Hrev_master Veins and Lymphatics 2017; volume 6:6817 [Veins and Lymphatics 2017; 6:6817] [page 61] Vascular anomalies in the mesenteric circulation of patients with Crohn’s disease: a pilot study Matilde Zamboni,1 Maria Grazia Sibilla,2 Roberto Galeotti,3 Massimo Pedriali,4 Simona Ascanelli2 1Department of Thoracic, Cardiac, and Vascular Sciences, Post Graduated School in Vascular Surgery, University of Padua; 2Department of Surgery, Unit of Translational Surgery, University- Hospital of Ferrara; 3Unit of Vascular and Interventional Radiology, University-Hospital of Ferrara; 4Unit of Anatomy, Histology and Pathological Citology, University-Hospital of Ferrara, Italy Abstract Crohn’s disease (CD) is a chronic inflammatory bowel disease and its patho- genesis is still not well understood. Previous studies suggested the possibility of the involvement of vascular system, but, todate, the mesenteric circulation has poor been investigated, especially in complicated CD cases requiring colectomy. We investigated the mesenteric circula- tion in a case-control pilot study, including 19 controls and 7 patients affected by com- plicated cases of CD. Cases and controls underwent selective angiography of both superior and inferior mesenteric district. Transit time was found either signifi- cantly shortened in 2/7 cases (29%), or pro- longed 5/7 (71%) (P=0.0034 in the superior mesenteric district; P=0.0079 in the inferior mesenteric district), respectively due to the presence of A-V malformations and of a miscellaneous of venous abnormalities, which included thrombosis, hypoplasia and extra-truncular venous malformations. Our study demonstrates the presence of congenital or acquired vascular anomalies in a small sample of CD patients not respon- der to current treatment and with severe complications. The present pilot study war- rants further investigations. Introduction Crohn’s disease (CD) is an inflammato- ry bowel disease and its pathogenesis is still unknown. So many have been the hypothesis: viral and bacterial infections, hereditary factors, disregulation of the immunitary system, enviromental factors etc.1-6 CD is clinically characterized by both bowel and extrabowel symptoms. The first are abdominal pain, diarrhea, meteorism, loss of weight, anorexia; the second and less frequent are tipically rheumatological: ery- thema nodosum, pyodherma gangrenosum, anklylosing spondylitis, arthropathy, uveitis, episcleritis.1 In the majority part of the population CD does not remain steady but it progresses into a serious of dramatic and surgical situ- ations such as bowel obstruction/perfora- tion, recurrent fistulas (enterocutaneous, enteroenteric, enterocolic, enterovaginal) which affect on the quality of life of this population.1-6 Old and recent studies seems to indicate the possible involvement of the vascular system in the pathogenesis of the disease.6-12 The first big chapter concernes deep venous thrombosis (DVT). During years it has been noticed and confirmed that DVT is highly increased in CD (2-4 times more respect to healthy controls).10 This phenomenon could be explained by a series of organic situations which are usually pres- ent in CD patients: systemic inflammatory, loss of water, stillness, surgery, steroid ther- apy.8-10 The second chapter looks after vascular abnormalities and CD. There are just a few studies conducted in the 70’s by some Swedish groups. They investigated celiac and mesenteric arteries with angiographies and demonstrated that the majority part (90%) of population with CD or ulcerative colitis exhibited different angiographic anomalies.11-12 We hypothesized that an aggressive CD clinical course could be related to acquired and/or congenital mesenteric circulation pathology. Aim of the present study was to investigate patients with aggressive and complicated clinical course of CD studying selective angiographies of the mesenteric circulation. Ethical approval Our study is a pilot case-control study, approved by our Ethical Committee and reg- istered at number #140686. All procedures performed were in accordance with the ethi- cal standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical stan- dards. Informed consent was obtained from all individual participants included in the study. Materials and Methods Patient populations The control population was selected from 109 patients who underwent a mesen- teric angiography in the last 5 years and none was affected by CD. Selection was based on the availability of a complete superior and inferior mesenteric study, with both arterial inflow and venous outflow, until the opacification of the portal trunk. The final control population was consisted of 19 patients, 12 males and 7 females and the reason why they underwent angiogra- phy includes a miscellaneous of digestive pathology (9 tumors, 2 visceral artery aneurysms, 4 bleedings, 2 angina abdomin- is, 1 vasculitis). The case patients were 7 CD patients with one or more complications mentioned before. They were 5 men and 2 women with an average age of 45 years old. They all underwent to a selective angiography study. They were all acquainted about the pro- cedure with risks and benefits and they all signed an informed consent. Case popula- tion and its demographic characteristics are shown in Table 1. Selective catheter angiography Standard angiography was performed selectively to show mesenteric arteries, superior and inferior, and their outflows. Angiography was performed by a pre- treatment with one butylscopolamine vial i.v. followed by Seldinger’s technique and record of both arterial and venous time. We used a 5 French introducer and a Cobra Correspondence: Matilde Zamboni, Department of Thoracic, Cardiac, and Vascular Sciences, Post Graduated School in Vascular Surgery, University of Padua, Italy. E-mail: wambazamba@icloud.com Key words: Crohn’s disease; mesenteric circu- lation; angiography; AV malformations. Conflict of interest: the authors declare no conflict of interest. Received for publication: 25 May 2017. Revision received: 13 July 2017. Accepted for publication: 14 July 2017. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright M. Zamboni et al., 2017 Licensee PAGEPress, Italy Veins and Lymphatics 2017; 6:6817 doi:10.4081/vl.2017.6817 No n c om me rci al us e o nly Article catheter to study superior mesenteric dis- trict (25-30 mL at a flow rate equal to 3 mL/sec) and a Simmons catheter for the inferior one (15-20 mL at a flow rate equal to 2 mL/sec). The iodinated contrast medium con- centration was equally 400 mgI/mL. We studied angiographies in both cases and controls, specially we looked after the vascular morphology and the transit time (TT) evaluation. TT was calculated from the beginning of the automated injection until the portal vein appeared opacified by the contrast dye. In one case we performed a selective angiography on the resected sigma soon after the surgical procedure. Statistical analysis Data were summarized as mean ± stan- dard deviation (SD). Ordinary ANOVA Test was used to estimate TT; two sided Fischer Exact Test was used to estimate differences in the fre- quency of vascular abnormalities in both populations. Statistical significance was set with p<0.05. Results Firstly TT was evaluated in the control population: 12.5±0.9 sec in the superior mesenteric circulation and 17.9±1.4 sec in the inferior one. This functional result permitted to compare the mesenteric circulation in complicated CD respect to controls. Comparing TT results and angiography morphology we noticed that every CD patient had an altered TT accompanied by a vascular anomaly. Cases with AV malformation/fistulas In case #2 we documented an A-V mal- formation (AVM) by the means of selec- tive angiography of the inferior mesenteric artery at the level of the superior haemor- rhoidal artery (Figure 1). The patient clini- cally presented multiple not healing diges- tive fistulas, topographically correspon- ding to the bowel segment with low perfu- Table 1. Patients’ cohort demographics and clinical characteristics. Patients Age M/F Smoke Time to disease Site of disease Bowel Anorectal Surgery Therapies complication complication L.Z. 55 M Yes 22 yrs Ileum Colon Obstruction Fistulas 3 Metronidazole Abscess C.D. 60 M Yes 17 yrs Colon Obstruction Fistulas 2 Mesalazine Abscess F.M. 55 F Yes 14 yrs Jejunum Obstruction Fistulas 3 Infliximab Ileum Abscess N.M. 32 F Yes 7 yrs Ileum Perforation Abscess 2 Steroids Colon D.M. 48 M Yes 24 yrs Ileum Obstruction Fistulas 1 None Colon C.R. 62 M Yes 10 yrs Colon Perforation No 1 Steroids P.M. 46 M Yes 22 yrs Ileum Perforation No 2 None Colon Table 2. Transit time evaluation, mean and standard deviation, in the superior and inferior mesenteric district. Controls Crohn’s disease vs AV shunt Other Crohn’s disease cases Transit time superior meseneteric district 12.5±0.9 sec 10.5±0.7 sec 14.8±3.0 sec Transit time inferior mesenteric district 17.9±1.4 8.5 ± 4.9 sec 22±4.8 sec Figure 1. AV malformation. Figure 2. Extratroncular AV fistulas. [page 62] [Veins and Lymphatics 2017; 6:6817] No n c om me rci al us e o nly Article sion due to the A-V shunt. TT was reduced in the inferior mesenteric artery: 5 sec. The preoperative angiographic assessment per- mitted to regulate the margins of bowel resection. The relative bowel ischemia is well apparent in the post-operative selec- tive angiography of the operatory speci- men. In case #5 catheter arteriography of the superior mesenteric artery demonstrated the presence of multiple extratroncular AV fistulas (Figure 2) with an evident over- load of the iliac veins, which appeared abnormally