Splenic artery-to-superior mesenteric artery bypass for chronic mesenteric ischemia--a case report

Chronic mesenteric ischemia (CMI) is a serious vascular condition that if left untreated may progress to acute ischemia resulting in bowel necrosis and high surgical morbidity/mortality rates. Elective intervention has been shown to prevent this progression and relieve symptoms. Current open surgical intervention involves arterial bypass using a vein or synthetic graft conduit with the inflow originating from the aorta or iliac artery. In some circumstances, the splenic artery provides an additional treatment option for revascularization of the superior mesenteric artery. In certain cases, the splenic artery has several advantages over traditional surgical options. The splenic artery is an arterial conduit much like the internal mammary artery used in coronary artery bypass grafting. These grafts are known for their long-term patency and in selected clinical circumstances are preferred over venous grafts. Because the splenic artery has a natural inflow, only a single vascular anastomosis at the outflow vessel (the SMA) is necessary. This lessens the risk of anastomotic stenosis by decreasing the number of anastomoses created and it makes the procedure shorter in duration. The fact that the inflow is provided by the splenic artery makes cross-clamping of the aorta unnecessary, thereby lessening the risk of producing cardiac ischemia and declamping hypotension. A disadvantage is the risk of splenic ischemia with the possible need for splenectomy. The majority of individuals will have adequate collateral supply to the spleen via the short gastric arteries. The risk to the patient of splenectomy versus the benefits of a less complicated arterial reconstruction with avoidance of aortic cross-clamping must be weighed on a case-by-case basis. Preventing the progression to acute mesenteric ischemia with its increased mortality by timely restoration of adequate vascular supply is an important principle in treating patients with CMI. Controversy still exists over the best treatment option for these patients, whether it be antegrade versus retrograde bypass, single-vessel versus multivessel reconstruction, or open surgical repair versus endovascular intervention. In selected patients, the use of the splenic artery can be considered as an additional option for arterial reconstruction of the SMA.     

Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia

INTRODUCTION: Acute mesenteric ischemia (AMI) caused by arterial occlusive disease requires prompt diagnosis and revascularization to avoid the high mortality associated with this disease. In an attempt to minimize the magnitude of operation for arterial occlusive AMI, we have developed a new technique of endovascular recanalization and open retrograde stenting of the superior mesenteric artery (SMA) during laparotomy so that the bowel can also be assessed and resected if necessary. METHODS: All emergent mesenteric revascularizations for arterial occlusive AMI performed at Dartmouth-Hitchcock Medical Center from 2001 to 2005 (n = 13) were retrospectively reviewed. Outcomes were analyzed with respect to the method of revascularization and other perioperative variables. Restenosis was evaluated with duplex ultrasound imaging. RESULTS: Three different revascularization methods were used: surgical bypass (n = 5), antegrade percutaneous stenting (n = 2), and retrograde open mesenteric (SMA) stenting (ROMS, n = 6). Satisfactory revascularization was achieved in all cases and all methods. ROMS was successfully accomplished in three of six patients after antegrade attempts to cross the SMA from the arm were unsuccessful. At 17%, the ROMS group had the lowest hospital mortality compared with bypass at 80% (P = .08) and percutaneous stent at 100% (P = .11). All five of the surviving patients treated with ROMS were discharged to home after a mean hospital stay of 20 days (range, 6 to 38 days). During a mean follow-up of 13 +/- 7 months, three patients died of unrelated causes, of which two were being followed with asymptomatic recurrent SMA stenosis detected by duplex scan. The two surviving patients are alive and well, but one has required percutaneous SMA stenting of a progressive asymptomatic restenosis. CONCLUSION: Retrograde open SMA stenting during laparotomy for AMI has a high technical success rate and provides an attractive alternative to surgical bypass in these often critically ill patients. Because it is combined with open laparotomy, it honors the essential surgical principles of evaluating and resecting nonviable bowel. Restenosis rates appear to be high, so that patients must be followed closely. Further study and development of this new hybrid technique is warranted.     

Superior mesenteric artery-to-renal artery bypass: A rare but useful alternative for renal artery revascularization

The aorta, celiac axis, and iliac arteries are the most common inflow arteries used for renal revascularization. When these inflow vessels are diseased, the superior mesenteric artery (SMA) can be an alternative source of renal artery graft inflow. Previous reports have suggested that only an enlarged SMA should be used for this purpose, for fear of developing mesenteric ischemia. We report a patient who required renal artery revascularization with a saphenous vein graft from a normal-caliber SMA who did not develop subsequent mesenteric ischemia. The procedure was unique in demonstrating that the SMA can be used as a viable source of graft inflow even when it is anatomically normal.     

