extent of bowel infarction predict mortality. A successful outcome depends on prompt diagnosis, rapid resuscitation, and surgical or endovascular revascularization, intestinal resection, and judicious use…

Duplex Scanning in the Diagnosis of Splanchnic Artery Occlusive Disease

Duplex scanning of the mesenteric vessels is performed to determine the presence, location, extent, and severity of stenosis, aneurysm, or other disease of the mesenteric arteries. It includes assessment of the superior mesenteric artery (SMA), the celiac artery (CA), and the inferior mesenteric artery (IMA). Of these, assessment of the SMA and CA is the most important. The IMA is often difficult to examine, and the…

Arteriography Evaluation of Splanchnic Artery Occlusive Disease

Splanchnic artery occlusive disease can involve the origin, branches, or distal arteries of the splanchnic arteries, depending on the underlying pathologic process. The newer imaging modalities (including ultrasound, computed tomography [CT], and magnetic resonance angiography [MRA]) provide much of the diagnostic information about splanchnic artery occlusive disease that can be derived from catheter-based angiography. Diagnostic angiography is performed only when necessary information about the splanchnic circulation…

Pediatric Iatrogenic Vascular Injury

Pediatric injuries and accidents are the most common causes of childhood death, and nonfatal injuries are innumerable in this age group. Conversely, iatrogenic trauma accounts for an extremely small subset of injuries occurring in childhood. These particular injuries are not often life threatening, but they can carry significant morbidity. The majority of arterial injuries occur with some type of vascular access, including phlebotomy, peripherally inserted central…

Cold Injury

Cold weather has been known to be a threat to humans since the beginning of recorded history. Cold injury as a threat has intensified during periods of armed conflict. Its devastating results were detailed during the American Revolution and in Napoleon’s campaign in Russia, and similar devastating experiences occurred in World War I, World War II, and the Korean conflict. Frostbite, immersion foot, and trench foot…

Vascular Injury Secondary to Drug Abuse

Arterial Injury Inadvertent intraarterial drug injection (IADI) can result from administration of medication by health care providers or injection of illicit substances. Iatrogenic intraarterial injection was first reported 60 years ago and is estimated to occur in between 1 in 3440 and 1 in 56,000 cases of parenteral medication administration. The incidence following illicit drug administration is unknown but is thought to be more common, although…

Ischemia-Induced Muscle Myonecrosis, Myoglobinuria, and Secondary Kidney Failure

Despite many advances in the management of acute limb ischemia, this sudden-onset disease entity continues to have a high morbidity and mortality related both to limb loss and to the development of adverse systemic complications that can lead to renal failure, arrthymia, acute respiratory distress syndrome (shock lung), and death. Improvements in catheter-based delivery of lytic agents have contributed to improved outcomes, but the overall 1-month…

Fasciotomy for Compartmental Hypertension and Acute Compartment Syndrome

The term compartment syndrome invokes the concept of a pathophysiologic process in which elevated tissue pressures within inelastic surroundings result in neurovascular or muscular damage. The development of compartment syndrome is commonly anticipated in certain clinical scenarios, particularly in patients with blunt (or occasionally penetrating) extremity trauma and patients with severe acute limb ischemia that is successfully revascularized. Pathophysiology Two separate biophysical phenomena can result in…