Aortic Intramural Hematoma due to Intercostal Artery Aneurysms

Background Intercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.

Unraveling Variations in Celiac Trunk and Hepatic Artery by CT Angiography to Aid in Surgeries of Upper Abdominal Region

Understanding of variations in the course and source of abdominal arteries is crucial for any surgical intervention in the peritoneal space. Intricate surgeries of the upper abdominal region, such as hepato-biliary, pancreatic, gastric and splenic surgeries, require precise knowledge of regular anatomy and different variations related to celiac trunk and hepatic artery. In addition, information about the origin of inferior phrenic artery is important in conditions such as hepatocellular carcinoma and gastroesophageal bleeding management. The present study gives an account of anatomical variations in origin and branching pattern of celiac trunk and hepatic artery by the use of CT (computed tomographic) angiography. The study was performed on 110 (66 females and 44 males) patients in a north Indian population. Results unraveled the most common celiac trunk variation as hepatosplenic trunk with left gastric artery, which was observed in 60% of cases, more common in females than in males. Gastrosplenic and hepato-gastric trunk could be seen in 4.55% and 1.82% cases respectively. Gastrosplenic trunk was more commonly found in females, whereas hepato-gastric trunk was more common in males. A gastrosplenic trunk, along with the hepato-mesenteric trunk, was observed in 1.82% cases and was more common in males. A celiacomesenteric trunk, in which the celiac trunk and superior mesenteric artery originated as a common trunk from the aorta, was seen only in 0.91% of cases, and exhibited an origin of right and left inferior phrenic artery from the left gastric artery. The most common variation of hepatic artery, in which the right hepatic artery was replaced and originated from the superior mesenteric artery, was observed in 3.64%, cases with a more common occurrence in males. In 1.82% cases, the left hepatic artery was replaced and originated from the left gastric artery, which was observed only in females. Common hepatic artery originated from the superior mesenteric artery, as observed in 1.82% cases, with slightly higher occurrence in males. These findings not only add to the existing knowledge apart from giving an overview of variations in north Indian population, but also give an account of their correlation with gender. The present study will prove to be important for various surgeries of the upper abdominal region.

Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies

Purpose To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. Technique We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. Conclusion Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.

Postoperative Hepatic Dysfunction After Frozen Elephant Trunk for Type A Aortic Dissection

Background: This study was aimed to investigate the incidence, risk factors, and outcomes of patients with postoperative hepatic dysfunction (PHD) after frozen elephant trunk (FET) for type A aortic dissection (TAAD).Method: A retrospective study was performed with 492 patients who underwent FET for TAAD between 2015 and 2019. Independent risk factors for PHD were determined by multivariate mixed-effect logistic analysis with surgeon-specific factor as a random effect.Results: The incidence of PHD was 25.4% (n = 125) in our cohort. Patients with PHD presented higher early mortality (10.4 vs. 1.1%, p < 0.001), rates of acute kidney injury (42.4 vs. 12.8%, p < 0.001), and newly required dialysis (23.2 vs. 3.0%, p < 0.001) compared with those without PHD. Moreover, with the median follow-up period of 41.3 months, the survival curve was worse in patients with PHD compared with no PHD group (log-rank p < 0.001), whereas it was similar after excluding patients who died within 30 days (log-rank p = 0.761). Multivariable analyses suggested that PHD was predicted by preoperative aspartate transferase [odds ratio (OR), 1.057; 95% confidence intervals (CI), 1.036–1.079; p < 0.001], celiac trunk malperfusion (OR, 3.121; 95% CI, 1.008–9.662; p = 0.048), and cardiopulmonary bypass time (OR, 1.014; 95% CI, 1.005–1.023; p = 0.003). Retrograde perfusion (OR, 0.474; 95% CI, 0.268–0.837; p = 0.010) was associated with a reduced risk of PHD. Celiac trunk malperfusion was an independent predictor for PHD but not associated with early mortality and midterm survival.Conclusions: PHD was associated with increased early mortality and morbidity, but not with late death in midterm survival. PHD was predicted by preoperative aspartate transferase, celiac trunk malperfusion, and cardiopulmonary bypass (CPB) time, and retrograde perfusion was associated with a reduced risk of PHD.

Clinical and Variant Anatomy of the Blood Supply to the Body and Tail of the Human Pancreas

The aim of the study was to specify peculiarities of the blood supply to the body and tail of the human pancreas determining topographic variants and vascular bed of the splenic artery.Material and methods. The artery basin of the pancreas body and tail was studied in 46 native and 42 organ complexes consisting of the pancreas, duodenum, spleen, retropancreatic tissue, celiac trunk with the main branches, a section of the superior mesenteric artery up to the entrance into the root of the small intestine mesentery with the preliminary artery injection by gelatin mass. The organ complexes were fixed in 10% formalin solution.Results. The study revealed two variants of the splenic artery topography in relation to the pancreas and determined the degree of tortuosity of the artery. In 31.7% of cases the vessel passed retro-pancreatically and in 68.3% suprapancreatically. Moderate tortuosity of the splenic artery was detected most frequently (44.82%); in 34.48% of cases severe tortuosity was detected; in 17.24% of cases there was no tortuosity in the artery. The correlation between area/convolution and the number of pancreatic arteries was found to be 0.864 (p=0.05), which is considered to be a high parameter according to the Cheddock scale. In severe tortuosity of the splenic artery 3.16±0.37 pancreatic arteries on average closed to the corpus caudal segment of the pancreas, in moderate tortuosity – 5.09±1.24, in straight passage – 9±1.22.Conclusion. The regularities revealed in the spleen artery topography, blood supply of the pancreas body and tail allow determining operational risks and tactics of surgical interventions on the corpus caudal segment of the pancreas.

Anatomical Variations of Celiac Trunk and Its Branching Pattern with Special Reference to Surgical Implications in Mysore Based Population

BACKGROUND Celiac trunk (CT) is the first major abdominal branch of the aorta. Anatomic variations and accessory vessels have been reported with variable percentages. We report here a particularly rare variant involving absence of the celiac trunk in association with trifurcation of the common hepatic artery (CHA). The purpose of this study was to report the pattern of the celiac trunk and its anatomic variations in a sample of Mysore population. METHODS Celiac trunk dissection was performed in 10 fresh cadavers and 50 cases of contrast enhanced computed tomography (CECT) images of Mysore based subjects at JSS Medical College and Hospital aged 18 years and above were included. Celiac trunk variations, length, diameter, accessory vessels, and vertebral level of origin were described. RESULTS The branching pattern of coeliac trunk was observed in 60 cases (37 males, 23 females) by dissection and CECT scan method. Type I was found in 48 cases (80 %), Type I form 2a was found in 2 cases (3.3 %). Type II form 1 in 6 cases (10 %). Type III was observed in 1 case and in another case left hepatic artery (LHA) arising from coeliac trunk, Type VII was found in 2 cases (3.3 %). The length and diameter of coeliac trunk were analysed using descriptive statistics and mean ± SD for length was 1.8 ± 0.4 and diameter 0.5 ± 0.2 respectively. CONCLUSIONS Awareness of CT variations is important in surgical resection, transplantation, and interventional radiology procedure. KEY WORDS Celiac Trunk, Variations, Morphometry, Contrast Enhanced Computed Tomography Scan Method