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Purpose: To provide detailed reports on radiation doses during transarterial chemoembolization (TACE) in the cone-beam computed tomography (CBCT) era and to identify the associated factors. Methods: This retrospective study included 385 consecutive patients who underwent initial conventional TACE for hepatocellular carcinoma (HCC) between January 2016 and December 2017. In most cases, CBCT was performed at the common hepatic artery or celiac axis to confirm the location of the tumor and the three-dimensional hepatic artery anatomy. Superselective TACE was performed for all technically feasible cases. Information on total dose area product (DAP), total cumulative air kerma (CAK), fluoroscopy time, and DAP and CAK of each digital subtraction angiography (DSA) and CBCT scan was recorded. Multiple linear regression analysis was performed to identify the factors associated with increased DAP during TACE. Results: The mean values of total DAP and CAK were 165.2 ± 81.2 (Gy·cm²) and 837.1 ± 571.0 (mGy), respectively. The mean fluoroscopy time was 19.1 ± 10.3 min. The mean DAP caused by fluoroscopy, DSA, and CBCT was 51.8 ± 43.9, 28.0 ± 24.1, and 83.9 ± 42.1 Gy·cm², respectively. Male sex, a high body mass index, largest tumor size > 3 cm, presence of aberrant right and left hepatic arteries, and superselective TACE were identified as independent predictors of increased total DAP during TACE. Conclusion: We were able to provide detailed reports on radiation doses during TACE and associated factors. [ABSTRACT FROM AUTHOR]

Median arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap‐MALR) procedures are rare. In this study, we performed lap‐MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap‐MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato‐biliary‐pancreatic surgery, and one symptomatic case. In all cases, lap‐MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap‐MALR procedure in the treatment of MALS‐related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression. [ABSTRACT FROM AUTHOR]

Purpose: Median arcuate ligament syndrome (MALS) is a rare disorder caused by compression of the celiac artery (CA) by the median arcuate ligament (MAL). Common symptoms include postprandial abdominal pain, diarrhea, and weight loss. While laparoscopic MAL division has long been considered the procedure of choice, robotic-assisted procedures have been increasingly used since their introduction. Aim of this study was to evaluate peri- and postoperative outcomes after minimally invasive MAL release. Methods: A retrospective analysis of patients undergoing minimally invasive MAL release at the Department of Surgery, Charité - Universitätsmedizin Berlin, between 2014 and 2023 was performed. Results: 20 patients met the inclusion criteria and underwent either laparoscopic (n = 3) or robotic (n = 17) MAL release. Most common preoperative symptoms were postprandial abdominal pain (90%), weight loss (45%), diarrhea (30%), and nausea (25%). Comparing laparoscopic and robotic surgery, neither the median duration of surgery (minutes: 98 (90–290) vs. 125 (80–254); p = 0.765), the median length of hospital stay (days: 4 (3–4) vs. 5 (3–6); p = 0.179) and intraoperative blood loss (< 50 ml in both groups, p = 1.0) showed significant differences. Peak systolic velocity in the CA was significantly reduced postoperatively (cm/s: 320 (200–765) vs. 167 (100–500), p < 0.001). Postoperatively, 17 (85%) patients reported symptom improvement, while 4 (20%) patients had no symptom relief at last follow-up. In 3 cases, follow-up imaging showed evidence of respiratory-related CA stenosis. Conclusion: Despite being complex and challenging procedures, laparoscopic and robotic-assisted MAL release are safe procedures with low risk of postoperative complications and good longterm outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: Distal pancreatectomy with celiac axis resection (DP-CAR) has equivalent morbidity and survival outcomes compared to standard distal pancreatectomy (DP) in patients with pancreatic adenocarcinoma requiring modern neoadjuvant chemotherapy. Background: Distal pancreatectomy with celiac axis resection (DP-CAR) has been used for selected patients with pancreatic cancer infiltrating the celiac axis. We compared the short- and long-term outcomes between DP-CAR and distal pancreatectomy alone (DP) in patients receiving neoadjuvant therapy. Methods: Patients undergoing DP-CAR from 2013 to 2022 were retrospectively reviewed. Clinicopathologic features, post-operative morbidity, and survival outcomes were compared with patients undergoing DP after neoadjuvant chemotherapy. Results: Twenty-two DP-CAR and thirty-four DP patients who underwent neoadjuvant chemotherapy were identified. There were no differences in comorbidities or CA19-9 levels. OR time was longer for DP-CAR (304 vs. 240 min, p = 0.007), but there was no difference in the transfusion rate (22.7% vs. 14.7%). Vascular reconstruction was more common in DP-CAR (18.2% vs. 0% arterial, p = 0.05; 40.9% vs. 12.5% venous, p = 0.04). There was no difference in morbidity or mortality between the two groups. Although there was a trend towards larger tumors in DP-CAR (5.1 cm vs. 3.8 cm, p = 0.057), the overall survival from the initiation of treatment (32 vs. 28 months, p = 0.43) and surgery (30 vs. 24 months, p = 0.43) were similar. Discussion: DP-CAR is associated with similar survival and morbidity compared to DP patients requiring neoadjuvant chemotherapy and should be pursued in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries. [ABSTRACT FROM AUTHOR]

Background: Median arcuate ligament syndrome (MALS) poses a considerable challenge in terms of diagnosis due to its manifestation of diverse symptoms linked to constriction of the median arcuate ligament surrounding the celiac artery. The present study introduces an earlier diagnostic modality using ultrasound measurements of the flow velocity of the celiac artery during the inspiratory and expiratory phases, with the latter being higher than the former, to avoid prolonged follow-up of postprandial symptomatology. Case Report: A 46-year-old female patient presented with acute postprandial abdominal pain, which was alleviated by analgesic medication. The findings from the physical examination and laboratory tests were within normal limits. Further investigations were conducted due to persistent symptoms, revealing an elevation in celiac artery flow velocity during expiration on ultrasound. The diagnosis of median arcuate ligament syndrome (MALS) was confirmed through contrast-enhanced CT and angiography. Subsequently, the patient underwent laparoscopic release of the median arcuate ligament, leading to alleviation of symptoms at the 1-year follow-up assessment. Conclusions: Our case report highlights the importance of a dynamic imaging diagnostic strategy for MALS. When encountering challenging postprandial abdominal pain that is hard to diagnose, it could be crucial to utilize abdominal ultrasound to measure the flow velocity of the celiac artery. This approach may serve as a valuable screening method for identifying MALS and, subsequently, prompt the need for further diagnostic tests. [ABSTRACT FROM AUTHOR]

