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. 2024 Feb 12:23:e20230148.
doi: 10.1590/1677-5449.202301482. eCollection 2024.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Bruno Pagnin Schmid  1   2 , Vinícius Adorno Gonçalves  1 , Lucas Marcelo Dias Freire  1 , Felipe Nasser  2 , Fábio Hüsemann Menezes  1
Affiliations

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Bruno Pagnin Schmid et al. J Vasc Bras. .

Abstract
in English, Portuguese

Background: Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

Objectives: To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Methods: Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature.

Results: All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Conclusions: Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Contexto: A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta.

Objetivos: Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição.

Métodos: Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C.

Resultados: Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos.

Conclusões: A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Keywords: blood vessel prosthesis; mesenteric arteries; mesenteric ischemia; mesenteric vascular occlusion; superior mesenteric artery.

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Conflict of interest statement

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Figures

Figure 1
Figure 1. Intraoperative and imaging findings for patient #2. (a) Preoperative computed tomography angiography showing the superior mesenteric artery (SMA) and the inferior mesenteric artery occluded; (b) Intraoperative view of a polyester aortobifemoral graft with a reinforced PTFE graft from the aortic graft to the SMA.
Figure 2
Figure 2. Intraoperative and imaging findings for patient #3. (a) Preoperative computed tomography angiography (CTA) with celiac trunk stenosis. The superior mesenteric artery (SMA) and the inferior mesenteric artery are occluded; (b) Postoperative CTA with a patent reinforced PTFE graft from the right iliac artery to the SMA.
Figure 3
Figure 3. Intraoperative and imaging findings for patient #4. (a) Preoperative computed tomography angiography (CTA) with all 3 trunks occluded. Riolan’s arcade is filled by the left internal iliac artery; (b) Polyester aortobiiliac graft for correction of an abdominal aortic aneurysm with a reinforced PTFE graft from the right graft limb to the median colic artery at Riolan’s arcade; (c) Postoperative CTA showing the patent graft (highlighted in orange) and the polyester aortobiiliac graft (highlighted in purple).
Figure 4
Figure 4. Proposed algorithm for chronic mesenteric ischemia (CMI) management. CTA = computed tomography angiography; DUS = duplex ultrasound; ER = endovascular repair; OR = open repair.
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References

    1. Chandra A, Quinones-Baldrich WJ. Chronic mesenteric ischemia: how to select patients for invasive treatment. Semin Vasc Surg. 2010;23(1):21–28. doi: 10.1053/j.semvascsurg.2009.12.003. - DOI - PubMed
    1. Menezes FH. In: Protocolos e condutas em terapia intensiva. Dragosavac D, Araújo S, editors. São Paulo: Atheneu; 2014. Angina abdominal e trombose mesentérica. pp. 571–579.
    1. Erben Y, Jean RA, Protack CD, et al. Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia. J Vasc Surg. 2018;67(6):1805–1812. doi: 10.1016/j.jvs.2017.10.071. - DOI - PubMed
    1. Gibbons CP, Roberts DE. Endovascular treatment of chronic arterial mesenteric ischemia: a changing perspective? Semin Vasc Surg. 2010;23(1):47–53. doi: 10.1053/j.semvascsurg.2009.12.006. - DOI - PubMed
    1. Kruger AJ, Walker PJ, Foster WJ, Jenkins JS, Boyne NS, Jenkins J. Open surgery for atherosclerotic chronic mesenteric ischemia. J Vasc Surg. 2007;46(5):941–945. doi: 10.1016/j.jvs.2007.06.036. - DOI - PubMed

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