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。

Mini-laparotomy retrograde recanalization by transmesenteric puncture under ultrasound guidance for total ostial occlusion of the superior mesenteric artery

Background and Aims: For patients with superior mesenteric artery (SMA) occlusion, especially those with no obvious stump due to atherosclerotic occlusion of the orifice, retrograde open mesenteric stenting (ROMS) is an effective treatment method. However, the surgical trauma of this procedure is relatively large, so it may not be feasible in some patients with poor physical status. Here, the authors present a surgical technique of modified minimally invasive ROMS through reporting the treatment process for a case with total SMA occlusion, so as to provide a treatment option for some clinical situations. Methods: The clinical data of a patient with total SMA occlusion treated in October 2019 in the Department of Vascular Surgery of Xiamen Branch, Zhongshan Hospital, Fudan University were reviewed. The patient was a 64-year-old woman, was diagnosed as chronic mesenteric ischemia caused by SMA occlusion, and then underwent hybrid procedures for SMA recanalization. Results: The patient had a flush ostial SMA occlusion without stump, and also no collateral vessels connecting the celiac artery and splenic artery were observed, so either antegrade or retrograde total endovascular revascularization attempt failed. In addition, the patient was unlikely to tolerate an open revascularization procedure or the traditional ROMS due to poor general condition. Then, a mini-laparotomy was made and a pathway to the distal portion of the SMA was created by transmesenteric puncture under ultrasound guidance. A retrograde guidewire successfully passed the occlusion of the SMA and was advanced into the descending aorta. An antegrade catheter from the right brachial artery access was successfully passed the occlusion of the SMA after engaging with the retrograde guidewire. After that, balloon predilation and stenting were performed. The patient recovered uneventfully after operation, with total alleviation of symptoms. The follow-up CTA on 3 months after operation demonstrated undeformed shape and accurate position of the stent as well as excellent patency of the vessel.  Conclusion: For patients with the SMA total occlusion and poor general condition following failed endovascular intervention, mini-laparotomy retrograde recanalization by transmesenteric puncture under ultrasound guidance is a feasible strategy.