Superior Mesenteric Artery Bypass Research Articles

Features of Surgical Treatment of Symptomatic Patients with Isolated Superior Mesenteric Artery Dissection (Clinical Cases and Literature Review)

Introduction. Isolated superior mesenteric artery dissection (ISMAD) is a rare disease with high variability of clinical manifestations: from incidental findings to the development of acute or chronic mesenteric ischemia and the formation of aneurysms with the probability of their rupture. Despite significant world experience, surgical and conservative treatment of patients with ISMAD remains debatable.
 The aim. Improvement of the diagnosis and surgical treatment of patients with ISMAD.
 Clinical cases.
 In the first clinical observation, a 78-year-old patient with chronic visceral ischemia was diagnosed with an aneurysm of the upper mesenteric artery with signs of dissection and malperfusion. Previous unsuccessful attempts of endovascular treatment at another hospital caused the need for open surgical intervention – resection of the aneurysm and upper mesenteric artery reconstruction.
 
 In the second clinical case, a 61-year-old patient had acute abdominal pain syndrome, and based on clinical examination, laboratory and instrumental examination, the diagnosis of acute mesenteric ischemia with signs of dissection of the superior mesenteric artery was confirmed, which determined immediate indications for surgical treatment – resection of the affected segment of superior mesenteric artery and aorta-superior mesenteric bypass.
 
 The surgical interventions contributed to complete regression of clinical symptoms. Follow-up of the patients showed promising long-term results.
 
 Conclusion. Computed tomography angiography is the method of choice in the diagnosis of ISMAD and makes it possible to provide prompt diagnosis, determine treatment tactics and prevent the development of fatal complications. Open surgical intervention in some cases remains the method of choice in the treatment of ISMAD.

Cadaver Simulation is Associated with Increased Comfort in Performing Open Vascular Surgery Among Integrated Vascular Surgery (0+5) Residents and Recent Graduates

With the evolution in vascular surgery toward increased endovascular therapy and decreased open surgical training, comfort with open procedures by current trainees is declining. A proposed method to improve this discomfort is simulator training. We hypothesized that open, cadaver, and endovascular surgery simulation would be associated with increased self-perceived comfort in performing corresponding procedures. Integrated (0+5) vascular surgery residents and recent graduates in the United States were asked to complete a survey quantifying comfort via a Likert scale with procedures and experience with simulation training. Simulation groups were then matched using coarsened exact matching. Ordinal logistic regression assessed the association between simulation experience and comfort in performing procedures. Surveys were completed by 68 trainees and 20 attending surgeons in their first 5years of practice. On unmatched analyses, there were no significant differences in comfort in performing any open or endovascular aorto-mesenteric or peripheral vascular procedures between respondents who reported experience with open or endovascular simulation, respectively. However, respondents who reported cadaver simulation experience (58%, 51/88) had a significantly higher reported comfort score performing open juxtarenal aortic repair (2.4 vs. 1.7), superior mesenteric artery thrombectomy or bypass (2.5 vs. 1.9), inferior vena cava or iliac vein repair (2.2 vs. 1.7), axillary-femoral artery bypass (3.4 vs. 2.5), femoral-popliteal artery bypass (3.7 vs. 2.8), and inframalleolar artery bypass (2.8 vs. 2.1; all P<0.05). After matching on training level, number of abdominal cases completed, and number of open vascular cases completed, ordinal logistic regression demonstrated that previous cadaver simulation was significantly associated with increased comfort in performing open aortic repairs, venous repair, visceral revascularization, and peripheral bypasses. In this nationally representative sample, cadaver, but not open or endovascular, simulation was associated with increased comfort in performing open vascular surgery. Providing cadaver simulation to trainees may help to improve comfort levels in performing open surgery. Integrated vascular surgery training programs should consider implementing these experiences into their curriculum.