Endovascular exclusion of superior mesenteric artery pseudoaneurysms: an alternative to open laparotomy in high-risk patients

Superior mesenteric artery (SMA) aneurysms are rare. However, patients are frequently symptomatic on presentation and require urgent repair. SMA aneurysms have the potential for severe complications, including thrombosis or rupture, resulting in acute mesenteric ischemia and death. In patients with adhesions secondary to prior abdominal surgery, traditional open exposure of the aneurysm neck via dissection at the base of the transverse colon mesentery may be technically difficult. Endovascular exclusion of visceral artery aneurysms using covered stent grafts presents a reasonable alternative to the morbidity associated with laparotomy. We report an interesting case of a patient with a large SMA aneurysm and multiple prior laparotomies treated percutaneously with a combined expanded polytetrafluoroethylene/nitinol self-expanding stent-graft allowing maintenance of end-organ perfusion and bowel viability.     

A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection

BACKGROUND: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. METHODS: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. RESULTS: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002). CONCLUSIONS: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.     

An experimental evaluation of the lactate concentration following mesenteric ischemia

PURPOSE: Although a diagnosis of mesenteric necrosis can easily be made, mesenteric ischemia is sometimes overlooked, especially in the acute phase. We experimentally evaluated the time course of the lactate concentration, which may be a possibly useful variable in making a diagnosis of mesenteric ischemia, and determined how an early diagnosis can be made. METHODS: The superior mesenteric artery (SMA) was surgically ligated in an anesthetized pig. Blood tests, including a blood gas analysis, were done using samples from the superior mesenteric vein (SMV), hepatic vein, femoral vein, and artery until 6 h after SMA ligation. RESULTS: There were no variables in any samples that showed a significant change within 4 h after SMA ligation except for samples taken from the SMV. All acidosis-related variables had changed significantly within 6 h after ischemia. Among them, the lactate concentration only in the SMV was observed to have increased significantly within one hour after SMA ligation. CONCLUSIONS: Currently available peripheral blood tests, including tests using blood obtained from the hepatic vein, do not enable the detection of mesenteric ischemia within 4 h after onset. In a case in which an exploratory laparotomy is performed, the measurement of the lactate concentration in SMV is thus considered to be a useful supplementary test for making a prompt diagnosis of mesenteric ischemia in an early phase.     

经腹腔干-胃十二指肠弓逆向介入治疗肠系膜上动脉开口处完全闭塞无残端病变1例

目的:探讨逆向入路支架植入治疗肠系膜上动脉(SMA)闭塞的技术。方法:回顾2017年2月1例于复旦大学附属中山医院血管外科行逆向开通SMA闭塞的患者临床资料。结果:患者为47岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血(CMI),行腔内治疗再通SMA。由于SMA开口处完全闭塞性,无残端,经肱动脉和股动脉双侧入路均无法开通病变部位。利用腹腔干和SMA之间的胃十二指肠弓,通过此通路逆向开通SMA闭塞处;肱动脉入路导管和导丝对接后顺利正向通过病变,完成球囊扩张和支架植入术。术后患者CMI症状消失,3个月后随访CTA显示,支架定位良好,远端血管通畅。结论:对于常规血管内介入治疗方法失败的SMA闭塞患者,通过有效的侧支通路进行逆行开通是可行的。     

Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemia--a case report

Acute mesenteric ischemia continues to be a highly morbid diagnosis with a high mortality rate. Percutaneous management of mesenteric ischemia is being more widely applied. Its utility is limited, though, for patients who present with an acute abdomen from ischemic bowel. The authors report a novel combination of open and endovascular techniques via a retrograde superior mesenteric artery (SMA) approach to treat acute mesenteric ischemia in the setting of an acute abdomen.     

