Journal Article Survival with Collateral Circulation after Gastrointestinal Ischemia Caused by Aortic Dissection : A Case Report

Kusumoto, Eiji  ,  Endo, Kazuya  ,  Ota, Mitsuhiko  ,  Tsutsumi, Norifumi  ,  Hashimoto, Kenkichi  ,  Egashira, Akinori  ,  Sakaguchi, Yoshihisa  ,  Kusumoto, Tetsuya  ,  Ikejiri, Koji

106 ( 7 )  , pp.223 - 229 , 2015-07-25 , 福岡医学会
We report a case of a 43-year-old man who presented with gradually intensifying abdomenal pain of acute onset and was shown by contrast-enhanced computed tomography (CT) examination to have acute aortic dissection (Stanford type B). A diagnosis of gastrointestinal necrosis was made and he underwent emergency surgery. At laparoscopy, he was found to have no superior mesenteric arterial pulse and intestinal necrosis from the upper jejunum to the right transverse colon. Resection of the superior mesenteric artery (SMA) perfusion area was performed. Postoperatively, ischemia in the perfusion area of the celiac artery was also diagnosed, manifesting as gallbladder necrosis, portal vein gas accompanying gastric wall necrosis, perforation of the remaining upper jejunum, and hepatic and splenic infarction. However, development of a collateral circulation originating in the left colic branch of the inferior mesenteric artery (IMA) enabled retrograde provision of blood to the celiac artery through the SMA pancreaticoduodenal arcade. Thus, in this case, spontaneous development of a natural bypass created a new route for arterial perfusion, contributing to the patient’s survival. When ischemia of the celiac artery and SMA perfusion areas occur, collateral circulation can develop from the IMA.
症例は43 歳男性.急性大動脈解離(Stanford type B)の診断で厳重な血圧管理を行われていたが,増強する腹痛出現し消化管壊死と診断され当科加療要請された.緊急手術の所見で上腸間膜動脈の拍動なく,上位空腸から横行結腸右側にかけて腸管が壊死していたため,上腸間膜動脈潅流域の大量腸切除を行った.術後に胆嚢壊死,門脈内ガスを伴う胃壁壊死,残存した上位空腸の穿孔,肝梗塞,脾梗塞など腹腔動脈の潅流域にも虚血所見を認めた.しかし下腸間膜動脈の分枝である左結腸動脈の側副血行路が発達することで,逆行性に上腸間膜動脈の膵十二指腸アーケードを介し腹腔動脈に供血され,上記虚血症状は軽快し救命し得た.腹腔動脈や上腸間膜動脈の虚血がある場合,下腸間膜動脈の側副血行路が発達しやすいことが示唆された.

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