Occlusion Of Visceral Arteries Research Articles

The rheolytic thrombectomy AngioJet™ is a safe and technically feasible method for treating acute and sub-acute occluding lesions in the visceral arteries.

The aim of this study is to evaluate the safety and feasibility of the AngioJet™ device in the endovascular treatment of visceral ischemia with stenotic or occlusive lesions. Retrospective analysis of patients treated for visceral artery occlusion with thrombectomy using the AngioJet™ (Boston Scientific, MA, USA). Inclusion criteria: patients with stenotic or occluding lesion in visceral arteries including renal and mesenteric arteries, who received endovascular treatment with AngioJet™. Eighteen patients with acute and sub-acute visceral arteries occlusions underwent endovascular thrombectomy. In twelve cases the procedure was successful, and the patients were discharged with patent target arteries. Four cases required re-intervention and two cases ended with a fatal complication. The technical and clinical success rate in our study was 88,9% (sixteen out of eighteen), these patients were discharged from hospital with patent target arteries. The thrombectomy using the AngioJet™ device is an effective and feasible method for the treatment of stenotic or occluding lesions of the visceral arteries with rapid post-interventional clinical improvement and minimal adverse events.

STABILISE for acute type B aortic dissection.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) is an extended downstream endovascular management technique for acute type B aortic dissection (TBAD), that aimed to achieve complete aortic remodeling. This systematic review aimed to assess the early and mid-term clinical outcomes with STABILISE in the management of TBAD. A literature search was performed on the Medline, Web of Science, Scopus, and SciELO databases, which returned 195 studies. Five studies were included. Data were extracted using predefined forms. In total, one hundred patients with acute or subacute TBAD managed with STABILISE were included. All studies reported a technical success of 100%. Thirty-day mortality was estimated at 4% (4/100) with no further deaths documented during an estimated mean follow-up of 12.7 months (range 12-15 months). Five percent developed spinal cord ischemia and another 5% developed visceral artery occlusions. One case of aortic rupture during time of balloon inflation was reported. Rare complications included delayed retrograde dissection (1%), aortobronchial fistula (1%), and renal failure (1%). One case of disconnection between stent-graft and bare stent was documented. Six percent of patients developed endoleak, predominately type I. Overall re-intervention rate was 21%, as reported in all studies. Complete obliteration of the false lumen in the thoracic aorta was achieved in 99% of patients and in the abdominal aorta in 96% of patients. STABILISE technique carries promising early and mid-term outcomes with high technical success and low mortality and morbidity. Excellent results on complete false lumen obliteration were observed. However, the heterogeneity among available studies' methodology does not permit firm conclusions, and further prospective analyses are needed to study the long-term outcomes of STABILISE.

Reimplantation of a Stenotic Inferior Mesenteric Artery for Chronic Visceral Artery Occlusion after Failed Bypass to the Superior Mesenteric Artery.

The patient was a 71-year-old man complaining of postprandial abdominal pain and weight loss. Computed tomography angiography showed occlusion of the superior mesenteric artery and the celiac axis. The inferior mesenteric artery, supplying the mesenteric circulation, was stenotic at its origin. The patient had portal vein thrombosis and was diagnosed as having antiphospholipid antibody syndrome. The reimplantation of the inferior mesenteric artery was successfully performed after failed bypass grafting to the superior mesenteric artery from the abdominal aorta.

Risk of Mesenteric Ischemia Following Branched Endovascular Repair for Thoracoabdominal Aortic Aneurysm