经腹小切口超声引导系膜穿刺逆向开通治疗肠系膜上动脉开口全堵病变

背景与目的：对于肠系膜上动脉（SMA）闭塞患者,尤其是存在开口处动脉粥样硬化性无残端病变,开腹逆行肠系膜动脉支架置入术（ROMS）是一种有效的治疗方法,但该手术创伤较大,一些身体条件差的患者并不适合。笔者通过报告1例SMA全堵病变病例的治疗过程介绍一种改良的微创ROMS技术,以期为临床治疗方法的选择提供参考。 方法：回顾复旦大学附属中山医院厦门医院血管外科2019年10月收治的1例SMA全堵病变患者的临床资料。患者为64岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血,行杂交手术再通SMA。 结果：患者SMA开口处为无残端完全闭塞病变且无侧支血管与腹腔干动脉及脾动脉沟通,顺行或逆行血管腔内开通均无法进行。因患者全身条件较差,难以耐受开放血运重建手术和传统的ROMS。遂做腹部做小切口,超声引导下经系膜穿刺SMA远端建立通路,导丝顺利逆向通过SMA闭塞处进入降主动脉;右侧肱动脉入路导管和逆向导丝对接后顺利正向通过病变,完成球囊扩张和支架置入术。术后患者恢复良好,症状消失,3个月后随访CTA示,支架形态、位置良好,血流通畅。 结论：对于血管腔内治疗失败且全身条件较差的SMA闭塞患者,通过经腹小切口超声引导系膜穿刺逆向开通SMA是可行的。     

腹腔动脉和肠系膜上动脉狭窄的介入治疗

目的评价介入技术治疗腹腔动脉（CA）和肠系膜上动脉（SMA）狭窄的安全性和临床疗效。方法对8例CA／SMA局限性狭窄患者进行了经皮穿刺经腔球囊血管成型术（PTA）和支架置入术,单纯CA狭窄2例、单纯SMA狭窄4例、CA和SMA均有狭窄2例。4例患者有典型进餐后腹痛,5例有上腹部血管杂音,8例于发病后均有不同程度的体重下降（平均8kg）。7例患者病因为动脉硬化,1例为膈肌中脚压迫综合征（MALS）所致。结果PTA和支架置人均成功,其中治疗CA狭窄3例、SMA狭窄5例,7例用1个支架,1例用2个支架。治疗结束时复查造影显示置人支架的血管血流通畅,管径接近正常。术后于穿刺侧腹股沟区出现小血肿2例,无须外科处理、自行吸收。术后腹痛完全消失5例、有所减轻2例、无改善1例;术后3个月时,体重恢复至发病前水平者6例。8例患者随访6-72个月（平均42个月,中位值28个月）,复查Doppler超声波无明确再狭窄证据。5例无症状、1例仍然有间歇性腹痛,2例分别于术后14个月、24个月死于其他原因。结论PTA和支架置入术是治疗CA、SMA局限性狭窄的安全有效方法,尤适宜于存在外科治疗高风险的患者。     

The effect of glucose infusion on survival after acute mesenteric ischemia/reperfusion

Perfusion of ischemic tissue with glucose has been shown to be deleterious to heart, spinal cord, and kidney. Observations that glucagon improves survival after acute mesenteric ischemia, however, suggest that hyperglycemia may not be deleterious during bowel ischemia. This experiment examined the effect of glucose infusion on survival in an established rat model of acute mesenteric ischemia. The superior (cranial) mesenteric artery (SMA) was occluded for 85 min in 36 anesthetized Sprague-Dawley rats. Animals were randomized to receive 5% glucose in normal saline (n = 15; 16.5 mL/kg.min iv), normal saline alone (n = 13; 16.4 mL/kg.min iv), or no intravenous fluid (n = 8). Ninety-minute intravenous infusions were initiated 10 min after SMA occlusion. Survival to 48 h was 47% in glucose-saline-treated rats, 31% in saline-only-treated rats, and 12.5% in control rats. These results demonstrate no deleterious effect of glucose infusion on mortality after acute mesenteric ischemia in this model.     

Radioxenon washout for the diagnosis of low-flow mesenteric ischemia

Angiogram is accepted as one of the investigations necessary to establish the diagnosis of acute mesenteric ischemia. Unfortunately, the changes seen in the mesenteric arteriogram of patients with low-flow intestinal ischemia are not always clear and easily interpreted. In this study the washout of an intraarterial injection of radioxenon (¹³³Xe), from nonocclusive ischemic bowel, was recorded to determine if it might aid in the diagnosis of low-flow ischemia. For these investigations, a model of low-flow mesenteric ischemia was produced by infusion of noradrenalin into the dog's superior mesenteric artery (SMA). Under experimental conditions of normal and low mesenteric blood flow, the percentage disappearance at 2 min (washout), from the bowel, of a bolus intraarterial (SMA) injection of radioxenon was recorded to determine if this gave a measure of the intestinal blood flow. It was found that Xe washout and the corresponding SMA blood flow, measured with an electromagnetic flow probe, correlated well in the normal and nonocclusive ischemic bowel (r = 0.924). Measurement of the washout of an intraarterial injection of ¹³³Xe to the bowel may be a helpful adjunct to arteriogram for the clinical diagnosis of low-flow mesenteric ischemia.     

