Symptomatic Chronic Mesenteric Ischemia Research Articles

Trapdoor endarterectomy for coral reef plaque of the paravisceral aorta in the modern era

Coral reef atherosclerosis of the paravisceral aorta is a rare disease whose description is confined to before contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with coral reef aorta treated with trapdoor endarterectomy at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients with coral reef aorta were treated with trapdoor endarterectomy. The patient data were obtained via a retrospective medical record review. The patients were predominantly women (79%) with a median age of 65 years (interquartile range [IQR], 60-70 years). The patients universally had a tobacco smoking history and hypertension. More than 85% had previously diagnosed carotid stenosis. Two patients (14%) had undergone prior aortofemoral reconstruction, and one patient (7%) had undergone prior axillobifemoral bypass. The most common presenting symptoms were claudication (71%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Of the 14 patients, 8 (57%) underwent isolated endarterectomy and 6 (43%) underwent concomitant aortobifemoral bypass. In addition, 13 patients (93%) required a supraceliac aortic clamp position with a median clamp time of 23 minutes (IQR, 20-30 minutes). The median estimated blood loss was 1650 mL (IQR, 1025-3000 mL). A cell saver was used in 13 procedures (93%), with a median transfusion of 563 mL (IQR, 231-900 mL). The median operative time was 341 minutes (IQR, 315-416 minutes). Eight patients (57%) experienced acute kidney injury in the postoperative period with a peak creatinine of 1.96 mg/dL (IQR, 1.50-2.84 mg/dL). The median length of stay was 11 days (IQR, 6-16 days), with an intensive care unit stay of 4 days (IQR, 2-7 days). One patient (7%) required reoperation in the immediate perioperative period for a retroperitoneal hematoma. The postoperative ankle brachial index increased from a median of 0.58 (right) and 0.57 (left) bilaterally in the preoperative period to 1.09 (right) and 1.10 (left) postoperatively. Eight patients (57%) had follow-up data available for >2 years postoperatively, with five patients (36%) having follow-up data available for >3 years. Two major adverse cardiac events were reported at the last follow-up. One patient reported mild recurrent symptoms of chronic mesenteric ischemia during 3 years of postoperatively, with no concurrent imaging findings or loss of patency found on computed tomography angiography. Symptomatic coral reef atherosclerosis of the paravisceral aorta is a complex disease rarely encountered even at high-volume referral centers. These patients can be expected to experience short-term postoperative morbidity and require intensive care. Despite these challenges, trapdoor endarterectomy is a safe and effective procedure for coral reef aorta, and most patients achieve dramatic symptomatic improvement with durable results.

Pancreatic Ischemia-Reperfusion Injury Following Endovascular Treatment of Symptomatic Celiac and Superior Mesenteric Artery Stenosis.

With endovascular therapy becoming the first-line treatment for symptomatic chronic mesenteric ischemia, acute pancreatitis within the context of abdominal ischemia-reperfusion injury may be seen more often in cross-sectional imaging following this kind of interventions and should therefore be kept in mind by the reading physician.

Chronic Mesenteric Ischemia, More Attention is Needed in Cases with Prolonged Abdominal Pain: A Case Report and Brief Review

Introduction: Symptomatic chronic mesenteric ischemia (CMI) is a rare condition that usually occurs due to mesenteric artery stenosis (MAS) with a common incidence. Although the prevalence of symptomatic CMI is less than 2%, MAS is more common in the elderly. Case Presentation: A 60-year-old woman with prolonged eating-related abdominal pain and weight loss treated as cholelithiasis by endoscopic retrograde cholangiography was readmitted by recurrent epigastric pain. At this time, she was reevaluated by computed tomography angiography (CTA), and CMI was confirmed. She was treated with percutaneous mesenteric artery stenting and was discharged without pain. There were no complications or pain after 3 months of follow-up. Conclusions: The most prevalent causes of CMI are atherosclerotic processes, such as hypertension, hyperlipidemia, overweight, metabolic syndrome, and smoking. The diagnosis of CMI is confirmed by CTA. Recently, endovascular treatment by percutaneous mesenteric artery stenting is more common than the surgical approaches because of lower in- and out-hospital complications.

Trapdoor Endarterectomy for Coral Reef Plaque of the Paravisceral Aorta in the Modern Era