New classification for juxta renal aortoiliac occlusion-based on imaging for safe clamping and contemporary surgical management results

Objectives: The objective is to decide the site of aortic clamping based on preoperative imaging and intraoperative findings and assess the outcomes on midterm follow-up in patients with juxtarenal aortoiliac occlusion (JRAIO) managed with aortic thromboendarterectomy and bypass grafting. Methods: Forty patients (39 males and one female) with JRAIO were managed with aortobifemoral bypass (ABFB). Two patients required concomitant superior mesenteric artery (SMA) bypass. The aortic clamping site was inter-renal, suprarenal, or supra-celiac, depending on the extent of thrombus relative to the renal artery and SMA ostia. We compared serum creatinine levels with renal ischemic time in the postoperative period. At the mean follow-up of 26.7 months, patients were assessed for graft patency, limb salvage, and survival rate. Results: The mean age of patients was 53.9 years, and 97.5% of patients were heavy smokers. Of the total patients, inter-renal clamping was done in 12.5%, suprarenal clamping in 70%, and supra-celiac clamping in 17.5%. Perioperative morbidity and mortality were 22.5% and 5%, respectively. Five patients with renal ischemic time ≥20 min developed acute kidney injury, showing a significant positive correlation (r = 0.465; P < 0.0001) with clamp time. Postoperative mean serum creatinine values also showed a significant difference (P = 0.0001) between <20 and ≥20 min groups. At follow-up, graft patency and limb salvage rates were 100%, and the survival rate was 97.4%. Conclusion: The risk of atheroembolic renal ischemia in ABFB for JRAIO can be lowered by good preoperative planning and safe intraoperative clamping technique, based on a simple classification for aortic clamping.

Impact of the collateral network on central-repair-first strategy in superior mesenteric artery occlusion with type A acute aortic dissection.

Surgery for acute type A aortic dissection with mesenteric malperfusion is challenging. Although the peripheral-reperfusion-first strategy has shown good results, more discussion regarding indicated patients is needed. This study aimed to describe the imaging features and surgical outcomes of mesenteric malperfusion and to clarify which cases should be considered for the peripheral-reperfusion-first strategy. A total of 200 patients underwent emergent aortic repair for acute type A aortic dissection at our institution between October 2011 and July 2019. Superior mesenteric artery occlusion on preoperative contrast-enhanced computed tomography was detected in 12 patients, who were categorized into two groups based on enhancement (n = 7) or non-enhancement (n = 5) of the superior mesenteric artery peripheral branches. Operative outcomes after central repair were compared between groups. Four patients in the enhanced group had no postoperative abdominal complications, and three patients required superior mesenteric artery bypass grafting with the central-repair-first strategy. However, all patients in the enhanced group survived and did not require intestinal resection. In contrast, four patients (80%) in the non-enhanced group had intestinal necrosis, three patients required intestinal resection, and one patient died from multiple organ failure. The presence or absence of an enhancement of the peripheral superior mesenteric artery by the collateral network could be helpful for decision-making. The central-repair-first strategy may be permitted in patients with enhanced peripheral branches. Conversely, in patients with non-enhanced peripheral branches, a more invasive assessment should be considered before central aortic repair, and peripheral-reperfusion-first strategy may be required.

Significance of Prior Endovascular Intervention on Contemporary Outcomes of Open Mesenteric Revascularization

