Inferior Mesenteric Artery Revascularization for Salvage of Mesenteric Ischemia

Abstract

Often sacrificed in favor of the celiac and superior mesenteric arteries, the inferior mesenteric artery (IMA) can provide crucial inflow to the abdominopelvic viscera and spinal cord, especially in the presence of concomitant celiac or superior mesenteric artery (SMA) disease. We sought to elucidate the presentation and course of patients who had undergone IMA-specific revascularization. A retrospective analysis was performed of IMA revascularization procedures performed at an urban quaternary center from 2010 to 2020. Patients were included if concomitant renal artery, celiac artery, or SMA revascularization had been performed. Angioplasty, stenting, and open procedures were included. The patient characteristics, indications, and perioperative and long-term outcomes were analyzed. From 2010 to 2020, 10 patients had met the inclusion and exclusion criteria. Of the 10 patients, 9 were women (90%). Their median age was 71 years (range 47-88), and 80% had a history of smoking. Six patients had undergone elective IMA revascularization for chronic disease. Of the remaining four patients with acute symptoms, two had presented with an acute-on-chronic exacerbation of symptoms. All four patients with acute symptoms had presented as hospital transfers and had undergone intervention within 12 hours of transfer. However, two patients had had symptoms lasting >8 days before transfer. The 10 patients had undergone 16 procedures. Of the 10 patients, 8 had undergone IMA stenting, 1 had undergone percutaneous transluminal angioplasty alone, and 1 had undergone open IMA and aortic endarterectomy with patch angioplasty. Four patients had received concomitant celiac artery or SMA revascularization, with a large meandering mesenteric artery determining the choice to revascularize the IMA. In the six patients without celiac artery or SMA revascularization, three patients had had known SMA and celiac artery occlusions, and one had had a known occluded celiomesenteric trunk. In the four patients with acute symptoms, three small bowel resections and two laparotomies without bowel resection were performed. Six patients had required intensive care unit admission. Seven patients had had >1 year patency or had been lost to follow-up without known failure of IMA revascularization. Two patients died within 30 days with patent IMAs after withdrawal of care because of necrotic small bowel requiring resection. Two patients had undergone aortovisceral bypass after IMA occlusion—one patient on the day after IMA stenting and one patient at 17 months after IMA stenting. Revascularization of the IMA can serve as a reliable salvage option for patients with chronic or acute-on-chronic mesenteric ischemia, and should be considered for patients with high-grade stenosis or occlusion of the celiac artery and SMA.