Bypass grafting for chronic mesenteric ischemia

Air within surgical arterial graft on computed tomography-An alarming finding of a rare complication

We present a case of a 61 years old lady operated 2 years back for severe superior mesenteric artery stenosis with a surgical vascular graft and presenting as acute severe abdominal pain and vomiting. Her CT angiography showed occlusion of the surgical vascular graft with graft migration into small bowel. Both the findings of graft occlusion and bowel perforation were optimally demonstrated on the CT angiography study. The alarm of bowel perforation in addition to graft infection was raised by the presence of air pockets within the graft and its communication with bowel lumen. Coexistent graft infection was evident on graft culture.

Recurrent Mesenteric Ischemia from Celiomesenteric Trunk Stenosis

A common origin of the celiac trunk and superior mesenteric artery (SMA), also termed as celiomesenteric trunk (CMT), is a rare occurrence. We report a rare case of symptomatic CMT stenosis requiring multiple interventions. The patient underwent an initial superior mesenteric artery bypass graft but required a subsequent endoluminal intervention. We present this case for the rarity of CMT stenosis and its potential to cause recurrent mesenteric ischemia. The treatment outcome in this patient suggests that revascularization of the SMA alone can result in adequate perfusion of the entire mesenteric bed and resolve symptoms of mesenteric ischemia including weight loss and food avoidance.

Transaortc Endarterectomy for Primary Mesenteric Revascularization

The optimal approach to revascularization for chronic mesenteric ischemia has not been firmly established during the past three decades. The present study was undertaken to evaluate the safety and results of primary mesenteric revascularization for chronic mesenteric ischemia by transaortic endarterectomy. A descriptive retrospective analysis of 14 patients who underwent trap-door transaortic endarterectomy for primary mesenteric revascularization was performed. Clinical presentations of the patients included abdominal pain (n = 13) and weight loss (n = 7). All patients underwent preoperative aortography and subsequent elective reconstruction. Demographic features, perioperative, and long-term outcomes were analyzed. The study population consisted of 12 females and two males with a mean age of 67 years. The mean operative duration was 3 hours with an ischemic time of 33 minutes. The initial success rate of mesenteric revascularization was 93%. One early graft failure was salvaged with urgent embolectomy without bowel resection. There was no hospital mortality, but the overall postoperative morbidity rate was 50% (n = 7). Thirteen patients (93%) were discharged within 2 weeks. Late recurrent ischemia and intestinal infarction developed in one patient, requiring emergency bowel resection. Sustained relief of symptoms was achieved in 13 of 14 patients (93%). The overall survival rates were 85% ± 10.0% and 77% ± 11.7% at 1 and 3 years, respectively. Transaortic endarterectomy is a safe and effective technique for elective primary mesenteric revascularization for patients with chronic mesenteric ischemia. This approach allows simultaneous revascularization of multiple visceral arteries and achieves durable relief of symptoms.

Anatomic and radiologic review of chronic mesenteric ischemia and its treatment

Chronic mesenteric ischemia (CMI) is a vascular occlusive disease process that generally affects the elderly population. Clinical presentation occurs when two of the three mesenteric arteries are affected and includes non-specific abdominal pain and weight loss. The most common cause of CMI is atherosclerotic arterial occlusion. The aim of this review is to present the vascular anatomy of the mesenteric arterial circulation including the different collateral pathways. The imaging findings and the different treatment options with a brief review of the literature is presented.

Triple-vessel mesenteric ischaemia presenting with gastric ulceration

We present an unusual presentation of chronic mesenteric ischaemia in a patient with recurrent gastric ulceration that highlights both the importance of recognition of ischaemia as a possible aetiology in those refractory to conventional treatment and the success of percutaneous transluminal mesenteric angioplasty in these cases.

MDCT angiography of mesenteric bypass surgery for the treatment of chronic mesenteric ischemia

OBJECTIVE

Chronic mesenteric ischemia (CMI) is a serious condition that requires surgical or endovascular intervention. Surgical revascularization for the treatment of CMI uses different operative techniques including endarterectomy, vessel reimplantation, and mesenteric bypass. A basic understanding of the operative techniques is essential for the adequate interpretation of imaging studies in patients who have undergone surgery for CMI. In this article, we review the different operative techniques used in the treatment of CMI, discuss the results of surgical intervention for CMI, and illustrate how MDCT angiography (MDCTA) can be used for follow-up and for the detection of early and late complications after surgery.

CONCLUSION

MDCTA is a powerful tool for the postoperative evaluation of patients with CMI. Early detection of graft dysfunction is critical to prevent graft occlusion and the development of potentially fatal mesenteric ischemia. MDCTA can detect early and late complications after surgery and guide additional surgical or endovascular interventions.