Endovascular treatment has emerged as the primary modality of revascularization in patients with chronic mesenteric ischemia (CMI). The purpose of this study was to determine whether patients undergoing open mesenteric revascularization in the setting of failed prior endovascular intervention had worse outcomes compared to those without prior endovascular intervention. A single-center retrospective review of patients with CMI treated with open mesenteric bypass from 2000 to 2019 was conducted. Demographic, comorbidities, perioperative variables, and outcomes were collected. Patients were categorized into those with prior endovascular intervention and those without. Categorical factors were compared with Pearson χ2 tests or Fisher exact tests, and the life-table method for survival analysis was used to estimate event rates at predefined time frame. From 2000 to 2019, there were 236 patients who underwent open mesenteric bypasses, of which 92 were performed for CMI. Antegrade aortomesenteric bypasses constituted 95% (87/92) of cases. Total of 145 vessels were revascularized: celiac artery (33 vessels), hepatic artery (25 vessels), and superior mesenteric artery (87 vessels). Seventy-six percent (70/92) of patients had undergone a prior endovascular intervention, which subsequently failed. In 91% (84/92) of patients, one or more visceral vessel was chronically occluded on imaging prior to bypass procedure. Patients with prior endovascular intervention were older (64 ± 15 years vs 54 ± 11 years; P = .006). Demographics and comorbidities were otherwise similar between the groups. Primary patency for celiac artery bypass was 93% and 89% at 1 and 3 years, respectively. Primary patency for superior mesenteric artery bypass was 92% and 84% at 1 and 3 years, respectively. There was no statistically significant difference in primary bypass patency rates of those with or without prior endovascular intervention (P > .05). Patients with prior endovascular intervention had a higher all-cause mortality trend at 30 days, 1 year, and 3 years (5.8% vs 0%; 13.7% vs 5.4%; and 30% vs 5.4%; P = .1); however, this did not reach statistical significance. Open mesenteric bypass remains a durable revascularization procedure in patients with CMI. Failed endovascular intervention does not significantly impact open mesenteric revascularization outcomes; however, it likely signifies an overall higher atherosclerotic disease burden.

Physician-Modified Endograft With Double Inner Branches for Urgent Repair of Supraceliac Para-Anastomotic Pseudoaneurysm

Purpose: To demonstrate the feasibility of a physician-modified endograft (PMEG) with inner branches for 2 mesenteric arteries as an alternative to fenestrations or directional branches. Technique: A symptomatic 60-year-old man presented with supraceliac para-anastomotic pseudoaneurysm involving an antegrade aorta to celiac artery and superior mesenteric artery bypass. Since an off-the-shelf multibranched endograft was inappropriate, a Zenith Alpha thoracic stent-graft was modified with 2 inner branches fashioned of 8-mm Viabahn endoprostheses with preloaded guidewires. The procedure was technically successful, and the patient had no postoperative complications. Conclusion: Inner branches might offer an alternative to fenestrations or directional branches in patients with narrow aortas.

SS13. Bypass Configuration Outcomes for Acute Mesenteric Ischemia

Acute mesenteric ischemia is associated with extremely high morbidity and mortality rates. Open revascularization has been considered the “gold standard” treatment; however, there have been concerns about supraceliac clamping in potentially unstable patients as well as patency rates for iliac-based bypasses. The purpose of this study was to compare outcomes for antegrade and retrograde mesenteric bypass configurations in acute mesenteric ischemia. The registry of a single vascular group was queried for bypasses performed for acute mesenteric ischemia. Demographics, operative details, and perioperative and long-term outcomes were recorded and compared using χ2 analysis, Fisher exact test, t-test, and log-rank analysis. There were 53 patients identified who underwent open reconstruction for acute mesenteric ischemia from 2007 to 2017. There were 34 patients who underwent aorta to superior mesenteric artery/common hepatic bypass (antegrade) and 19 who underwent iliac to superior mesenteric artery bypass (retrograde) and were followed up for a mean of 15 months (range, 1-99 months). Demographics and comorbidities, such as hypertension, hypercholesterolemia, coronary disease, tobacco use, diabetes, and renal failure, were similar among the patients. The study included a sex split of 20 male and 23 female patients; 46 bypasses were performed with polytetrafluoroethylene, and 7 bypasses used excised vein as conduit. Operative blood loss was similar between groups (antegrade range, 100-2000 mL; retrograde range, 50-800 mL; P = .664). Perioperative complications were similar between groups and included pulmonary failure, sepsis, abdominal compartment syndrome, bowel ischemia, and myocardial infarction. Five (26.3%) retrograde patients had an attempt at supraceliac clamping; however, technical difficulties secondary to calcific disease led to use of the iliac artery as inflow. Bowel resection rates were similar between groups (antegrade, 20.58%; retrograde, 12.63%; P = 1.0). Perioperative mortality rates were similar (11.32% antegrade vs 9.47% retrograde; P = .378). The 1-year survival rates were similar for antegrade and retrograde (59% vs 42%; P = .247). All bypasses were patent in survivors at 1 year (P = 1.0). Acute mesenteric ischemia is associated with very high mortality rates, and open bypass remains the treatment standard. Bypasses using supraceliac aorta as inflow appear to offer perioperative mortality rates equivalent to those of their iliac-based counterparts. In terms of patency, iliac-based bypasses offered similar outcomes to aorta-based bypasses.