Background: The pathophysiology of median arcuate ligament syndrome (MALS) is poorly understood. The diagnostic process remains inadequately standardized, with an absence of precise criteria to guide therapeutic management. Methods: We studied consecutive subjects referred to the Department of Angiology at the University Hospital of Zurich over the past 17 years due to suspected MALS. We focused on (1) the imaging criteria that led to diagnosis, notably the results of color duplex ultrasound and the consistency with different imaging tests; (2) the clinical consequences focusing on symptom resolution. Results: We included 33 subjects; in 8 subjects (24.2%), the diagnosis of MALS was retained. The median expiration peak systolic velocity (PSV) on ultrasound was 3.05 (Q1; 2.1–Q3; 3.3). To confirm the sonographic results, either a CT or MRI was performed on all patients, with consistent findings confirming a significant stenosis. Seven patients underwent surgery, all involving arcuate ligament release. Four procedures were laparoscopic, one was via laparotomy, and two were robot-assisted. Additionally, two patients required angioplasty with stenting as a secondary intervention. Only two (28.6%) of the seven operated patients experienced a relief of symptoms. None experienced a relief of symptoms following secondary angioplasty, despite stent patency. The prevalence of psychiatric disorders was comparable between patients with retained and rejected diagnoses, 38% and 36%, respectively. Conclusions: Our study confirmed sonography and CT/MRI consistency. However, most patients with MALS did not benefit from invasive treatment. The majority (83%) of patients without MALS were diagnosed with alternative conditions, mainly functional disorders. [ABSTRACT FROM AUTHOR]

This document provides abstracts of clinical case presentations from the 2024 Vascular Scientific Sessions of the Society for Vascular Medicine. The cases cover a range of vascular conditions and highlight the challenges in diagnosing and managing these conditions. Topics include pulmonary embolism, Erdheim-Chester disease, polycythemia vera, cyanoacrylate closure, antiphospholipid syndrome, heavy metal toxicity, aortic aneurysms, COVID-19 multisystem inflammatory syndrome, large vessel vasculitis, arterial dissections, acute limb ischemia, ruptured abdominal aortic aneurysm, deep venous thrombosis, thoracic outlet syndrome, carotidynia, adrenal leiomyosarcoma, aortic dissection, transgender health, giant cell arteritis, cancer-related venous thrombosis, and vasopressor-induced peripheral ischemia. The cases emphasize the need for prompt diagnosis, appropriate management, and consideration of alternative treatments when necessary. [Extracted from the article]

Although anomalies of the celiac and/or superior mesenteric arteries are occasionally encountered during abdominal surgery, anomalous venous confluence is seldom reported during pancreatic surgery. Herein, we present a rare case of laparoscopic spleen‐preserving distal pancreatectomy (LSPDP) for the treatment of a solid pseudopapillary neoplasm in an asymptomatic 37‐year‐old male with an anomalous splenic vein (SpV) confluence. Computed tomography angiography (CTA) revealed an anomaly of the SpV, which coursed transversely through the superior border of the pancreas, over the celiac artery and into the portal vein, along the superior line of the common hepatic artery. We successfully performed an LSPDP without peripancreatic vessel injury by exposing the SpV and splenic artery through an approach from the superior position of the pancreas. Preoperative imaging, especially CTA, is crucial to ensuring a safe, successful laparoscopic pancreatectomy. [ABSTRACT FROM AUTHOR]

Blunt traumatic dissection of the celiac artery without aortic dissection is a rare event. There is paucity of data on the appropriate management of such injuries. In this brief report, we present a patient with isolated celiac artery dissection after blunt abdominal trauma. The patient was managed non-operatively with anticoagulation and developed splenic infarct. Due to its rarity, no grading criteria and management guidelines exist for the spectrum of isolated blunt CA injuries. Furthermore, it remains unlikely that injury volume will increase to create robust management guidelines. We therefore suggest that isolated celiac artery injury be graded based on the Biffl grading criteria for blunt cerebrovascular injury and managed accordingly. [ABSTRACT FROM AUTHOR]

Vascular compression syndromes are a group of conditions resulting from mechanical compression of blood vessels by adjacent structures leading to compromised blood flow and various associated symptoms. They frequently affect young, otherwise healthy individuals and are often underdiagnosed due to their rarity and vague clinical manifestations. Achieving an accurate diagnosis depends on the integration of clinical presentation and imaging findings. Imaging modalities including color doppler ultrasound, computed tomography angiography, magnetic resonance angiography, and catheter-directed digital subtraction angiography are essential for diagnosis and management. Dynamic imaging is crucial in eliciting findings due to the positional nature of many of these syndromes. In this paper, we will present a "head-to-toe" overview of vascular compression syndromes including Vascular Eagle Syndrome, Vascular Thoracic Outlet Syndrome, Quadrilateral Space Syndrome, Hypothenar Hammer Syndrome, Median Arcuate Ligament Syndrome, Renal Artery Entrapment Syndrome, Left Renal Vein Compression/Nutcracker Syndrome, May-Thurner Syndrome, Adductor Canal Syndrome, and Popliteal Artery Entrapment Syndrome. Treatment is variable but typically involves a combination of conservative and surgical management. Surgical approaches focus on decompression of affected neurovascular structures. Endovascular treatment alone is rarely recommended. We aim to equip general radiologists with the knowledge needed to accurately diagnose patients with vascular compression syndromes, allowing for timely treatment. • Vascular compression syndromes are rare and require a combination of clinical signs and imaging findings for diagnosis. • Dynamic imaging techniques are pivotal in enhancing the diagnostic sensitivity of vascular compression syndromes. • CTA and MRA yield comparable assessments of vascular compression syndromes, contingent upon the institutional protocols. [ABSTRACT FROM AUTHOR]

Background After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes. Methods All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann–Whitney test and the Kruskal–Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality. Results A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042). Conclusion Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality. [ABSTRACT FROM AUTHOR]

Anticipating a wide range of morphological variations of arterial anatomy of foregut derivatives beyond the classical pattern, a precise understanding is pertinent to preoperative diagnosis, operative procedure and to avoid potentially devastating post-operative outcome during various traumatic and non-traumatic vascular insult of foregut. The study aimed to revisit the morphological details and update unusual configurations of arteries of foregut to establish clinico-anatomical correlations. This study described the detailed branching pattern of coeliac trunk (CT) as principal artery of foregut with source & course of hepatic, gastric, duodenal and pancreatic branches in 58 cadaveric dissections. Based on morphology, different types and subtypes were made. The descriptions were explained using figures and pertinent tables. Among classical branches of CT, splenic artery was found as most stable whereas other two branches were found to be most variable with missing common hepatic artery in 11 cases. In addition to classical trifurcation (65.52%), different types of bifurcation (12.07%) and tetrafurcations (22.41%) of CT were observed. Regarding variations of hepatic arteries (27.59%), both non-classical origin and accessory hepatic branches were found. In case of gastric branches, more variant origins were seen with right gastric (50%) as compared to left gastric artery (34.48%). Other morphological variations included non-classical origin of gastro-duodenal artery (18.96%) along with presence of accessory pancreatic (17.13%) and duodenal arteries (6.38%). Awareness of anatomical variations regarding circulatory dynamics of foregut is worth knowing in order to facilitate successful planning of surgery involving upper abdominal organs with least complications. [ABSTRACT FROM AUTHOR]