Introduction - Branched endovascular aortic repair (BEVAR) has become an accepted option for treatment of thoracoabdominal aortic aneurysms (TAAA). Staged procedures with temporary aneurysm sac perfusion (TASP) were shown to reduce the risk of spinal cord ischemia in patients with extended aortic aneurysmal disease. However, only few data about the risk of perioperative mesenteric ischemia are available. Methods - Patients with TAAA were treated with branched EVAR between 09/2007 and 06/2016 using a single step or open branch staged procedure with temporary aneurysm sac perfusion. TASP side branches were completed after 1-12 months. Postoperative mesenteric ischemia was defined as laparotomy for suspected or proven intestinal malperfusion. Mesenteric ischema with intestinal resection, patency of visceral branches to the celiac trunk (CTR), the superior (SMA) and inferior mesenteric artery (IMA), rate of reintervention and perioperative mortality was analyzed. Results - 118 patients were treated with BEVAR, 46 without an aneurysm sac perfusion (single-step) and 72 with open branch and TASP. Laparotomy for suspected mesenteric ischemia was performed in 9 patients and 8 (6.7 %) patients had small bowel or colon resections 1-120 days (mean: 3.1 days) after the endovascular intervention. Cause of acute mesenteric ischemia was multiple embolic disease (n=1), multiorgan failure with secondary intestinal malperfusion (n=3), SMA malperfusion (n=1) and left colonic ischemia related to IMA occlusion (n=3). Mesenteric ischemia with intestinal resection was more frequently observed in the single step group (15.2 %) in comparison to the open branch TASP group (1.4 %, p=0.005). Other risk factors for mesenteric ischemia were age >80 years (0.021), perioperative hypotension (p=0.041), reoperation for bleeding (p=0.001), embolic events (p=0.036) and > 2 visceral arteries with occlusive disease (p = 0.001). Overall perioperative mortality caused by primary mesenteric ischemia related to visceral artery occlusion was 2.5 %, although mortality in patients with laparotomy, intestinal resections and other comorbidities was 7/8 (87.9 %). Conclusion - Mesenteric ischemia following branched EVAR is a relevant complication with high perioperative mortality requiring early diagnosis, regular follow-up and immediate reinterventions. Staged procedures with open branch/temporary aneurysm sac perfusion seem to reduce the risk of mesenteric ischemia.

Short- and Midterm Outcomes of Open Repair and Fenestrated Endografting of Pararenal Aortic Aneurysms in a Concurrent Propensity-Adjusted Comparison

Purpose: To compare outcomes of patients treated for pararenal aortic aneurysms using fenestrated endovascular aneurysm repair (fEVAR) vs open surgical repair (OSR) in 3 high-volume centers. Materials and Methods: A multicenter retrospective analysis was conducted of 200 pararenal abdominal aortic aneurysm patients electively treated with OSR (n=108) or fEVAR (n=92) from 1998 to 2015 at 3 tertiary institutions. Endpoints were 30-day morbidity and mortality, late reinterventions, visceral artery occlusion, and mortality. Analysis was conducted on the entire population and on a propensity score–matched population constructed on age, gender, coronary artery disease (CAD), and chronic renal failure. Results: In the total cohort, fEVAR patients were significantly (p<0.001) older and had higher frequencies of CAD (p<0.001) and previous stroke (p=0.003). OSR patients had higher risk of perioperative morbidity (OR 2.5, 95% CI 1.09 to 5.71, p=0.033), specifically respiratory failure (OR 4.06, 95% CI 1.12 to 4.72, p=0.034). These findings were confirmed in the propensity-adjusted analysis, where cardiac complications were also higher after OSR (OR 12.8, 95% CI 0.07 to 0.21, p=0.02). No difference in perioperative mortality (2.2% in fEVAR vs 1.9% in OSR) was identified. Mean follow-up was 50 months (range 0–119). Four-year results showed higher survival (91.2% vs 69.3%, p=0.02) and freedom from reintervention (95.6% vs 77.8%, p=0.01) after OSR in the unmatched population, with a small but significant (p=0.021) difference in the risk of late visceral artery occlusion/stenosis after fEVAR. On propensity analysis, no differences in late survival were found between groups. Conclusion: fEVAR and OSR may afford similar early and midterm survival rates. Higher risks of perioperative systemic complications after OSR are counterbalanced by higher risks of late visceral vessel patency issues and need for reintervention after fEVAR. Both procedures are safe and effective in the long term in experienced centers, where patient evaluation should drive the treatment strategy.

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Editor's Choice – Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair

The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Right-Side Colon Ischemia: Clinical Features, Large Visceral Artery Occlusion, and Long-Term Follow-Up