Neo-hepato-mesenteric Trunk for Chronic Mesenteric Ischaemia and Ischaemic Hepatic Dysfunction

A 48-year-old male diagnosed with classical chronic mesenteric ischaemia along with features of hepatic ischaemia as revealed by low prothrombin time index and contrast computerised tomography (CT) showing small tiny ischaemic fibrotic nodules in liver parenchyma. Computerised tomography angiogram of the abdomen showed occluded celiac artery, superior mesenteric artery and inferior mesenteric artery. Patient required early treatment and the need was to restore blood flow to common hepatic artery and superior mesenteric artery. Open surgical revascularisation was planned considering his young age, longer patency of open bypasses with lesser reintervention rate in follow-up. Patient was optimised by infusion of fresh frozen plasma and injection vitamin K before being taken for surgery. Antegrade supraceliac aorta to common hepatic and superior mesenteric artery bypass was done successfully. Patient developed ascites and elevation of transaminases postoperatively which settled gradually over a week after management with diuretics and albumin infusion. Patient is doing fine at follow-up of more than 16 months.

Results of retrograde open mesenteric stenting for acute thrombotic mesenteric ischemia

ObjectiveAcute mesenteric ischemia (AMI) is an emergent event with a high mortality rate; survivors have high rates of intestinal failure. Restoration of blood flow using endovascular or surgical revascularization is associated with better outcome in terms of survival rate and intestinal resection. Retrograde open mesenteric stenting (ROMS), which is a hybrid technique, combines two benefits: prompt blood flow restoration with an endovascular approach and inspection and resection of the small bowel. The aim of the study was to assess the results of ROMS in thrombotic AMI in a retrospective multicenter study. MethodsWe retrospectively enrolled all consecutive patients who underwent ROMS revascularization for occlusive thrombotic AMI in three participating tertiary care centers between November 2012 and March 2017. ResultsTwenty-five patients (14 men and 11 women; mean age, 64.9 ± 11.6 years) were included. In two patients, ROMS was not possible because of failure of re-entry in the aortic lumen (technical success, 92%). One patient required revascularization of two visceral arteries and underwent an aortohepatic bypass. Five patients (20%) underwent endarterectomy and patch angioplasty of the superior mesenteric artery before retrograde stenting. Thirteen patients (52%) required bowel or colon resection (11 patients required both resections) during the initial procedure with a mean length of small bowel resection of 52 ± 87 cm. The 30-day operative mortality rate was 25%, and the overall 1-year survival rate was 65%. The 1-year primary patency rate was 92%. In one patient, postoperative imaging at 1 month showed stent migration in the aortic bifurcation. ConclusionsROMS for thrombotic AMI has a high technical success rate and a high midterm primary patency rate. It could be an alternative procedure to retrograde superior mesenteric artery bypass for patients when percutaneous endovascular revascularization is not indicated or has failed.

The outcomes of prosthetic bypass grafting for chronic mesenteric ischemia.