Acute abdominal vascular emergencies

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.

Acute and chronic mesenteric ischemia

This article briefly reviews the various etiologies, presentation, and diagnosis of different types of mesenteric ischemia. Operative management techniques and the applicability of percutaneous endovascular intervention are discussed. Finally, the authors explore emerging technologies that have the potential to further improve diagnosis and treatment of this frequently lethal disease process.

Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is associated with high morbidity and mortality due in part to its diagnostic difficulty and operative challenges. The purpose of this study was to review our experience of surgical management in patients with this condition and to identify variables associated with adverse outcomes following surgical interventions.

METHODS

Hospital records and clinical data of all patients undergoing surgical interventions for AMI were reviewed during a recent 12-year period. Clinical outcomes as well as factors influencing mortality were analyzed.

RESULTS

A total of 72 patients (41 females, overall mean age 65 years, range 34 to 83 years) were included in the study. Thrombosis and embolism were the cause of AMI in 48 patients (67%) and 24 patients (33%), respectively. Abdominal pain was the most common presenting symptom (96%), followed by nausea (56%). Preoperative angiogram was performed in 61 patients (85%). All patients underwent operative interventions, which included thromboembolectomy (n = 22, 31%), mesenteric bypass grafting (n = 33, 46%), patch angioplasty (n = 9, 12%), reimplantation (n = 5, 7%), and endarterectomy (n = 3, 4%). Bowel resection was necessary in 22 patients (31%) during the initial operation, and second-look operation was performed in 38 patients (53%). Perioperative morbidity and 30-day mortality rates were 39% and 31%, respectively. Univariate analysis showed renal insufficiency (P < .02), age >70 (P < .001), metabolic acidosis (P < .02), and symptom duration (P < .005), and bowel resection in second-look operations (P < .01) were associated with mortality. Logistic regression analysis showed age >70 (P = .03) and prolonged symptom duration (P = .02) were independent predictors of mortality.

CONCLUSIONS

Elderly patients and those with a prolonged duration of symptoms had worse outcomes following surgical intervention for AMI. A high index of suspicion with prompt diagnostic evaluation may reduce time delay prior to surgical intervention, which may lead to improved patient survival. Aggressive surgical intervention should be performed as promptly as possible in patients once the diagnosis of AMI is made.

CTA and MRA in Mesenteric Ischemia: Part 2, Normal Findings and Complications After Surgical and Endovascular Treatment

OBJECTIVE

A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting.

CONCLUSION

We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.

Update in management of mesenteric ischemia

Mesenteric ischemia disorders are precipitated by a circulation insufficiency event that deprives one or several abdominal organs of adequate respiration to meet metabolic demands. Although mesenteric ischemia occurs infrequently, the mortality rate is from 60% to 100%, depending on the source of obstruction. The successful outcome is dependent upon a high index of suspicion and prompt management. We briefly review the pathophysiology and presentation of the various ischemic entities and review the current state of the art in diagnosis and treatment. Despite advances in both diagnosis and treatment, prompt diagnosis and supportive care remain critical for successful outcome. New imaging techniques, endovascular therapy and emerging research may improve our approach to this deadly condition.

[Surgical exposure of visceral arteries]

Surgery of visceral arteries is mainly indicated for ostial and juxtaostial atherosclerosis of the celiac axis and superior mesenteric arteries. Their surgical exposures are often difficult because of their deepness.

Acute occlusive mesenteric ischemia: surgical management and outcomes

Acute mesenteric ischemia secondary to arterial occlusion (AMI) remains a highly lethal condition. To examine recent trends in management and associated outcomes, we examined our institutional experience over a recent 10-year period. All patients treated for AMI between January 1990 and January 2000 were identified (76 patients, 77 cases) and their medical records examined. At presentation, 64% demonstrated peritonitis and 30% exhibited hypotension. The interval from symptom onset to treatment exceeded 24 h in 63% of cases. Etiology was mesenteric thrombosis in 44 patients (58%) and embolism in 32 patients (42%). Thirty-five patients (46%) had prior conditions placing them at high risk for the development of AMI including chronic mesenteric ischemia (n = 26) and inadequately anticoagulated chronic atrial fibrillation (n = 9). Surgical management consisted of exploration alone in 16 patients, bowel resection alone in 18 patients, and revascularization in 43 patients, including 28 who required concomitant bowel resection. Overall, intestinal necrosis was present in 81% of cases. Perioperative mortality was 62% and long-term parenteral nutrition (TPN) was required in 31% of survivors. Peritonitis (odds ratio [OR] 9.4, 95% confidence interval [CI] 1.6, 54.0; p = 0.012 and bowel necrosis (OR 10.4, CI 1.9, 56.3; p = 0.007) at presentation were independent predictors of death or survival dependent upon TPN. We conclude that AMI remains a highly lethal condition due in large part to advanced presentation and inadequate recognition and treatment of patients at high risk.

