The patient was discharged free of symptoms two weeks prior to presentation in our department. Following admission to our emergency room, an immediate Selleckchem Linsitinib CT-scan and a blood test were performed, as the patient showed signs of an initiating peritonitis. The CT scan showed an isolated re-dissection in the proximal part of the SMA with
embolization of a distal branch causing an almost complete decline of right hand side intestinal Pevonedistat perfusion. Aggravating, the right hepatic artery originated from the proximal part of the SMA as an anatomical variant. The origin was located directly in the region of the dissection entry. Figure 1 shows the major findings of the CT scan on admission. As endovascular therapy had a high risk of post interventional liver failure, the decision for open surgery was taken at an interdisciplinary level. Blood test PD0332991 supplier results showed a normal serum lactate level, while C-reactive protein (CRP) and leukocytes (WBC) were raised. Thus, the patient had to be transferred urgently to the operating theatre. We resected the dissection membrane from the origin of the SMA and a selective embolectomy of the arcade arteries was performed. The SMA was
re-constructed using a venous interponate. Thus, for the interposition the saphenous vein from the right upper leg was used. The patient was admitted to the intensive care unit (ICU) with an abdomen apertum. As hypercoagulability occurred during the operation and we suspected a heparin induced
thrombopenia (HIT), anticoagulation was managed using Argatroban with an activated partial thromboplastin time (aPTT) of 50-70 seconds. This suspicion was later confirmed due to a Heparin-induced Thrombocytopenia Platelet Factor 4 Antibody Test. Figure 1 demonstrates the representative findings of a CT-scan control five days after the operation. As a further course, negative wound pressure therapy was performed with wound dressing changes at intervals of two days and conducted within in the operating theatre (four times). In this context, the small intestinum was carefully inspected. We could not find any signs of hypoperfusion lesions. As the patient described persistent abdominal pain, performing a colonoscopy six Methocarbamol days after the operation meant that ischemic colitis could be ruled out. Figure 1 Representative CT scan findings. A: shown is the entry of the dissection at the proximal SMA. An abnormal origin of the right hepatic artery from the proximal SMA can be seen as an anatomical variant. B: An embolism of a distal branch of the SMA is shown. C: Reconstruction of the CT scan after admission. Almost complete decline of intestinal perfusion of the right abdominal side could be observed. D: findings of the control CT scan 5 days after operation. No residual membrane could be observed, normal perfusion of the SMA and the right hepatic artery.