This study aims to analyze early and late outcomes of the prosthetic bypass grafting procedure in the treatment of chronic mesenteric ischemia. Twenty-two patients (15 males, 7 females; mean age 60±10 years; range, 32 to 78 years) who underwent prosthetic bypass grafting for chronic mesenteric ischemia due to atherosclerosis between March 2009 and March 2017 were included in this study. The demographic and operative data were analyzed retrospectively. The most common risk factors for atherosclerosis were hypertension, diabetes, and hyperlipidemia. A total of 72% of the patients were active tobacco users. The common symptoms were postprandial angina and weight loss. Six patients (27%) had a history of endovascular intervention for mesenteric revascularization. Celiac artery bypass grafting was performed in 17 patients, while superior mesenteric artery bypass grafting was performed in 21 patients. Retrograde bypass was done in all patients and polytetrafluoroethylene grafts were used in 20 patients (90%). The mean hospital stay was 10.5 days and the mean follow-up was 44.7 months. The most common postoperative complications were respiratory failure (9%) and infection (9%). In-hospital mortality was observed in one patient (%4.5)who had acute myocardial infarction-related low cardiac output. One patient had graft thrombosis resulting in early graft infection a month after discharge. Late graft thrombosis was observed in two patients at 44 and 85 months, respectively. Late mortality was observed in two patients due to malignancy and cerebral bleeding, respectively. Prosthetic bypass grafting via open surgery for chronic mesenteric ischemia seems to be an effective treatment in long-term and can be implemented with low surgical risks.

Selection and Determination of Treatment for the Spontaneous Isolated Dissection of the Superior Mesenteric Artery.

Objective: This study aimed to clarify the selection and determination of appropriate treatment for acute symptomatic spontaneous isolated dissection of the superior mesenteric artery (SIDSMA).Methods: Data from 10 consecutive patients, who were diagnosed with symptomatic SIDSMA using computed tomography angiography and were managed in our hospital from January 2010 to October 2015, were retrospectively collected and analyzed.Results: There were nine males and one female; mean patient age was 50.3 (range, 35–64) years. All patients experienced acute abdominal pain, and three patients experienced concomitant vomiting. Only one patient exhibited symptoms of suspected peritonitis and intestinal ischemia. Three patients showed improved abdominal pain before admission to our hospital. One patient experienced severe abdominal pain that could not be managed using morphine; he underwent right external iliac to superior mesenteric artery bypass with a great saphenous vein graft. No patient presented with intestinal necrosis. All patients survived, and no patient developed complications during the follow-up period of up to 42 (24.5±16.5) months.Conclusion: Conservative management appears to be the most feasible treatment for SIDSMA. However, open surgery can be performed in patients presenting with any symptoms of intestinal ischemia.

A case of chronic mesenteric ischemia managed by ascending aorta to superior mesenteric and hepatic artery bypass

Chronic mesenteric ischemia is a rare and life-threatening condition which occurs due to occlusion of two or more mesenteric arteries following atherosclerosis. Multi-vessel revascularization forms the mainstay of treatment. This is a case of a middle-aged smoker who presented with abdominal angina and was diagnosed to have chronic mesenteric ischemia due to atherosclerotic occlusive aortic disease with coeliac artery and superior mesenteric artery occlusion. He was successfully managed with extra anatomic bypass from the ascending aorta to superior mesenteric and hepatic artery.

One Case of Left External Iliac Artery–superior Mesenteric Artery Bypass for Superior Mesenteric Artery Occlusion

One Case of Left External Iliac Artery–superior Mesenteric Artery Bypass for Superior Mesenteric Artery Occlusion

VH08. Supraceliac Aorta to Common Hepatic Artery and Superior Mesenteric Artery Bypass for Chronic Mesenteric Ischemia

VH08. Supraceliac Aorta to Common Hepatic Artery and Superior Mesenteric Artery Bypass for Chronic Mesenteric Ischemia

A Hybrid Repair of a Superior Mesenteric Artery Pseudoaneurysm Using Open Mesenteric Bypass and Endovascular Exclusion

Superior mesenteric artery (SMA) aneurysms and pseudoaneurysms are uncommonly encountered in vascular surgery practice, but they typically require repair. Historically, they have been repaired with open aneurysmorrhaphy, bypass and exclusion, or simple ligation. More recently, endovascular repair with coil embolization and stent graft exclusion have been advocated. We present a repair of an SMA pseudoaneurysm via a hybrid approach with common hepatic artery to SMA bypass, exclusion of the pseudoaneurysm with ligation of the SMA proximal to the bypass, plug occlusion of the proximal SMA, and coil embolization of the pseudoaneurysm.