急性肠系膜上动脉缺血37例诊治转归

目的 探讨急性肠系膜上动脉缺血的诊治方法,提高诊治水平.方法 回顾分析1996年1月至2007年8月收治的37例急性肠系膜上动脉缺血患者的临床资料,结合文献讨论其病因、诊断及治疗.结果 急性肠系膜上动脉栓塞19例(51.4%),急性肠系膜上动脉血栓形成15例(40.5%),孤立的肠系膜上动脉夹层2例(5.4%),肠系膜上动脉瘤1例(2.7%).急诊误诊19例(51.4%).院内死亡18例(48.6%),多死于重症感染和多器官功能衰竭.存活的19例中3例遗留严重后遗症(短肠综合征2例,脑出血1例).共9例患者获得随访,平均随访15个月,其间5例死亡.结论 急性肠系膜上动脉缺血病因多样,早期干预可显著改善患者预后.     

Distal thoracic aorta as inflow for the treatment of chronic mesenteric ischemia

PURPOSE: Mesenteric revascularization for chronic mesenteric ischemia (CMI) traditionally involves antegrade or retrograde bypass graft originating from the supraceliac or infrarenal aorta. The distal thoracic aorta (DTA) may provide a better inflow source than the abdominal aorta. The purpose of this study was to evaluate the results with the DTA used as inflow for the surgical treatment of CMI. METHODS: All patients undergoing mesenteric revascularization for CMI with grafts originating from the DTA were identified from 1990 to 1999. A ninth interspace thoracoretroperitoneal incision was used for exposure, and distal aortic flow was maintained by use of a partial occlusion clamp. RESULTS: Eighteen consecutive patients with CMI underwent mesenteric bypass grafting with the DTA used as inflow. All patients were admitted with chronic abdominal pain or weight loss, with two (12%) requiring urgent revascularization because of acute exacerbation of chronic symptoms. Fourteen (78%) patients had both celiac and superior mesenteric artery bypass grafts placed, and three (17%) patients had superior mesenteric artery grafts alone. There was one (6%) perioperative death and three (17%) major complications. There was no kidney failure, mesenteric infarction, or spinal cord ischemia. The life-table survival rate was 89%, 89%, and 76% at 1, 3, and 5 years, respectively. All 18 patients remained symptom free and required no additional procedures to assist patency. There was no evidence of graft stenosis or occlusion (100% patency) for those grafts evaluated objectively during the mean follow-up of 34.8 months (range, 1-97 months). CONCLUSIONS: Antegrade mesenteric revascularization with the DTA used as inflow is associated with low morbidity and mortality rates. Furthermore, it provides excellent midterm patency and survival results and should be considered as a primary approach for reconstruction of patients with CMI.     

Technical consideration in the management of chronic mesenteric ischemia

Our aging population may result in a rise in the prevalence of chronic mesenteric ischemia. This report reviews our contemporary experience with a tailored surgical approach to chronic mesenteric ischemia. The medical records of 17 patients operated on for chronic mesenteric ischemia were retrospectively reviewed. Symptom-free survival and long-term patency documented by duplex scanning when available were also analyzed. Sixteen patients ranging in age from 32 to 80 years were included in the study. Seventy-five per cent of the patients were female. The most common preoperative complaints were postprandial abdominal pain and weight loss. Revascularization was tailored to the arterial anatomy and included bypass to the superior mesenteric artery (SMA) alone (eight), bypass to the celiac artery and SMA (six), SMA reimplantation onto the aorta (one), SMA/inferior mesenteric artery reimplantation (one), and transaortic endarterectomy of the celiac artery/SMA (one). Bypass conduits included Dacron (eight), saphenous vein (four), and polytetrafluoroethylene (two). Bypass grafts originated from the supraceliac aorta in 12 patients; the remaining bypass originated from the left limb of an aortofemoral graft. There was one perioperative death (mortality 5.6%). Follow-up duplex scans at a mean of 34 months (range 1-114) showed no graft thromboses. We conclude that a variety of surgical techniques can provide durable relief of mesenteric ischemia. A tailored approach to revascularization optimizes patency and provides long-term symptom-free survival.     