Celiac trunk and superior mesenteric artery (SMA) are the main blood supply to the liver and pancreas. The data of anatomical variations in these arteries or their branches are very important clinically and surgically. The aim of this study was to describe the different variants in these arteries through the examination of the angiographs of a large series of Egyptian individuals. This research involved 389 selective angiographies to celiac artery, its branches, and the SMA. Anatomy of the target arteries of people who experienced visceral angiograph was reviewed and the data were recorded. From the total available angiograms in this work, 286 patients (73.52%) had the standard anatomy of celiac trunk and superior mesenteric arteries, and 103 patients (26.47%) had a single or multiple vessel variation. The inferior phrenic artery originates from celiac trunk in 2.05% of patients, while quadrifurcation of the celiac trunk was noticed in only 0.51% of patients. Absence of celiac trunk is also found in 0.51% of patients. Left gastric artery showed an abnormal origin from the splenic artery in 0.51% of patients. Quadrifurcation of common hepatic artery was also noticed. Variant anatomy of the left hepatic artery (LHA) was seen in 9.51% of patients, while variations of the right hepatic artery (RHA) were 14.13%. With the different origin of hepatic arteries, the gastroduodenal artery arose either from the LHA (2.82%), RHA (2.31%) or even from the celiac trunk (1.79%). [ABSTRACT FROM AUTHOR]

Purpose: To compare the inter-reader agreement of pancreatic adenocarcinoma resectability assessment at pancreatic protocol photon-counting CT (PCCT) with conventional energy-integrating detector CT (EID-CT). Methods: A retrospective single institution database search identified all contrast-enhanced pancreatic mass protocol abdominal CT performed at an outpatient facility with both a PCCT and EID-CT from 4/11/2022 to 10/30/2022. Patients without pancreatic adenocarcinoma were excluded. Four fellowship-trained abdominal radiologists, blinded to CT type, independently assessed vascular tumor involvement (uninvolved, abuts ≤ 180°, encases > 180°; celiac, superior mesenteric artery (SMA), common hepatic artery (CHA), superior mesenteric vein (SMV), main portal vein), the presence/absence of metastases, overall tumor resectability (resectable, borderline resectable, locally advanced, metastatic), and diagnostic confidence. Fleiss's kappa was used to calculate inter-reader agreement. CTDIvol was recorded. Radiation dose metrics were compared with a two-sample t-test. A p <.05 indicated statistical significance. Results: 145 patients (71 men, mean[SD] age: 66[9] years) were included. There was substantial inter-reader agreement, for celiac artery, SMA, and SMV involvement at PCCT (kappa = 0.61–0.69) versus moderate agreement at EID-CT (kappa = 0.56–0.59). CHA had substantial inter-reader agreement at both PCCT (kappa = 0.67) and EIDCT (kappa = 0.70). For metastasis identification, radiologists had substantial inter-reader agreement at PCCT (kappa = 0.78) versus moderate agreement at EID-CT (kappa = 0.56). CTDIvol for PCCT and EID-CT were 16.9[7.4]mGy and 29.8[26.6]mGy, respectively (p <.001). Conclusion: There was substantial inter-reader agreement for involvement of 4/5 major peripancreatic vessels (celiac artery, SMA, CHA, and SMV) at PCCT compared with 2/5 for EID-CT. PCCT also afforded substantial inter-reader agreement for metastasis detection versus moderate agreement at EID-CT with statistically significant radiation dose reduction. [ABSTRACT FROM AUTHOR]

Purpose: In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL). Methods: Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done. Results: Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties. Conclusion: This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions. [ABSTRACT FROM AUTHOR]

To clarify the risk factors for the aggravation of esophagogastric varices (EGVs) after hepatitis C virus (HCV) eradication with direct-acting antiviral (DAA) therapy, we enrolled 167 consecutive patients with HCV-related compensated cirrhosis who achieved a sustained virological response (SVR) after DAA therapy. During a median of 69 months, EGVs were aggravated in 42 (25%) patients despite SVR. The cumulative 1-, 3-, 5-, and 10-year aggravated EGV rates were 7%, 23%, 25%, and 27%, respectively. Multivariate analysis identified a platelet count < 11.0 × 104/μL, LSM ≥ 18.0 kPa, total bile acid ≥ 33.0 μmol/L, and a diameter of left gastric vein (LGV) ≥ 5.0 mm at HCV eradication as independent risk factors for EGV aggravation post-SVR. In groups that met all of these risks, the cumulative EGV aggravation rates at 1, 3, and 5 years were 27%, 87%, and 91%, respectively. However, none of the patients who had only one or none of the risk factors experienced EGV aggravation. Platelet count, LSM, total bile acid, and diameter of LGV at HCV eradication were associated with aggravated EGV post-SVR. EGVs tend to worsen as two or more of these risk factors increase. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to assess the safety and efficacy of endovascular treatment of unruptured pancreatic arcade aneurysms in a single-center series. Materials and Methods: The electronic medical records of patients who underwent endovascular treatment for unruptured pancreatic arcade aneurysms between 2011 and 2022 at our tertiary center were retrospectively reviewed. The presence of celiac artery stenosis/occlusion; aneurysm number, location, and size; endovascular technique; procedure-related complication incidence; and clinical outcomes were assessed. Results: Twenty-three patients (12 men and 11 women; mean [range] age, 63.8 [45–84] years) with 33 unruptured pancreatic arcade aneurysms were identified. Celiac artery stenosis/occlusion coexisted in 17 (74%) patients. Five (21%) patients had multiple aneurysms. The median aneurysm size was 9.3 mm (range, 4–18 mm). Seven, 6, 6, 5, 4, 3, and 2 aneurysms were located in the gastroduodenal, dorsal pancreatic, anterior superior pancreaticoduodenal, inferior pancreaticoduodenal, posterior inferior pancreaticoduodenal, posterior superior pancreaticoduodenal, and anterior inferior pancreaticoduodenal arteries, respectively. Four (15%) and 22 (85%) aneurysms were treated with endosaccular packing alone and coil embolization with endosaccular packing and parent artery occlusion, respectively, with resulting exclusion from arterial circulation. The remaining 7 aneurysms coexisting with larger aneurysms in other peripancreatic arteries were observed without embolization because they were small and for preserving collateral blood flow to the celiac artery. The treated aneurysms did not rupture or recur during the follow-up period (median, 40 months). Conclusion: Endovascular treatment is a safe and effective treatment for unruptured pancreatic arcade aneurysms. Level of Evidence: 3, non-controlled retrospective cohort study. [ABSTRACT FROM AUTHOR]

This document describes a case study presented at a medical conference about a preterm neonate with a congenital hepatic hemangioma (CHH). The neonate had right heart failure and pulmonary hypertension, as well as a patent ductus arteriosus (PDA) and atrial septal defect (ASD). Due to the neonate's small femoral arteries and bleeding diathesis, a trans-umbilical venous approach was used to access the arterial system via the PDA. The embolization procedure was successful, and the neonate's condition improved in the following weeks. This approach offers an alternative for neonates with difficult arterial access and coagulopathy. [Extracted from the article]

Abstract Median arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap‐MALR) procedures are rare. In this study, we performed lap‐MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap‐MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato‐biliary‐pancreatic surgery, and one symptomatic case. In all cases, lap‐MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap‐MALR procedure in the treatment of MALS‐related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression.