Editor's Choice – Hybrid Treatment of Thoracic, Thoracoabdominal, and Abdominal Aortic Aneurysms: A Multicenter Retrospective Study

The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature. The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases. There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients. Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Chronic mesenteric ischemia and therapeutic paradigm of mesenteric revascularization

Chronic mesenteric ischemia is a life-threatening clinical problem resulting in death from inanition and/or bowel infarction, if left untreated, albeit low disease prevalence. Typical presentation is postprandial abdominal pain, severe weight loss, and altered bowel habit. Surgical revascularization of the superior mesenteric artery provides effective long-term treatment for chronic intestinal ischemia. Eleven patients underwent superior mesenteric artery revascularization, nine of them with open retrograde superior mesenteric artery bypass and two with angioplasty and stenting. All patients except one made a satisfactory recovery in this cohort. Major complication included one graft thrombosis leading to bowel ischemia and death. The rest all recovered weight in 3-6 months with a follow up period of 6 to 28 months. Two patients had recurrence of symptoms due to failing bypass requiring stenting for assisted primary patency. Superior mesenteric artery revascularization can be performed with minimal morbidity and mortality, providing excellent symptom relief and quality of life.

Eight Years Experience in the Management of Median Arcuate Ligament Syndrome by Decompression, Celiac Ganglion Sympathectomy, and Selective Revascularization

We aim to review an 8-year experience of median arcuate ligament syndrome (MALS) with chronic gastrointestinal ischemia (CGI) and evaluate clinical outcomes of arcuate ligament decompression, celiac sympathectomy, and selective revascularization. Between December 2002 and March 2012, of 25 patients referred with symptoms of CGI, 11 patients (10 women and 1 man) had clinical signs of abdominal angina and radiological evidence of MALS. Mean age was 50 ± 20.4 years. Median symptom duration was 34 months. All patients had median arcuate decompression and celiac sympathectomy. In all, 8 did not require revascularization, 2 had retrograde celiac and/or superior mesenteric artery (SMA) stenting, and 1 had SMA bypass. There was no mortality. The 30-day morbidity was 9%. Mean follow-up was 60 months. Eight patients noted complete relief of abdominal pain, and 1 reported some improvement. The MALS is not solely a vascular compression syndrome. The neurological component requires careful celiac plexus sympathectomy in addition to arcuate ligament decompression.

Surgical treatment of chronic mesenteric ischemia with splenic artery-to-superior mesenteric artery bypass: a case report

Chronic mesenteric ischemia is a rare, but important cause of abdominal pain with high mortality and morbidity rates. Postprandial abdominal pain, sitophobia and weight loss are the important clinical signs and symptoms. The main goal of the treatment is to relieve patient&#8217;s symptoms by restoration of intestinal perfusion and to prevent intestinal necrosis. Doppler ultrasound, computed tomography angiography, magnetic resonance angiography and conventional angiography are used in the diagnosis of chronic mesenteric ischemia. Surgical or endovascular interventions as well as medical therapy may be used in the treatment of chronic mesenteric ischemia. In this article, we present a 60-year-old female case of chronic mesenteric ischemia with inferior and superior mesenteric artery occlusion, who was successfully treated with splenic arteryto- superior mesenteric artery bypass surgery.

Post-Bypass Extensive Ascites due to Splanchnic Bypass and the Effectiveness of Hyperalimentation Treatment

Reperfusion edema may develop in the early periods of chronic ischemic tissue reperfusion. Reperfusion edema may be represented after the splanchnic bypass with ascites, abdominal distension, and liver and kidney function impairment. In this article, we are reporting the hyperalimentation treatment and its results for the common ascites and hepatorenal syndrome, after a coeliac and superior mesenteric artery bypass.