Mesenteric arterial ischaemia: diagnosis and therapeutic options

Ischaemia of the bowel may arise from a number of causes affecting the arterial and venous compartments of the vascular tree. This article addresses the causes and consequences of arterial obstruction, which may compromise the supply of oxygenated blood to the bowel. These events may occur as an acute phenomenon, or they may present in a chronic fashion. The therapeutic options available to treat this condition are largely dependent on the mode of presentation and the amount of time that is available before irreversible damage occurs to the bowel integrity. In the acute phase, the viability of the bowel is in doubt, and this necessitates an open operative approach to assess the amount of bowel infarction which has already occurred. A variety of operative procedures are then available to limit this bowel loss and to secure the viability of the remaining bowel. In the more chronic phase there are alternative, less invasive procedures that may be appropriate for the patient, who may have suffered a prolonged period of undernourishment and dehydration. In such cases the immediate bowel viability is not in doubt, but the medium/long-term survival is compromised. Treatment options appropriate to each clinical scenario are discussed, along with the major technical issues associated with these treatments. A team approach to the most appropriate management plan is stressed, and the published outcomes reviewed.

Retrograde aortomesenteric bypass with tunneling behind the left renal pedicle

This report describes a new technique for revascularization of the superior mesenteric artery (SMA) which creates a retrograde bypass tunneled behind the left renal pedicle. The procedure can be performed by the left retroperitoneal or transperitoneal route, alone or in association with reconstruction of the infrarenal aorta. Proximal anastomosis is retrograde on the left side of the infrarenal aorta or aortic prosthesis. The course of the bypass runs first in the back and top of the retrorenal dissection plane, then loops behind and over the left renal pedicle, and finally turns downward and forward to the SMA. Distal anastomosis can be made either end-to-end or end-to-side. This large, loop-shaped course not only reduces the risk of kinking but also gives the bypass enough length to adapt to movements of the SMA. This technique has been performed in association with reconstruction of the infrarenal aorta in three patients. Postoperative control using Doppler ultrasound, arteriography, and helical CT scan showed no kinking or other abnormality. One patient died a month after the procedure from myocardial infarction. Follow-up Doppler ultrasound in the two surviving patients showed bypass patency with no stenosis at 19 and 30 months.

Stent implantation for mesenteric bypass graft stenosis

PURPOSE

To present a case of symptomatic mesenteric bypass graft stenosis treated with Palmaz stent implantation.

METHODS AND RESULTS

A 65-year-old man with a history of mesenteric ischemia and superior mesenteric artery (SMA) occlusion presented with recurrent symptoms 3 years after Dacron graft revision surgery for occlusion of a venous aorto-SMA bypass graft. Graft thrombectomy revealed a tortuous segment of narrowed graft proximally, and a Palmaz stent was deployed across the defect. Adequate flow was restored through the conduit, and the patient has remained asymptomatic for 2 years.

CONCLUSIONS

Mesenteric ischemia is a rare and potentially fatal condition requiring major vascular intervention. Revision surgery may be avoided by angioplasty and stent insertion across flow-limiting stenoses, even in prosthetic grafts.

Repair of type IV thoracoabdominal aneurysm with a combined endovascular and surgical approach

We report an unusual case of type IV Thoracoabdominal Aneurysm (TAA) with Superior Mesenteric Artery (SMA), celiac artery, and bilateral renal artery aneurysms in a patient who underwent an earlier repair of two infrarenal Abdominal Aortic Aneurysm (AAA) ruptures. Because of the presence of the visceral artery aneurysms and the earlier operation through the retroperitoneum, standard surgical treatment via a retroperitoneal approach with an inclusion grafting technique was considered difficult. A combined surgical approach achieving retrograde perfusion of all four visceral vessels and endovascular grafting allowing exclusion of the TAA was accomplished. Complete exclusion of the aneurysm and normal perfusion of the patient's viscera was documented by means of follow-up examinations at 3 and 6 months. The repair of a type IV TAA with a Combined Endovascular and Surgical Approach (CESA) allowed us to manage both the aortic and visceral aneurysms without thoracotomy or re-do retroperitoneal exposure and minimized visceral ischemia time. If the durability of this approach is confirmed, it may represent an attractive alternative in patients with aneurysmal involvement of the visceral segment of the aorta.

Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.