Spontaneous celiac artery dissection is uncommon. Abdominal pain is a common clinical presentation. Conservative medical treatments, endovascular interventions, and open surgery are used to treat spontaneous celiac artery dissection. A 49-year-old male patient visited our hospital, with back and subxiphoid pain that had persisted for 11 hours. He has been smoking 40 cigarettes a day for 20 years. The blood pressure was 180/100mmHg. Aortic computed tomography angiography (CTA) images revealed dissection of the celiac artery, common hepatic artery, left hepatic artery, right hepatic artery, and splenic artery. Urapidil hydrochloride and isosorbide dinitrate were administered to lower the blood pressure to approximately 110/70 mmHg. However, the back and subxiphoid pain persisted without relief. Angiography was performed and a vascular stent (BARD, LIFE STENT, VASCULAR, 8 × 60) was implanted into the celiac artery without involving the branches. Pain was immediately relieved after interventional therapy. The patient was discharged after 4 days. A subsequent aortic CTA after 10 months confirmed that the celiac artery dissection had still not reoccurred.

Anatomical variations in hepatic arteries are both common and diverse. According to the classic classification systems, a replaced right hepatic artery typically originates from the superior mesenteric artery, supplying blood to the right liver lobe in the absence of the right branch of the proper hepatic artery. This article reports 2 cases of a rare variation, a replaced right hepatic artery arising directly from the celiac trunk. In these cases, the artery courses posterior to the common hepatic artery and then behind the portal vein within the hepatoduodenal ligament. The first case, involving a 62-year-old male with intraductal papillary mucinous neoplasm (IPMN) of the pancreas, was identified intraoperatively during a pancreaticoduodenectomy. The second case, involving a 58-year-old female with chronic sclerosing cholangitis, was detected through contrast-enhanced computed tomography angiography. Identification of such variations is critical in hepatobiliary and pancreatic surgeries to prevent serious postoperative complications. Injury to a replaced right hepatic artery can lead to biliary-enteric anastomosis dehiscence after pancreaticoduodenectomy or ischemic liver complications. While hepatic arteries display numerous anatomical variations, classic classification systems fail to encompass all these anomalies. A more comprehensive classification system, such as CRL and ex-CRL classification, is necessary to ensure safer surgical outcomes.

The article discusses a rare case of emphysematous gastritis (EG) in a patient with gastric malperfusion due to congenital absence of the celiac axis and previous splenectomy. The patient presented with chest and lower extremity pain, and was managed with conservative treatment including IV antibiotics, fluid resuscitation, and surgical intervention. The patient underwent a superior mesenteric artery to gastric artery bypass to improve perfusion to the stomach and prevent further complications. The article emphasizes the importance of recognizing and treating ischemic gastropathy to ensure patient survival. [Extracted from the article]

Purpose: To report a unique entity and its management that occurred at our facility: combined spontaneous isolated renal and celiac arterial dissection (SIRCAD) with resultant renal and gastrointestinal symptoms. Case Report: A 50-year-old man with no past medical history presented with a 4 day history of nausea, intermittent stabbing epigastric pain, right flank pain, and uncontrolled hypertension. After full physical examination and imaging studies, the diagnosis of SIRCAD was established and confirmed. Selective right renal artery catheterization revealed dissection limited to the main trunk, and after careful selective hand-injection and successful cannulation of the distal renal artery branches through the true lumen assisted by intravascular ultrasound, a balloon expandable covered stent (6 mm in diameter and 60 mm in length) was deployed in the main renal artery. The same steps were performed for management of the celiac artery dissection. The patient was treated with clopidogrel 75 mg for 6 weeks and lifetime aspirin. A week after the procedure, his symptoms completely resolved. Conclusion: The pathology of SIRCAD in the absence of other vascular dissections is extremely rare, which speaks for the necessity of reporting this case and highlights the great role of evolving imaging modalities in the diagnosis and management of such cases. Clinical Impact: Symptomatic combined spontaneous isolated renal and celiac arterial dissection (SIRCAD) remain rare despite the increased frequency of reports on asymptomatic dissections. The etiology of SIRCAD is not precisely defined. Moreover, treatment of SIRCAD remains controversial with only a few cases of percutaneous interventional treatment are reported in the literature. [ABSTRACT FROM AUTHOR]

Background: Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, is a rare condition characterized by persistent post-meal or post-exercise abdominal discomfort, often more pronounced during expiration. Additional symptoms include nausea, vomiting, and weight loss. Aims and Objectives: To document the clinical presentation, diagnostic process, and treatment outcomes of seven patients diagnosed with MALS and to evaluate the effectiveness of surgical release of the median arcuate ligament (MAL) over a follow-up period of at least six months. Materials and Methods: The study included seven patients diagnosed with MALS from 2019 to 2021. Diagnosis was based on the presence of chronic abdominal pain and associated symptoms, absence of alternative diagnoses after various clinical assessments, and angiographic evidence of CA compression. The primary treatment involved surgical decompression of the CA by releasing the MAL through either open or laparoscopic techniques. Results: All seven patients underwent successful surgical release of the MAL. The patients were followed up for at least six months post-surgery. The study evaluated the persistence of symptoms and the need for additional interventions such as revascularization techniques. Conclusion: Surgical release of the MAL is the primary treatment for MALS, providing relief for many patients. However, long-term follow-up is essential as some patients may continue to experience symptoms post-surgery, necessitating further interventions.

