Acute revascularization syndrome following successful treatment of chronic mesenteric ischemia.

Abstract

Chronic mesenteric ischemia (CMI) is a rare condition, usually caused by stenosis or occlusion of two visceral arteries. As its early symptoms are unspecific, this condition can be diagnosed late or misdiagnosed. Duplex ultrasound or CT angiography or MR angiography is available to reach the diagnosis. Open surgical or endovascular revascularization are two valid options in CMI, even if there is not an evidence-based technique recommended for its intervention. Morbidity and 30-day mortality differ based on the option chosen. We discuss a case of 59-year-old woman referred for chronic post prandial abdominal pain and weight loss. A computed tomography angiogram (CTA) of the chest, abdomen and pelvis with multiplanar and centerline reconstructions of the mesenteric vessels revealed a multivessel splanchnic mesenteric occlusive disease. We treated her with hybrid revascularization: a retrograde iliac-SMA bypass was performed using a 6-mm diameter PTFE graft end-to-side with SMA and a 5x12mm balloon-expandable stent was inserted into the main trunk of the IMA, via retrograde IMA access. After the second post-operative day, the patient developed several complications: chest pain associated with dyspnea, abdominal pain with diarrhea and melena, oliguria, sinus tachycardia and laboratory tests’s alterations (anemia, neutrophilic leucocytosis, thrombocytopenia, hyperbilirubinemia, increase in transaminases, troponin I and serum creatinine). A CT scan showed a normal perfusion of the aortic-SMA by-pass and a normal perfusion of the IMA stenting. Blood smear examination revealed presence of schistocytes. The etiopathogenesis was probably a thrombotic microangiopathy due to revascularization of both SMA and IMA. The patient was successfully treated with high volume fresh plasma infusion and red blood cells units. For those patients an early diagnosis should be considered, together with an aggressive treatment in the case of occurrence of a systemic inflammatory response syndrome. We therefore suggest to treat these patients only in centers which have the availability of multidisciplinary monitoring and adequate treatment options. No cases of revascularization syndrome after treatment for CMI are reported in literature.