1. 64 ♀ E/A worsening abdo pain 6/12 post-prandial epigastric pain. Weight loss 6/12 post-prandial epigastric pain. Weight loss BMI 44 BMI 44 Moderate COPD, hypertension Moderate COPD, hypertension Persistently elevated WCC 14.9 Persistently elevated WCC 14.9 U/S no gallstones, OGD gastritis U/S no gallstones, OGD gastritis MRA requested ?mesenteric ischaemia MRA requested ?mesenteric ischaemia

2. MRA Coeliac occlusion Coeliac occlusion SMA 95% stenosis SMA 95% stenosis IMA occlusion IMA occlusion 5.2cm AAA 5.2cm AAA LCIA stenosis 75% LCIA stenosis 75% RCIA stenosis 85% RCIA stenosis 85%

3. CT Atrophic right kidney Atrophic right kidney Stenosis origin left renal artery Stenosis origin left renal artery

4. Options? Percutaneous stent SMA Percutaneous stent SMA Access? Access? Back up plan/ bail out? Back up plan/ bail out? Need for subsequent AAA repair Need for subsequent AAA repair Open repair and mesenteric, renal revascularisation Open repair and mesenteric, renal revascularisation Iliac angioplasty, hybrid AAA repair with revascularisation Iliac angioplasty, hybrid AAA repair with revascularisation

5. Emergency! Hypotension Hypotension Worsening abdominal pain Worsening abdominal pain Rising WCC 31 Rising WCC 31 Renal impairment Renal impairment No peritoneal signs No peritoneal signs CT- no rupture AAA, no perforation/free fluid CT- no rupture AAA, no perforation/free fluid ITU sepsis ?source ITU sepsis ?source resuscitation. Would not survive major open procedure resuscitation. Would not survive major open procedure Transbrachial angioplasty & stent Transbrachial angioplasty & stent

10. Post SMA stent Abdominal pain improved Abdominal pain improved Improved gases and WCC halved Improved gases and WCC halved No peritonism No peritonism Acutely ischaemic arm! Acutely ischaemic arm! Brachial thrombectomy and patch Brachial thrombectomy and patch

11. Day 3 Diarrhoea Diarrhoea Rise in WCC, abdominal tenderness Rise in WCC, abdominal tenderness Gases normalised BE -0.6, lactate normal Gases normalised BE -0.6, lactate normal CT performed CT performed still deemed high anaesthetic risk for laparoscopy/laparotomy still deemed high anaesthetic risk for laparoscopy/laparotomy

12. 3 days

13. Day 8 Vomiting overnight, increasing pain Vomiting overnight, increasing pain Rise in inflammatory markers Rise in inflammatory markers BE -6.3 BE -6.3 ?occluded stent ?occluded stent Duplex- stent patent, dilated SB loops Duplex- stent patent, dilated SB loops CT CT

14. Day 8

16. Laparotomy Multiple small areas infarction terminal ileum. Remainder very well perfused Multiple small areas infarction terminal ileum. Remainder very well perfused Infarcted segment left lobe liver Infarcted segment left lobe liver Ischaemic GB Ischaemic GB Ileal resection, cholecystectomy Ileal resection, cholecystectomy

17. Discussion Awareness of possible diagnosis essential Awareness of possible diagnosis essential Definitive diagnosis often only made when advanced complications and clear clinical signs Definitive diagnosis often only made when advanced complications and clear clinical signs Revascularisation often possible with angioplasty/stent/surgery Revascularisation often possible with angioplasty/stent/surgery Need for vigilance post reperfusion to detect non viable bowel Need for vigilance post reperfusion to detect non viable bowel CT/ relook laparotomy CT/ relook laparotomy Stormy post operative course normal Stormy post operative course normal Mucosal sloughing/ loss of gut barrier/ need for parenteral nutrition Mucosal sloughing/ loss of gut barrier/ need for parenteral nutrition