Background: Gastric venous congestion (GVC) is one of the complications of total pancreatectomy (TP). Here, we report a case of intraoperative severe GVC during TP with a replaced common hepatic artery (RCHA). Case presentation: A 65-year-old female patient was diagnosed with intraductal papillary mucinous carcinoma. Her CHA branched from the superior mesenteric artery as RCHA. She underwent subtotal stomach preserving TP. The tumor was resected with splenic artery (SpA) and total gastric vein transections. Severe GVC and bleeding from the stomach tube occurred intraoperatively. A strong pulsation was observed in the left gastric artery (LGA), and we suspected an increased blood flow from the celiac artery (CeA) to the LGA after SpA resection. Total gastrectomy (TG) was then performed to control the severe GVC-related bleeding. The patient was discharged without complications 19 days postoperatively. Conclusion: TP with RCHA may increase the risk of severe GVC due to increased blood flow from CeA to LGA. [ABSTRACT FROM AUTHOR]

Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P =.84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P =.02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management. [ABSTRACT FROM AUTHOR]

Blood flow to the active muscles and arterial blood pressure (ABP) increase during dynamic exercise, whereas blood flow to inactive organs (e.g., splanchnic organs and inactive limbs) declines. Aging leads to exaggerated ABP responses to exercise in females, but whether this is related to greater splanchnic vasoconstriction is unknown. This study sought to clarify the effect of aging in females on celiac artery blood flow during dynamic light-intensity exercise. Twelve healthy young females (YF: 20 ± 2 yr, mean ± SD) and 12 healthy older females (OF: 71 ± 4 yr) performed dynamic knee-extension and knee-flexion exercises at 30% of heart rate reserve for 4 min. The absolute changes from baseline (Δ) for mean arterial blood pressure (MAP), celiac artery mean blood flow (celMBF), and celiac vascular conductance (celVC) during exercise were calculated. ABP was measured using an automated sphygmomanometer, and celMBF was recorded by Doppler ultrasonography. The increase in MAP during exercise was greater in OF than in YF (YF: +14 ± 7 mmHg, OF: +24 ± 13 mmHg, P = 0.028). The celMBF decreased during exercise in both groups, but there was no significant difference in the response between YF and OF (YF: −93.0 ± 66.1 mL/min, OF: −89.6 ± 64.0 mL/min, P = 0.951). The celVC also decreased during exercise and remained lower than baseline during exercise. However, the response was not different between YF and OF (YF: −1.8 ± 1.0 mL/min/mmHg, OF: −1.5 ± 0.6 mL/min/mmHg, P = 0.517). These results demonstrate that aging in females has minimal influence on splanchnic artery hemodynamic responses during dynamic light-intensity exercise, suggesting that exaggerated ABP responses during exercise in OF are not due to greater splanchnic vasoconstriction. NEW & NOTEWORTHY: During exercise, the splanchnic arteries vasoconstrict, contributing to blood flow redistribution and the blood pressure response. Blood pressure responses to exercise are exaggerated with aging in females; however, the physiological mechanism responsible has not been clarified. We show that celiac artery blood flow changes during light-intensity dynamic exercise do not differ with age in females. This indicates the exaggerated blood pressure to exercise with aging is likely not due to a difference in splanchnic vasoconstriction. [ABSTRACT FROM AUTHOR]

Background: Median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery (CA) compression syndrome, is a rare condition characterized by persistent post-meal or post-exercise abdominal discomfort, often more pronounced during expiration. Additional symptoms include nausea, vomiting, and weight loss. Aims and Objectives: To document the clinical presentation, diagnostic process, and treatment outcomes of seven patients diagnosed with MALS and to evaluate the effectiveness of surgical release of the median arcuate ligament (MAL) over a follow-up period of at least six months. Materials and Methods: The study included seven patients diagnosed with MALS from 2019 to 2021. Diagnosis was based on the presence of chronic abdominal pain and associated symptoms, absence of alternative diagnoses after various clinical assessments, and angiographic evidence of CA compression. The primary treatment involved surgical decompression of the CA by releasing the MAL through either open or laparoscopic techniques. Results: All seven patients underwent successful surgical release of the MAL. The patients were followed up for at least six months post-surgery. The study evaluated the persistence of symptoms and the need for additional interventions such as revascularization techniques. Conclusion: Surgical release of the MAL is the primary treatment for MALS, providing relief for many patients. However, long-term follow-up is essential as some patients may continue to experience symptoms post-surgery, necessitating further interventions. [ABSTRACT FROM AUTHOR]

Median arcuate ligament (MAL) syndrome or celiac artery (CA) compression syndrome previously treated mainly by vascular surgeons using the open approach is now being increasingly performed by general surgeons with training in advanced laparoscopy. Although this approach has all the advantages of minimal access surgery, the procedure is fraught with serious complications like injury to major vascular structures during dissection. Vascular injury by far is the major cause of conversion to open procedure. Herein, we report a laparoscopic repair of iatrogenic CA injury by intra-corporeal suturing during MAL release. We also elaborate the causes, the preventive measures that can be applied to avoid such catastrophic occurrences in future. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release. [ABSTRACT FROM AUTHOR]

Background: Distal pancreatectomy (DP) with lymph node (LN) dissection is the standard procedure for pancreatic ductal adenocarcinoma of the tail (Pt‐PDAC). However, the optimal surgery including extent of LN dissection is still being debated. The present study investigated the incidence and prognostic impact of LN metastasis on patients suffering from Pt‐PDAC. Patients and method: This multicenter, retrospective study involved 163 patients who underwent DP for resectable Pt‐PDAC at 12 institutions between 2013 and 2017. The frequency of LN metastasis and the effect of LN dissection on Pt‐PDAC prognosis were investigated. Results: There were high incidences of metastases to the LNs along the splenic artery in the patients with Pt‐PDAC (39%). The rate of metastases in the LNs along the common hepatic, left gastric, and celiac arteries were low, and the therapeutic index for these LNs was zero. In pancreatic tail cancer located more distally, there were no metastases to the LNs along the common hepatic artery. Multivariate analysis revealed that tumor size was the only independent factor related to recurrence‐free survival (HR = 2.01, 95% CI = 1.33–3.05, p = 0.001). The level of pancreas division and LN dissection along the common hepatic artery did not affect the site of tumor recurrence or recurrence‐free survival. Conclusions: LN dissection along the hepatic artery for Pt‐PDAC has little significance. Distal pancreatic transection may be acceptable in terms of oncological safety, but further examination of short‐term outcomes and preservation of pancreatic function is required. [ABSTRACT FROM AUTHOR]

GH acts in numerous organs expressing the GH receptor (GHR), including the brain. However, the mechanisms behind the brain's permeability to GH and how this hormone accesses different brain regions remain unclear. It is well-known that an acute GH administration induces phosphorylation of the signal transducer and activator of transcription 5 (pSTAT5) in the mouse brain. Thus, the pattern of pSTAT5 immunoreactive cells was analyzed at different time points after IP or intracerebroventricular GH injections. After a systemic GH injection, the first cells expressing pSTAT5 were those near circumventricular organs, such as arcuate nucleus neurons adjacent to the median eminence. Both systemic and central GH injections induced a medial-to-lateral pattern of pSTAT5 immunoreactivity over time because GH-responsive cells were initially observed in periventricular areas and were progressively detected in lateral brain structures. Very few choroid plexus cells exhibited GH-induced pSTAT5. Additionally, Ghr mRNA was poorly expressed in the mouse choroid plexus. In contrast, some tanycytes lining the floor of the third ventricle expressed Ghr mRNA and exhibited GH-induced pSTAT5. The transport of radiolabeled GH into the hypothalamus did not differ between wild-type and dwarf Ghr knockout mice, indicating that GH transport into the mouse brain is GHR independent. Also, single-photon emission computed tomography confirmed that radiolabeled GH rapidly reaches the ventral part of the tuberal hypothalamus. In conclusion, our study provides novel and valuable information about the pattern and mechanisms behind GH transport into the mouse brain. [ABSTRACT FROM AUTHOR]