Large visceral artery occlusion (LVAO) could underlie right-side colon ischemia (RSCI) but is little known. To assess patients with RSCI through long-term follow-up, including features and management of LVAO. Mesenteric ischemia and mortality. Retrospective observational study in an integrated health care system. Of 49 patients (30 women [61.2%]; mean [standard deviation] age, 69.4 [11.9] years), 19 (38.8%) underwent surgery—that is, 5 (83.3%) of 6 who developed RSCI in hospital following surgical procedures and 14 (32.6%) of 43 who had RSCI before hospitalization (p value = 0.03); overall, 5 (10.2%) died. Among 44 survivors with a median (range) follow-up of 5.19 (0.03-14.26) years, 5 (11.4%), including 3 (20.0%) of 15 operated cases, had symptomatic LVAO and underwent angioplasty and stent placement: 2 for abdominal angina that preceded RSCI, 1 for acute mesenteric ischemia 1 week after resection of RSCI, 1 for RSCI 6 weeks after resection of left-side ischemia, and 1 for abdominal angina that began 3 years after spontaneous recovery from RSCI. None had further mesenteric ischemia until death from nonintestinal disease or the end of follow-up (1.6 to 10.2 years later). Kaplan-Meier survival estimates for all 44 survivors at 1, 3, 5, and 10 years were 88.6%, 72.3%, 57.6%, and 25.9%, respectively. Thirty-one patients (70.4%) died during follow-up, 19 (61.3%) of a known cause; the 39 patients not treated for LVAO lacked mesenteric ischemia. Patients with RSCI may have symptomatic LVAO; therefore, we advise they undergo careful query for symptoms of abdominal angina and routine visceral artery imaging.

Novel Thrombectomy System for Below-the-Knee and Visceral Arterial Interventions: PRISM Retrospective Interim Results

Purpose Existing endovascular options in the treatment of peripheral and visceral arterial thromboembolism face the challenges of incomplete revascularization and significant bleeding risk (among other complications). The Penumbra/Indigo Systems (Alameda, California) are designed to address these challenges by providing a novel approach to mechanical thrombo-embolectomy in the periphery using a trackable, relatively small diameter aspiration system that has a proven track record in the treatment of ischemic stroke. The PRISM trial is the first multicenter study designed to obtain initial safety and effectiveness data as well as to define optimal technique for the use of these systems in patients with confirmed peripheral or visceral artery occlusions. This abstract outlines the current status of the trial and discusses its preliminary findings. Material and Methods To date, 38 patients have been enrolled in this retrospective, single-arm, multicenter trial (total planned enrollment = 100). Mechanical thrombo-embolectomy using the Penumbra/Indigo Systems was performed in cases of failed thrombolysis, acute ischemia without adequate time for thrombolysis, or in patients with emboli as a complication of an endovascular intervention. The primary site of occlusion was located in the popliteal (17/38 patients, 44.7%), peroneal (5/38, 13.2%), superficial femoral (4/38, 10.5%), posterior tibial (4/38, 10.5%), profunda femoris (2/38, 5.3%), superior mesenteric (2/38, 5.3%), anterior tibial (2/38, 5.3%), renal (1/38, 2.6%), or brachial (1/38, 2.6%) arteries. Baseline characteristics were obtained and an angiographic assessment of vessel patency was recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications both before and after use of the device in order to assess technical effectiveness. A review of procedural complications and adverse events was conducted to monitor safety. Results Mean patient age was 71.6 (standard deviation [SD] 14.8) years and 44.4% (16/38) were female. Procedural information presented in the following analyses was available for 24 patients and final revascularization data was available for 22 patients at the time of this abstract (data collection ongoing). A baseline angiographic TIMI score of 0 or 1 was reported for all 24 patients. Prior to intervention with the Penumbra/Indigo Systems, 41.7% of patients had no prior treatment, 45.8% received thrombolytic therapy alone, 4.2% received mechanical intervention alone, and 8.3% received both. The mean time from symptom onset to procedure was 5.3 days (SD 7.4). Following mechanical thrombo-embolectomy, 86.4% of patients were successfully revascularized to TIMI 3 and 13.6% to TIMI 2 flow. Four adverse events were reported, 1 of which was classified as serious (cardiac arrest, not related to use of the study device). Three cases were noted in which distal branch occlusion occurred secondary to emboli during the procedure. None of these 3 events were clinically significant. Conclusions Early experience with the Penumbra/Indigo Systems shows promising results with safe and effective mechanical thrombo-embolectomy in the peripheral arterial vasculature. Its successful use across a broad range of clinical applications including acute ischemia, removal of emboli that occurred during other endovascular procedures, and after failed thrombolysis is encouraging. Optimal technique will be discussed.

Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography

The purpose of this study was to explore the accuracy of multi-detector row helical CT (MDCT), using a biphasic mesenteric angiography protocol for evaluation of acute mesenteric ischemia (AMI). In total, 79 consecutive patients with clinical signs of AMI underwent contrast enhanced 16- or 40-channel MDCT. MDCT findings were correlated with surgery, endoscopy and clinical outcome. Sensitivity, specificity, and positive and negative predictive values were calculated using the patients in which AMI had been excluded as a control group. In 28 patients the final diagnosis was AMI. In 27 patients (96.4%) MDCT correctly diagnosed AMI (specificity of 97.9%). A sensitivity of 93%, specificity of 100%, and positive and negative predictive values of 100% and 94%, respectively were achieved for the CT findings of visceral artery occlusion, intestinal pneumatosis, portomesenteric venous gas or bowel wall thickening in combination with either portomesenteric thrombosis or solid organ infarction. Our findings suggest that mesenteric MDCT angiography is an accurate tool for fast diagnostic work-up of patients with suspected AMI.

Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia

Percutaneous angioplasty and stenting (PTAS) is emerging as a therapeutic option for patients with chronic mesenteric ischemia. This study evaluated patency and mortality, and their relationship between degree of vessel occlusion (stenotic or totally occluded), stent characteristics, and comorbidities in patients who were treated with PTAS of the visceral vessels for chronic mesenteric ischemia. A retrospective review was performed of the records of all patients who underwent PTAS of the celiac, superior mesenteric, or inferior mesenteric arteries, or both, for symptomatic chronic mesenteric ischemia between January 2001 and December 2005. Patient demographics, lesion characteristics (stenosis or occlusion), interventional details, and early and late mortality rates were recorded. Cumulative mortality and patency rates and factors associated with outcomes were determined using Kaplan-Meier method and Cox proportional hazards modeling. Eighty-seven mesenteric vessels (57 superior mesenteric, 23 celiac, and 7 inferior mesenteric arteries) were treated in 65 patients (29 men and 36 women). Completely occluded vessels were treated in 18 patients (28%), and >60% stenosis was treated in 47 patients (72%). Mesenteric angina was the most common symptom (97%). For the entire series, the cumulative 1-year results were primary patency, 65% (95% confidence interval [CI], 50%-80%); primary assisted patency, 97% (95% CI, 92%-100%); secondary patency, 99% (95% CI, 96%-100%); and survival, 89% (95% CI, 80%-98%). All deaths occurred <or=60 days after treatment. The endovascular treatment of visceral artery occlusion was not associated with diminished patency or survival, irrespective of stent size or number. Patients requiring bowel resection were less likely to survive than those who did not (odds ratio [OR], 26; 95% CI, 3.5-192; P < .001). One-year primary patency was worse among patients with chronic obstructive pulmonary disease (OR, 3.2; 95% CI, 1.4-7.7; P = .009) or who had femoral access (OR, 3.0; 95% CI, 1.1-7.9; P = .015). For patients with chronic mesenteric ischemia, the results of endovascular treatment of occluded mesenteric arteries are indistinguishable from those treated for stenotic vessels. Patients requiring bowel resection are less likely to survive, and those with chronic obstructive pulmonary disease or who had femoral access have higher reintervention rates.

Endovascular Repair of a Type III Thoracoabdominal Aortic Aneurysm in a Patient with Occlusion of Visceral Arteries

The successful endovascular repair of a type III thoracoabdominal aortic aneurysm (TAAA) with the use of a tube endograft is reported. A 56-year-old male with a 6.4-cm type III TAAA, a 4.2-cm infrarenal abdominal aortic aneurysm, and chronic renal insufficiency presented with flank pain, nausea, acute anuria, and serum creatinine of 6.1 mg/dl. Acute occlusion of the left solitary renal artery was diagnosed and emergent recanalization with percutaneous transluminal angioplasty and stenting was performed successfully, with reversal of the serum creatinine level at 1.6 mg/dl. Further imaging studies for TAAA management revealed ostial occlusion of both the celiac artery (CA) and the superior mesenteric artery (SMA) but a hypertrophic inferior mesenteric artery (IMA) providing retrograde flow to the aforementioned vessels. This rare anatomic serendipity allowed us to repair the TAAA simply by using a two-component tube endograft without fenestrations (Zenith; William Cook, Bjaeverskov, Denmark) that covered the entire length of the aneurysm, including the CA and SMA origins, since a natural arterial bypass from the IMA to the CA and SMA already existed, affording protection from gastrointestinal ischemic complications. The patient had a fast and uneventful recovery and is currently doing well 6 months after the procedure. To our knowledge, this is the first report in the English literature of successful endovascular repair of a TAAA involving visceral arteries with the simple use of a tube endograft.

