Mesenteric arterial bypass grafts: early and late results and suggested surgical approach for chronic and acute mesenteric ischemia.

Abstract

The purposes of this study were to determine the early and late results of placement of arterial bypass grafts in the treatment of chronic and acute intestinal ischemia and to ascertain whether multiple grafts provide better late results than a single graft. Records of 34 patients who underwent mesenteric vascular graft placement were retrospectively reviewed. All 21 patients with chronic ischemia had a history of intestinal angina and weight loss. Food fear was reported by 33% of patients; also, diarrhea in 57%, constipation in 29%, acalculous cholecystitis in 19%, ischemic gastritis or peptic ulcer in 19%, and elevation of liver enzymes in 22% were reported. Angiogram showed more than 50% stenosis or occlusion of the superior mesenteric artery (SMA) in 100% of patients, celiac artery in 90%, and inferior mesenteric artery in 90%. Although not described previously, a reduction in collateral flow from the internal iliac arteries was caused by severe pelvic disease in 56% of patients. There were no in-hospital deaths. The rate of survival at 1 year was 100%; at 2 years it was 93% +/- 6%, at 3 years 86% +/- 9%, at 5 years 79% +/- 11%, and at 10 years 50% +/- 15%. During follow-up, graft thrombosis occurred in three patients. Of the patients who underwent only a single SMA or celiac bypass, two of five died of bowel infarction; only one of 16 patients who underwent both celiac and SMA bypass had to undergo a repeat surgical procedure because of graft occlusion. Three of 16 retrograde bypasses thrombosed, compared with zero of five prograde bypasses. In nine patients who underwent placement of mesenteric bypass grafts because of acute ischemia caused by acute mesenteric thrombosis, the early mortality rate was 22%; the two deaths were the result of bowel ischemia. The cumulative survival rate was 78% +/- 14% at 1 month, 65% +/- 17% at 1 year, and 52% +/- 16% at 5 years. One of the two late deaths was due to graft thrombosis and bowel infarction. Three of four patients who underwent concomitant mesenteric bypass at the time of aneurysm repair or aortobifemoral bypass survived the surgical procedure. When chronic and acute mesenteric ischemia are diagnosed and treated with a bypass graft, the early and late results are good. Complete revascularization of the SMA and celiac artery or pelvis or both and prograde bypass may reduce the risk of late bowel ischemia.