Background: Sutton–Kadir syndrome describes a rare pathology that commonly includes an aneurysm of the inferior pancreaticoduodenal artery in combination with a celiac trunk stenosis or occlusion, often caused by median arcuate ligament compression. Several therapeutic approaches exist including open surgical, endovascular, and hybrid treatments. Other combinations of visceral artery aneurysms and upstream stenoses exist but the cumulative body of evidence on these combinations is weak due to their rarity. Methods: A retrospective analysis of patient data from a single center was carried out. Electronic patient records were filtered for keywords including "visceral aneurysm", "Sutton–Kadir", and "median arcuate ligament". Imaging studies were re-examined by two blinded vascular surgeons with a third vascular surgeon as a referee in case of diverging results. Results: Sixteen patients had a visceral artery aneurysm with an upstream stenosis. All cases had a celiac trunk obstruction while one patient also had a concomitant superior mesenteric artery stenosis. Both median arcuate ligament compression and atherosclerotic lesions were identified. The location of the aneurysms varied even though the inferior pancreaticoduodenal artery was most frequently affected. A classification system based on the different combinations of stenoses and aneurysms is presented and introduced as a new pathologic entity: visceral artery aneurysm in the presence of upstream stenosis (VAPUS). Conclusions: The concomitant presence of visceral artery aneurysms, especially in the pancreaticoduodenal arteries, and blood flow impairment of the celiac axis or superior mesenteric artery is a rare pathology. The proposed VAPUS classification system offers an accessible and transparent route to the precise localization of the affected vessels. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to evaluate the efficacy of an artificial intelligence (AI) model designed to identify active bleeding in digital subtraction angiography images for upper gastrointestinal bleeding. Methods: Angiographic images were retrospectively collected from mesenteric and celiac artery embolization procedures performed between 2018 and 2022. This dataset included images showing both active bleeding and non-bleeding phases from the same patients. The images were labeled as normal versus images that contain active bleeding. A convolutional neural network was trained and validated to automatically classify the images. Algorithm performance was tested in terms of area under the curve, accuracy, sensitivity, specificity, F1 score, positive and negative predictive value. Results: The dataset included 587 pre-labeled images from 142 patients. Of these, 302 were labeled as normal angiogram and 285 as containing active bleeding. The model's performance on the validation cohort was area under the curve 85.0 ± 10.9% (standard deviation) and average classification accuracy 77.43 ± 4.9%. For Youden's index cutoff, sensitivity and specificity were 85.4 ± 9.4% and 81.2 ± 8.6%, respectively. Conclusion: In this study, we explored the application of AI in mesenteric and celiac artery angiography for detecting active bleeding. The results of this study show the potential of an AI-based algorithm to accurately classify images with active bleeding. Further studies using a larger dataset are needed to improve accuracy and allow segmentation of the bleeding. [ABSTRACT FROM AUTHOR]

Aims To identify radiographic differences between patients with uncomplicated and complicated descending aortic dissections. Methods and results Between April 2009 and July 2021, 209 patients with acute descending aortic dissections were analysed as complicated (malperfusion, rupture, diameter progress, and diameter ≥ 55 mm) or uncomplicated. Detailed CTA measurements (slice thickness ≤ 3 mm) were taken in multiplanar reconstruction. A composite endpoint (early aortic failure) was defined as reoperation, diameter progression, and early mortality. Seventy-seven patients were female (36.8%) [complicated n = 27 (36.5%); uncomplicated n = 50 (37.0%) P = 1.00]. Seventy-four (35%) patients were categorized as morphologically complicated, and 135 (65%) as uncomplicated. In patients with complicated dissections, the dissection extended more frequently to the aortic bifurcation (P = 0.044), the coeliac trunk (P = 0.003), the superior mesenteric artery (P = 0.007), and both iliac arteries (P < 0.001) originated less frequently from the true lumen. The length of the most proximal communication (entry) in type B aortic dissection was longer, 14.0 mm [12.0 mm; 27.0 mm] vs. 6.0 mm [4,0 mm; 13.0 mm] in complicated cases (P = 0.005). Identified risk factors for adverse aortic events were connective tissue disease [HR 8.0 (1.9–33.7 95% CI HR)], length of the aortic arch [HR 4.7 (1.5–15.1 95% CI HR)], a false lumen diameter > 19.38 mm [HR 3.389 (1.1–10.2 95% CI HR)], and origin of the inferior mesenteric artery from the false lumen [HR 4.2 (1.0–5.5 95% CI HR)]. Conclusion We identified significant morphological differences and predictors for adverse events in patients presenting complicated and uncomplicated descending dissections. Our morphological findings will help guide future aortic therapies, taking a tailored patient approach. [ABSTRACT FROM AUTHOR]

Background and Objectives: Median arcuate ligament syndrome is caused by compression and stenosis of the celiac artery. Incision of the median arcuate ligament improves persistent abdominal symptoms. The study aimed at evaluating the outcomes in patients who underwent median arcuate ligament syndrome decompression using a self-report questionnaire. Methods: This single-center retrospective study included patients with median arcuate ligament syndrome who underwent decompression surgery between April 2021 and February 2023. The medical records were retrospectively reviewed. Results: Ten patients were included in the study. Laparotomy and laparoscopic surgeries were performed in seven and three patients, respectively. The median operation time was 147 minutes. The median hospitalization period after the operation was seven days. The degrees of celiac artery stenosis before and after surgery were compared and the per cent diameter stenosis did not significantly improve; five of 10 patients (50%) had > 50% stenosis in the celiac artery after the operation. Compared to the baseline, the scores of upper gastrointestinal symptoms significantly improved during the six months' period (p < 0.001). Additionally, we evaluated the influence of post-operative per cent diameter stenosis and divided the patients into two groups (≥ 50% vs, < 50%). The scores of upper gastrointestinal (GI) symptoms in both groups improved significantly from baseline. However, the symptomatic improvement at six months in the post-operative per cent diameter stenosis < 50% group was significantly greater than that in the ≥ 50% group (p = 0.016). The scores of lower gastrointestinal symptoms did not change significantly during the six-month period. Conclusion: Decompression surgery for median arcuate ligament syndrome could improve upper gastrointestinal symptoms regardless of the post-operative per cent diameter stenosis. [ABSTRACT FROM AUTHOR]

Background: Distal pancreatectomy with celiac axis resection (DP–CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions. Case presentation: This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP–CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP–CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases. Conclusions: The case highlights the importance of recognizing and managing potential complications associated with DP–CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP–CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications. [ABSTRACT FROM AUTHOR]