Visceral and Renal Artery Complications of Suprarenal Fixation during Endovascular Aneurysm Repair

The effect of suprarenal fixation of endovascular grafts on renal and visceral artery function remains undefined. This study aimed to determine renal and visceral artery complications following suprarenal fixation during endovascular aneurysm repair (EVR). Prospectively collected data from 112 patients who received suprarenal fixation (group SF) and 36 patients who received infrarenal fixation (group IF) in a single institution from December 1997 to April 2005 were reviewed retrospectively. Median follow-up was 26 months (range 0.1-101 months). Stent struts extended to or above the level of 106 (94.6%) right renal arteries, 104 (92.9%) left renal arteries, 49 (43.8%) superior mesenteric arteries (SMA), and 7 (6.3%) celiac arteries in group SF. This group had 2 (1.8%) unintentional main renal artery occlusions, of which 1 was successfully treated at the first procedure with a renal stent. There was 1 (0.9%) SMA occlusion which resulted in bowel infarction and death. Group IF had no renal or visceral artery complications. There were no late-onset occlusions or infarcts. There was no significant difference in median serum creatinine between groups SF and IF at 1 month (p = 0.18) and 6 months to 12 months (p = 0.22) follow-up. The change in serum creatinine over time was also not significantly different within each group (SF, p = 0.09; IF, p = 0.38). In this study, suprarenal fixation was associated with a very small incidence of immediate renal and visceral artery occlusion. There did not appear to be any medium-term sequelae of suprarenal fixation.

A New Porcine Sponge Material for Temporary Embolization: An Experimental Short-Term Pilot Study in Swine

To evaluate the safety and efficacy of a porcine-derived gelfoam, Curaspon, for the temporary occlusion of the visceral arteries. Curaspon was used for the selective embolization of segmentary hepatic, unilateral polar renal, and single lumbar arteries of 10 pigs under general anesthesia. Sequential angiographic checks were carried out and the pigs killed between 3 days and 2 weeks later. Macroscopic and microscopic studies using standard techniques were used to evaluate the immediate efficacy of embolization, duration of and completeness of recanalization on angiography, macroscopic appearance of target-organ ischemia, and microscopic analysis of inflammatory reaction. Immediate arterial occlusion was obtained in all cases. Renal arteries showed a total recanalization in 63% of cases on day 7 and 100% on day 14. Total hepatic recanalization was obtained in 100% of animals on day 7. All lumbar arteries were recanalized on day 14. Microscopic analysis in the kidney revealed a mild inflammatory reaction and a progressive lysis of the Curaspon (87% of samples at day 3 showed a persistence of Curaspon and 5% at day 14). In some cases, localized and partial destruction of the arterial wall was visualized. In the liver the same patterns were observed but resolved more completely and more rapidly. Curaspon is an efficient material for the temporary occlusion of visceral and parietal arteries in pigs. However, arterial aneurysms were observed and a relationship of these with the material cannot be excluded.

Chronic mesenteric ischemia: imaging and percutaneous treatment.

Chronic mesenteric ischemia (CMI) is rare and is often diagnosed late. Fatal malabsorption-related complications or acute ischemic events occur in the absence of treatment. Diagnosis depends on careful acquisition of a medical history and elimination of other conditions. No sensitive and specific tests are available for functional diagnosis of CMI. If other causes of abdominal pain and weight loss have been confidently ruled out, evidence of visceral artery occlusion at noninvasive imaging (Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) suggests CMI. Until the 1990s, open surgery was considered the treatment of choice; percutaneous transluminal angioplasty (PTA) was reserved for patients for whom surgery carried a high risk. However, open surgery carries a nonnegligible risk of morbidity and mortality. In recent years, PTA with stent placement has been recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate and consequently has been suggested for primary treatment of CMI. New treatments including administration of fibrinolytic agents before PTA of chronic occlusions, routine revascularization of one or more arteries, and stent placement will probably be validated in the near future. Similarly, new data on selection of the best approach will become available soon.

