Use of the ascending aorta as bypass inflow for treatment of chronic intestinal ischemia

PURPOSE: Surgical revascularization of intestinal arteries is an effective long-term treatment for chronic intestinal ischemia (CII) regardless of the technique used. Conventional antegrade or retrograde bypass techniques are the most common modalities for extensive lesions that cannot be treated by endarterectomy or transposition. In this report, we describe our experience with an antegrade bypass technique from the ascending aorta in patients with no other available inflow. METHODS: From April 1990 to May 2004, we performed antegrade bypass from the ascending aorta to the celiac artery, superior mesenteric artery (SMA), or both in five patients. These cases accounted for 2.4% of the 211 patients who underwent surgery on intestinal arteries during the study period. Results: Four patients presented with symptomatic CII, and one patient had no intestinal ischemic symptoms. The underlying disease was Takayasu disease in two cases, Erdheim-Chester disease in one case, chronic aortic dissection in one case, and atherosclerosis in one case. Two patients had already undergone an unsuccessful revascularization attempt with another technique. Bypass was performed alone in three cases in association with revascularization of the ascending aorta, aortic arch, and proximal descending thoracic aorta in one case and in association with revascularization of the ascending aorta and proximal aortic arch and renal autotransplantation in one case. Recovery was uneventful in all cases. One venous graft occluded because of technical defects and required reoperation for prosthetic graft replacement on the 10th postoperative day. Symptoms of CII resolved in all cases. Four months after the procedure, one patient underwent dilatation of an asymptomatic stenosis of the SMA distal to the bypass. During the 50th month after the procedure, a new re-stenosis of the SMA appeared. Left untreated, this stenosis led to asymptomatic occlusion of the mesenteric segment of a sequential aortoceliomesenteric bypass 13 months later. This aortoceliac bypass and the other four bypasses were patent after 4, 31, 46, 52, and 120 months of follow-up. CONCLUSION: Antegrade intestinal artery bypass from the ascending aorta is an effective alternative for patients who have no other available inflow for conventional antegrade or retrograde bypass and for patients in whom major technical difficulties are likely after multiple exposures of the thoracoabdominal aorta. Although indications are uncommon, antegrade intestinal artery bypass can provide durable revascularization of the intestine.