Gastroduodenal artery aneurysms are a rare type of visceral aneurysm that can lead to rupture and death. We present a 75-year-old male with history of hypertension, diabetes, and hyperlipidemia with an incidental finding of a 3.2 × 3.7 cm gastroduodenal aneurysm found on abdominal computed tomography angiography (CTA). After refusing surgical intervention, he was seen two years later and presented with an enlarged gastroduodenal aneurysm, now 5.0 × 5.1 cm, visible on a repeat abdominal CTA. Upon his continued refusal for an open surgery, we elected for endovascular repair of this GDA aneurysm via coil embolization. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to evaluate the use of a new classification for safer transradial access hepatic interventional radiology, based on preoperative evaluation of the location of the left subclavian artery bifurcation in the aortic arch. Methods: A total of 38 consecutive patients with hepatocellular carcinoma and 74 sessions of radial access for visceral intervention (R.A.V.I.) were reviewed. We classified the location of the left subclavian artery bifurcation in the aortic arch in three areas using an oblique view computed tomography image matched with the curve of the aortic arches according to a new criteria Three Areas Criteria For R.A.V.I. (named "TAC‐F‐R"), and measured the required time from initial left radial artery arteriography to celiac artery or superior mesenteric artery arteriography. Results: The median time required for left radial artery arteriography to the celiac artery or superior mesenteric artery arteriography in each of the three areas were: area A, 0:11:10 (h, min, s); area B, 0:14:44; and area C, 0:31:51. There were significant differences between each area after Bonferroni correction (p < 0.01; A vs. B, p = 0.086; A vs. C, p = 0.001; and B vs. C, p = 0.045), with areas A and B requiring a significantly shorter time. Finally, no patients showed neurogenic disfunction within 1 week after the R.A.V.I. procedure. Conclusions: The new classification, "TAC‐F‐R," for safer transradial access hepatic interventional radiology is effective for avoiding difficult cases, and selects more suitable patients with hepatocellular carcinoma for the R.A.V.I. procedure. [ABSTRACT FROM AUTHOR]

Median arcuate ligament syndrome (MALS) involves coeliac artery compression, causing a range of symptoms from chronic pain to life-threatening complications. This case features a 52-year-old patient with recurrent retroperitoneal bleeding from MALS-related inferior pancreaticoduodenal artery aneurysms (PDAAs). Emergency interventions, including surgical bleeding control, angioplasty, percutaneous drainage, and median arcuate ligament release, were conducted. The case highlights challenges in diagnosing and managing MALS-related PDAA, emphasizing the importance of early identification and tailored interventions based on clinical symptoms and imaging. Surgical intervention to release the ligament is the primary treatment, with considerations for prophylactic intervention in PDAA cases. Lack of established PDAA management protocols underscores the need for prompt intervention to prevent complications. In conclusion, this report stresses the association between MALS and PDAA, advocating for early identification and tailored management to mitigate complications. [ABSTRACT FROM AUTHOR]

A 10‐year‐old Cocker spaniel presented with lethargy. Triple‐phase computed tomography was obtained with a contrast test bolus at the level of porta hepatis, which revealed a right lower abdominal mass. The mass was not connected to other abdominal organs; however, a linear structure was observed connecting the splenic hilum to the mass, which was suspected to be the feeding vessel. The arterial phase image was obtained again with a contrast bolus at the level of the celiac artery. A prominent contrast‐enhanced feeding artery originating from the splenic artery to the mass was observed. Histopathology confirmed an accessory splenic hemangiosarcoma. [ABSTRACT FROM AUTHOR]

Regarding the studied species, the literature has shown a variety of topographic, origin and distribution differences of the arterial supply compared to mammals, although they are not fully identified. The aim of this article is the macroscopical study of the arterial supply of the digestive tract of Gallus domesticus. The biological material was represented by 12 adult chicken bodies with an average weight of 2 kg. After procurement of the biological material, the feathers, skin, muscles and sternum were removed for easy access to the heart. After left ventricular cannulation, epoxy resin mixed with red dye was injected. The body was immersed in 5% formaldehyde for 24 hours. Next, stratigraphic dissection was performed. The celiac artery erupted from the right face of the descending aorta, on a level with the junction of the esophagus and the proventriculus. It gave off the Aa. esophageales, A. proventricularis dorsalis, then bifurcated into left and right branches. The left branch of the celiac artery gave off A. proventricularis ventralis and A. gastrica ventralis then continued with the A. gastrica sinistra. [ABSTRACT FROM AUTHOR]

Background: Pancreaticoduodenal artery aneurysm (PDAA) is a rare, but fatal disease. However, the association between aneurysm size and the risk of rupture remains unclear. There are many options for therapeutic strategies that should be discussed well because the treatment options are often complicated and highly invasive. However, it remains unclear whether additional endovascular therapy is essential for all patients undergoing bypass surgery. Here, we present a case of triple PDAAs with celiac axis occlusion and spontaneous complete regression of inferior PDAAs (IPDAA) after aneurysmectomy of superior PDAA (SPDAA) and aorto-splenic bypass. Case presentation: A 68-year-old woman presented with one SPDAA and two IPDAAs caused by celiac axis occlusion. Aneurysmectomy for IPDAAs was difficult because of their anatomical location and shape. Therefore, we planned a two-stage hybrid therapy. The patient underwent aorto-splenic bypass and resection of the SPDAA. Follow-up CT was performed to evaluate the IPDAAs before planned endovascular embolization. Spontaneous regression of the IPDAAs and normalized PDA arcade decreased the blood flow in the PDA arcade. The patient is doing well without graft occlusion, and the IPDAAs have completely regressed 7 years after surgery. Conclusion: Normalization of hyperinflow to the PDA arcade can lead to the regression of PDAA. Potentially, additional endovascular therapy may not be required in all cases when dilation of the PDA improves. However, more cases must be accumulated to establish criteria for predicting the risks of short- and long-term PDAA ruptures. [ABSTRACT FROM AUTHOR]

A 76-year-old man underwent distal pancreatectomy with celiac axis resection (DP-CAR) after preoperative chemotherapy for pancreatic cancer with celiac artery invasion. Although postoperative pancreatic leakage and ischemia-induced bile fistula developed, the patient's condition remained stable with good drainage. On postoperative Day 47, a pseudoaneurysm developed at the junction of the gastroduodenal artery and proper hepatic artery. However, cannulation of the guidewire was difficult, and relaparotomy pseudoaneurysm repair was performed. On postoperative Day 56, a pseudoaneurysm reappeared at the same site, and relaparotomy was performed again. On postoperative Day 61, CT confirmed the disappearance of the pseudoaneurysm and preservation of the right and left hepatic arteries. The patient was discharged 107 days postoperatively. Interventional radiology (IVR) remains the best technique to achieve hemostasis for pseudoaneurysms. However, this case demonstrates that even when hemostasis by IVR is difficult, relaparotomy pseudoaneurysm repair after DP-CAR may be useful after some postoperative. [ABSTRACT FROM AUTHOR]