Hybrid management of ruptured isolated superior mesenteric artery dissecting aneurysm

A 70-year-old woman, with history of asymptomatic isolated superior mesenteric artery (SMA) dissection was admitted for acute abdominal pain. Computed tomography showed ruptured isolated SMA dissection. Endovascular treatment was chosen over surgical repair because of prior abdominal surgeries. Because an angulated SMA trunk and compressed true lumen by the dilated false lumen prevented the insertion of a guidewire into the SMA via the transfemoral artery, transmesenteric approach under laparotomy was selected. After creating a pull-through condition from the SMA to the left brachial artery, a successful stent graft placement with adequate hemostasis was achieved. The aneurysm shrunk remarkably, with no complication at follow-up.     

肠系膜上动脉夹层15例诊治分析

目的 探讨肠系膜上动脉夹层的临床诊治路径.方法 分析2006年2月至2010年7月收治的15例肠系膜上动脉夹层患者的临床资料.男13例,女2例.年龄43～63岁,平均(53±8)岁.除1例有明确的外伤史,余无明确诱因.所有患者均经腹部增强CT扫描检查明确诊断.治疗方法包括腔内支架治疗、保守治疗及开放手术治疗.结果 腔内支架治疗成功5例,未成功而转保守治疗9例.1例因疑有严重肠缺血的患者接受开放手术,术中行肠系膜上动脉夹层开窗,恢复远端肠系膜上动脉血供.15例中13例患者得到随访,随访率为86.7％.随访时间12 ～60个月,平均(28±14)个月.在随访期内无腹痛复发及慢性肠缺血症状.保守治疗的患者CT随访无夹层瘤样扩张,腔内治疗成功的患者内支架均通畅.结论 腔内治疗肠系膜上动脉夹层的成功率不高;对于症状缓解的患者及无症状的患者,可在长期随访检测下进行保守治疗;症状不缓解或出现肠缺血坏死征象时应尽早行开放手术治疗.     

Isolated dissection of the superior mesenteric artery after living donor liver transplantation: a case report

Isolated dissection of the superior mesenteric artery (SMA) not associated with aortic dissection is rare, particularly after living donor liver transplantation (LDLT). We experienced a case of isolated dissection of the SMA after LDLT performed in a 56-year-old man diagnosed with hepatitis B virus-related cirrhosis and hepatocellular carcinoma within the Milan criteria. He had no past history of hypertension or diabetes mellitus. At 6 days after LDLT, the patient underwent an emergency portal vein thrombectomy with ligation of a huge left gastric vein shunt. Thereafter anticoagulant and antiplatelet therapy were initiated. At 12 days after LDLT, a contrast-enhanced computer assisted tomography (CT) scan revealed the presence of a thrombus in a false lumen and a thin flap enlarged in the SMA. Because he presented neither abdominal pain nor biochemical data suggesting mesenteric ischemia, he was treated with antihypertensive agents in addition to anticoagulant and antiplatelet therapy. The thrombus in the false lumen was reduced and the intimal flap in the SMA disappeared according to the results of a CT scan 4 months after LDLT. He has remained free of symptoms for 4 years. The strategy to treat isolated SMA dissection is not well established. Urgent surgery is indicated for acute symptomatic forms with a suspicion of mesenteric ischemia; conservative treatment is indicated for patients with minimal, resolving, or no pain, but requires close follow-up.     

血清D-二聚体测定对急性肠系膜上动脉栓塞的诊断价值

目的 评估测定血清D-二聚体（D-dimer）含量在诊断急性肠系膜上动脉（superior mesenteric artery,SMA）栓塞中的价值。方法将我院1998年6月-2006年6月入院诊断或出院诊断为急性肠系膜血管缺血性疾病的63例分为SMA栓塞（11例）和其它急腹症（52例）两组。使用ROC曲线法评价D-二聚体对SMA栓塞的诊断价值,明确D-二聚体的诊断临界点,绘制ROC曲线。结果ROC曲线下面积为0．939,并有统计学意义。通过ROC曲线确定诊断临界点为0．73mg／L,并具有较高的灵敏度和特异度。结论血清D-二聚体测定可用于急腹症中SMA栓塞的临床排除诊断。当血清D-二聚体高于0．73mg／L时,应高度怀疑为SMA栓塞。     

Superior mesenteric artery plasty for type A acute aortic dissection with visceral ischemia

Treatment of visceral ischemia complicated with acute type A aortic dissection is controversial. We had two cases of acute type A aortic dissection complicated by superior mesenteric artery (SMA) ischemia and successfully treated them with direct SMA perfusion during central aortic repair followed by SMA plasty. The presented procedures can be an option to treat visceral ischemia with a standard operative theater and equipment.