Stent Placement for Treatment of Mesenteric Artery Stenoses or Occlusions

To evaluate stent placement in the treatment of mesenteric ischemia. Twelve patients (eight women, four men; mean age, 63 years) with chronic mesenteric ischemia underwent stent placement for stenoses or occlusions during a 5.5-year period. Nine patients with 10 stenoses (three celiac arteries, seven superior mesenteric arteries) and three patients with three chronic occlusions (two superior mesenteric arteries, one aortosuperior mesenteric artery bypass graft) were treated. Initial technical success was achieved in 11 of the 12 patients (92%), including all three patients with chronic occlusions. There were no technical complications. There was one postprocedural death (<30 days) due to bowel ischemia and infarction, despite a technically successful procedure. Clinical follow-up was available in all 12 patients, with a mean follow-up of 15.7 months (range, 0-38.5 months). Primary and primary-assisted patency up to 18 months was 74% (standard error [SE], 13%) and 83% (SE, 11%), respectively. Secondary patency was 83% (SE, 11%) at 3 years. All three patients (100%) with chronic occlusions had relief of clinical signs and symptoms at a mean follow-up of 22 months (range, 13-38.5 months). Stent placement is safe and clinically effective as an adjunctive therapy to angioplasty or as a primary method of treatment for chronic mesenteric ischemia in patients with focal visceral artery stenoses or occlusions.

Mesenteric Bypass for Chronic Mesenteric Ischaemia

Chronic mesenteric ischaemia is an uncommon disease that requires treatment to relieve the symptoms of abdominal angina and to prevent intestinal infarction. Over a period of 3 years. 12 patients with visceral artery stenosis or occlusion were referred to the authors' service and 10 underwent mesenteric bypass grafting. Both the coeliac and the superior mesenteric arteries were revascularized in four patients, and the superior mesenteric artery alone in six patients, using a variety of grafts and graft configurations. This was done in conjunction with aortic graft placement in four cases and with renal bypass in three. All patients survived the procedure. At a mean follow-up of 28 months, one patient died of myocardial infarction 42 months after surgery, while all survivors are symptom-free. Chronic mesenteric ischaemia can be treated safely and effectively. The variation in the pattern of mesenteric occlusions and the frequent association with aortic and renovascular disease does not allow for a single ‘best’ technical solution but requires the surgical procedure to be individually tailored.

Mesenteric bypass for chronic mesenteric ischaemia

Chronic mesenteric ischaemia is an uncommon disease that requires treatment to relieve the symptoms of abdominal angina and to prevent intestinal infarction. Over a period of 3 years, 12 patients with visceral artery stenosis or occlusion were referred to the authors' service and 10 underwent mesenteric bypass grafting. Both the coeliac and the superior mesenteric arteries were revascularized in four patients, and the superior mesenteric artery alone in six patients, using a variety of grafts and graft configurations. This was done in conjunction with aortic graft placement in four cases and with renal bypass in three. All patients survived the procedure. At a mean follow-up of 28 months, one patient died of myocardial infarction 42 months after surgery, while all survivors are symptom-free. Chronic mesenteric ischaemia can be treated safely and effectively. The variation in the pattern of mesenteric occlusions and the frequent association with aortic and renovascular disease does not allow for a single `best' technical solution but requires the surgical procedure to be individually tailored.

Celiac territory ischemic syndrome in visceral artery occlusion

Abdominal angina that is characterized by postprandial pain, and often associated with weight loss, is a well-recognized symptom complex of mesenteric artery insufficiency (mesenteric territory symptoms). In the past 5 years, we have observed six patients with atypical symptoms who had mesenteric artery occlusion combined with stenosis or occlusion of the celiac artery. Atypical symptoms included severe nausea and vomiting at the sight or smell of food, anorexia, weight loss, and right upper quadrant or epigastric discomfort (celiac territory symptoms). An extensive work-up to rule out gastric, pancreatic, biliary, or colonic pathology was undertaken in these patients. The findings included gallbladder dysfunction, diffuse micro-ulceration of gastric mucosa, and colonic mucosal ulceration. The diagnosis of visceral artery occlusion was initially missed in all six patients. Four patients had cholecystectomy. Visceral angiography confirmed occlusion of the celiac, superior, and inferior mesenteric arteries. Five patients had dramatic resolution of symptoms after restoration of visceral circulation. One patient who developed intestinal infarction before revascularization died. Symptoms suggesting upper abdominal visceral pathology may be a manifestation of celiac artery stenosis/occlusion coexisting with mesenteric artery occlusive disease. Visceral angiography should be part of the work-up in these patients for early diagnosis and prompt management.