Odontocetes primarily rely on fish, cephalopods, and crustaceans as their main source of nutrition. In the digestive system, their polygastric complex exhibits similarities to that of their closest terrestrial relatives such as cows, sheep, and giraffes, while the entero‐colic tract shares similarities with terrestrial carnivores. The morphology, caliber, and structure of the odontocete intestine are relatively constant, and, since there is no caecum, a distinction between the small and large intestine and their respective subdivisions is difficult. To address this issue, we used the intestinal vascularization pattern, specifically the course and branching of the celiac artery (CA) and the cranial and caudal mesenteric arteries (CrMA and CdMA). A series of pictures and dissections of 10 bottlenose dolphins (Tursiops truncatus) were analyzed. Additionally, we performed a cast by injecting colored polyurethane foam in both arteries and veins to measure the caliber of the arteries and clarify their monopodial or dichotomous branching. Our results showed the presence of multiple duodenal arteries (DAs) detaching from the CA. The CrMA gave origin to multiple jejunal arteries, an ileocolic artery (ICA), and, in six cases, a CdMA. In four specimens, the CdMA directly originated from the abdominal aorta. The ICA gave rise to the mesenteric ileal branches (MIB) and mesenteric anti‐ileal branches and the right colic arteries (RCA) and the middle colic arteries. From the CdMA originated the left colic and cranial rectal arteries (LCA and CrRA). The measurements revealed a mixed monopodial and dichotomous branching scheme. The analysis of the arteries and their branching gave us an instrument, based on comparative anatomy, to distinguish between the different intestinal compartments. We used the midpoint of anastomoses between MIB and RCA to indicate the border between the small and the large intestine, and the midpoint of anastomoses between LCA and CrRA, to tell the colon from the rectum. This pattern suggested an elongation of the duodenum and a shortening of the colic tract that is still present in this species. These findings might be related to the crucial need to possess a long duodenal tract to digest prey ingested whole without chewing. A short aboral part is also functional to avoid gas‐producing colic fermentation. The rare origin of the CdMA on the CrMA might instead be a consequence of the cranial thrust of the abdominopelvic organs related to the loss of the pelvic girdle that occurred during the evolution of cetaceans. [ABSTRACT FROM AUTHOR]

Introduction: Computed tomography (CT) is routinely employed on the evaluation of dyspnea, yet limited data exist on its assessment of diaphragmatic muscle. This study aimed to determine the capability of CT in identifying structural changes in the diaphragm among patients with ultrasound-confirmed diaphragmatic dysfunction. Methods: Diaphragmatic ultrasounds conducted between 2018 and 2021 at our center in Marseille, France, were retrospectively collected. Diaphragmatic pillars were measured on CT scans at the L1 level and the celiac artery. Additionally, the difference in height between the two diaphragmatic domes in both diaphragmatic dysfunction cases and controls was measured and compared. Results: A total of 65 patients were included, comprising 24 with diaphragmatic paralysis, 13 with diaphragmatic weakness, and 28 controls. In the case group (paralysis and weakness) with left dysfunctions (n = 24), the CT thickness of the pillars at the level of L1 and the celiac artery was significantly thinner compared with controls (2.0 mm vs. 7.4 mm and 1.8 mm vs. 3.1 mm, p < 0.001 respectively). Significantly different values were observed for paralysis (but not weakness) in the right dysfunction subgroup (n = 15) (2.6 mm vs. 7.4 mm and 2.2 mm vs. 3.8 mm, p < 0.001 respectively, for paralysis vs. controls). Regardless of the side of dysfunction, a significant difference in diaphragmatic height was observed between cases and controls (7.70 cm vs. 1.16 cm and 5.51 cm vs. 1.16 cm, p < 0.001 for right and left dysfunctions, respectively). Threshold values determined through ROC curve analyses for height differences between the two diaphragmatic domes, indicative of paralysis or weakness in the right dysfunctions, were 4.44 cm and 3.51 cm, respectively. Similarly for left dysfunctions, the thresholds were 2.70 cm and 2.48 cm, respectively, demonstrating good performance (aera under the curve of 1.00, 1.00, 0.98, and 0.79, respectively). Conclusion: In cases of left diaphragmatic dysfunction, as well as in paralysis associated with right diaphragmatic dysfunction, CT revealed thinner pillars. Additionally, a notable increase in the difference in diaphragmatic height demonstrated a strong potential to identify diaphragmatic dysfunction, with specific threshold values. [ABSTRACT FROM AUTHOR]

Aneurysms and pseudoaneurysms of the visceral arteries are a rare pathology with a prevalence of 0.1-2% in the general population, most common in men. Despite low prevalence, visceral aneurysms pose a significant threat to the patient's health and life; a ruptured superior mesenteric branch aneurysm carries mortality rates of 10-25% and up to 30-90%. This article presents a case of a 50-year-old former active duty soldier and veteran of a military combat mission in Afghanistan, during which he sustained a traumatic injury resulting from a mine explosion under a vehicle. After completing the mission and returning home, the patient developed abdominal pain. The diagnosis made in the general surgery department of the district hospital was upper gastrointestinal obstruction and aneurysmal rupture of the superior mesenteric branch with inflammatory infiltration of the pancreatic–intestinal area. The patient underwent emergency gastrointestinal anastomosis and Braun enteroenterostomy. The aneurysm was not resected. One month later, the patient underwent a follow-up abdominal angiotomography, which revealed an approximately 20-mm aneurysm of a branch of the superior mesenteric artery and celiac artery subocclusion (Dunbar syndrome) with extensive collateral circulation. A diagnosis of pseudoaneurysm/traumatic aneurysm was made, and the patient was referred to a vascular surgery center for endovascular treatment. Following CT angiography, a decision was made to perform a two-stage endovascular repair. The first stage was a bridge therapy aimed to release celiac artery subocclusion with a stent; after 3 weeks, pseudoaneurysm embolization was performed. The decision to use two-stage endovascular treatment was attributable to the risk of gastrointestinal ischemia that might result from intraoperative technical difficulties and complications, coil dislocation, and thrombosis of the superior mesenteric artery or its branch; the coexisting subocclusion of the celiac artery was also considered. The patient was discharged in good condition and returned to normal everyday activities. He also continued follow-up appointments with a vascular surgeon. An angiotomography performed at 1 year of endovascular treatment confirmed good effects of the embolization procedure and coagulation of the aneurysm. Visceral aneurysms are a rare vascular pathology but are associated with significant morbidity and mortality rates. The incidence of ruptured aneurysms is probably underestimated as some patients may be operated on for acute abdominal symptoms, e.g. bowel obstruction. [ABSTRACT FROM AUTHOR]