Chronic mesenteric ischemia: Treatment of recurrent disease

Abstract

A 42-year-old man with history of transaortic endarterectomies of the celiac and superior mesenteric arteries for chronic mesenteric ischemia (CMI) and a descending thoracic aorta-to-left external iliac artery bypass for Leriche-type symptoms, presented to our clinic after emergency laparotomy for gangrenous small bowel 5 years after the primary operation. He reported postprandial abdominal pain and recurrent weight loss. Angiography showed recurrent occlusion of the celiac, superior, and inferior mesentericarteries.Thepatentaorto-leftexternaliliacgraft(A)suppliedmostofhis mesenteric blood flow through the left hypogastric artery (B). Because the native aorta was diseased, the aorto-left external iliac bypass was used as an inflow source for a bypass to the patent distal superior and inferior mesenteric arteries using a bifurcated polytetrafluoroethylene graft (Cover). The limb to the superior mesenteric artery was configured in a gentle, retrograde loop configuration (C, large arrow). The limb to the inferior mesenteric artery was short, straight, and antegrade (C, small arrow). A palpable pulse was appreciated distally in both the superior and inferior mesenteric arteries after the anastomoses were complete. Before discharge he complained of mild abdominal pain after eating. Angiography confirmed patency of the prosthetic bypass (C). The abdominal pain resolved without further treatment. At 2-year follow-up, he was asymptomatic, had gained 15 pounds, and had quit smoking. Recurrent CMI is a rare condition occurring in approximately 17% of patients. 1 Recurrence is more common in younger patients and those who present at follow-up with significant weight loss. Mean number of vessels revascularized is usually significantly less in those patients who have recurrent chronic ischemia. Postoperative mortality is high in patients with recurrent acute visceral ischemia (85% vs 7% in CMI). Patients with recurrent CMI present a treatment dilemma. Reoperation with the same technique may not provide long-term relief and may be technically challenging. Choosing a secondary procedure complementary to the original surgery (visceral bypass after transaortic endarterectomy, or vice versa) affords patients the best chance for long-term relief of symptoms. 1