dilated. CD lesions corre- sponded to the intestinal areas of relative ischemia. Also in case #5 TT was decreased (11 sec.) in the superior mesen- teric district. So, in these two AV shunt cases TT was significantly shorter: 10.5±0.7 in the superior district and 8.5±4.9 in the inferior one. Cases with prolonged mesenteric transit time In case #1, #3, #4, #6, #7 TT was sig- nificantly increased: 14.8±3 sec in the superior mesenteric district and 22±4.8 sec in the inferior one. The reason of a slower circulation was represented by a series of venous anom- alies: in case #2 and in case #7 we observed small sized mesenteric and/or iliac veins compatible with venous hypoplasia (Figure 3); dysplasia and vari- cosities of the parietal veins, compatible with extra-troncular venous malformation, were observed in case #3 and #4; and final- ly a mesenteric DVT was detected in case #6 (Figure 4). Overall TT was significantly different in the CD population: P=0.0034 in the superior district and P=0.0079 in the infe- rior one (TT are shown in Table 2). Finally, the presence of anomalies in the mesenteric circulation was significant- ly higher in complicated CD respect to controls (OR=25, 95% CI 1.2-504; P=0.0064). Discussion The original idea of this study has been to observe bowel from a circulatory point of view. Indication to vascular study was given by the treating physician to under- stand more about the continuous develop- ment of severe complications in this group of patients. We have found a set of vascu- lar anomalies and malformations, which are frequently observed in other districts of the human body. Particularly, out of the case of mesenteric DVT, the other six cases, according to a recent consensus statement, can be classified among the venous malformations.13 The IUP Classification divides the vas- cular malformations according to the flow rate and the stage of the vascular system development. In our survey we found two cases of high flow malformations and 5 of low flow rate. The latter could be extra- truncular, whether the arrest of the devel- opment happens during the first three months of pregnancy, and truncular whether it occurs in later stages (5th-7th months).13 Both arterial and venous side were involved, potentially contributing to the patho-physiology of the disease: hypoper- fusion, venous stasis, oedema and inflam- mation. The second exclusive finding has been to calculate TT in both populations and find them significantly changed. This result reflects a pathological vasculariza- tion of bowel tissues and, possibly, a vas- cular contribution to the pathogenesis. For instance, the case of the AVM clinically corresponded to multiple not healing digestive fistulas, topographically in the bowel segment with low perfusion due to the shunt. The relative bowel ischemia is well apparent in the post-operative selec- tive angiography of the operatory speci- men (Figure 5). Moreover, cases with venous hypoplasia and/or venous thrombo- sis corresponded to biopsy where histology documented oedema and chronic inflam- mation. Limitations of this preliminary study are the followings: i) angiographies in the control population have been performed mostly in bleeding patients, so TT could be distorted by haemodynamic adaptations of the body (blood loss and autonomic nerv- ous system disregulation); ii) CD patients were complicated patients, which means people who underwent a bowel resection. This fact is so important because it means that angiographies do not show completely the original vascularization; iii) we do not have a TT evaluation in healthy CD patients without complications; iv) a small casuistry. Furthermore, our data cannot clarify whether the vascular condition is a cause or a product of the bowel disease. However, our findings and results are very impressive and need to be amplified in a structured and wider case control study, including complicated patients before bowel resection. Figure 3. Troncular venous malformation. Figure 5. AVM after bowel resection. [Veins and Lymphatics 2017; 6:6817] [page 63] Figure 4. Deep venous thrombosis. No n c om me rci al us e o nly Article [page 64] [Veins and Lymphatics 2017; 6:6817] References 1. Sands BE, Siegel CA. Crohn’s disease. In: Feldman M, Friedman L, Brandt L, eds. Sleisenger and Fordtran’s gastroin- testinal and liver disease. Philadelphia, PA: Saunders; 2010. Chapter 111. 2. Balfour Sartor R. Bacteria in Crohn’s disease: mechanism of inflammation and therapeutic implications. J Clin Gastroenterol 2007;41:S37-43. 3. Chiodini RJ, Chamberlin WM, Sarosiek J. Crohn’s disease and the mycobacte- rioses: a quarter century later. Causation or simple association? Crit Rev Microbiol 2012,38:52-93. 4. Frolkis A, Dieleman LA, Barkema H, et al. 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