Coral reef atherosclerosis (CRA) of the paravisceral aorta is a rare disease whose description is largely confined prior to contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with CRA treated with trapdoor endarterectomy (TEA) at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients were identified who underwent TEA for symptomatic CRA. Data on patient demographics, operative details, hospital course, and outpatient follow-up were obtained via retrospective chart review. Patients were predominantly female (71%) with a median age of 65 years (interquartile range [IQR], 63-70) and had traditional vascular risk factors. Over 85% had previously diagnosed carotid stenosis; two patients (14%) had prior aortofemoral reconstruction, and one (7%) had prior axillobifemoral bypass. The most common presenting symptoms were claudication (64%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Eight patients (57%) received isolated TEA and six (43%) received concomitant aortobifemoral bypass (Table I). Thirteen patients (93%) required a supraceliac aortic clamp position with a median clamp time of 26 minutes (IQR, 20-30 minutes). Median estimated blood loss was 1650 mL (IQR, 1025-3750 mL). Cell saver was used in 13 procedures (93%) with median transfusion of 563 mL (IQR, 231-900 mL). Median operative time was 341 minutes (IQR, 315-316 minutes). Eight patients (57%) had acute kidney injury in the postoperative period with peak creatinine of 2.02 (IQR, 1.58-2.95) (Table II). Length of stay was 13 days (IQR, 7-16 days) with an intensive care unit stay of 4 days (IQR, 2-7 days). Two patients (14%) required reoperations in the immediate perioperative period, one for retroperitoneal hematoma and one for target vessel (superior mesenteric artery) occlusion. Postoperative ankle-brachial indices were increased from a median of 0.52 bilaterally in the preoperative period to >1 postoperatively. Eight patients (57%) had follow-up over 2 years after TEA, with five patients (36%) having follow-up over 3 years. Three major adverse cardiac events were reported at last follow-up. Just one patient reported persistent symptoms of chronic mesenteric ischemia at 11 years after TEA. Symptomatic CRA of the paravisceral aorta is a complex disease rarely encountered even at a high-volume quaternary referral center. These patients can be expected to experience short-term postoperative complications and require intensive care. Despite these challenges, trapdoor transaortic endarterectomy is a safe, effective procedure for CRA and most patients achieve dramatic symptomatic improvement with durable results.Table IGeneral operative characteristics (n = 14)VariablesMedian [IQR] or No. (%)Procedure types Trapdoor endarterectomy8 (57) Trapdoor endarterectomy with aortobifemoral bypass6 (43)Starting clamp position Supraceliac13 (93) Supramesenteric1 (7)Subsequent clamp position Infrarenal10 (71) None4 (29)Aortic closure Primary closure12 (86) Bovine patch angioplasty1 (7) Dacron patch angioplasty1 (7)Revascularized vessels Celiac3 (21)Eversion endarterectomy3 (100) Superior mesenteric artery5 (36)Eversion endarterectomy4 (80)Catheter embolectomy1 (20) Left renal5 (36)Eversion endarterectomy4 (80)Bypass graft1 (20) Right renal3 (21)Eversion endarterectomy3 (100) Bilateral renals3 (21)Eversion endarterectomy3 (100) IMA1 (7)Eversion endarterectomy1 (100)Cold renal perfusion8 (57)Estimated blood loss, mL1650 [1025-3750]Intraoperative transfusion, units2 [1-4]Cell saver13 (93) Volume transfused, mL563 [231-900]Suprarenal clamp time, minutes (n = 13)26 [20-30]Operative time, minutes341 [315-416]IQR, Interquartile range. Open table in a new tab Table IIPostoperative course, (n = 14)VariableMedian [IQR] or No. (%)Inpatient complications Anemia14 (100) Acute kidney injury8 (57)Creatinine (peak)2.02 [1.58-2.95]Dialysis1 (7) Cardiopulmonary complications5 (36) Reoperation2 (14)Retroperitoneal hematoma1 (7)Secondary intervention1 (7) Ileus2 (14) Colitis2 (14) Deep vein thrombosis1 (7) Myocardial infarction1 (7) Infection1 (7) Death1 (7)Intensive care unit admission14 (100) Length of stay, days4 [2-7]Total length of stay, days13 [7-16]Laboratory tests Blood urea nitrogen (preoperative)14 [10-16] Creatinine (preoperative)1.01 [0.91-1.31] Creatinine (discharge)1.06 [0.70-1.35]Hemodynamics Right ABI (preoperative), n = 100.52 [0.34-0.90] Left ABI (preoperative), n = 100.52 [0.38-0.81] Right ABI (postoperative op), n = 91.12 [1.06-1.16] Left ABI (postoperative), n = 91.10 [1.09-1.15]Readmission within 30 days3 (21)Duration of follow-up, years2 [0.5-3.0]Outpatient complications, time postoperative3 (21) Ureteral stricture, 2 months1 (7) Loss of primary patency, 18 months1 (7) New chronic mesenteric ischemia, 8 years1 (7)Amputation0 (0)Persistent symptomatology at last follow-up (n = 13)1 (7) Claudication or rest pain0 (0) Mesenteric angina1 (7)Major adverse cardiac events at last follow-up3 (21) Death2 (14) Myocardial infarction1 (7)IQR, Interquartile range. 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Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery.

Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations. A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels. Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients. It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.

Covered Versus Bare Metal Stents for Chronic Mesenteric Ischemia: Systematic Review and Meta-analysis

Endovascular revascularization through mesenteric stenting is the preferred initial treatment strategy for symptomatic chronic mesenteric ischemia (CMI), but restenosis and symptom recurrence are common. Emerging evidence suggests that covered stents (CS) may reduce or delay the incidence of in-stent restenosis compared with traditional bare metal stents (BMS). Our study objective was to compare the performance of CS to BMS in the management of CMI. We searched PubMed and Embase databases (inception to April 27, 2021) for studies comparing CS with BMS in the management of CMI following the PRISMA guidelines. The abstract and full-text screening were done in parallel by two authors, resolving conflicts by reviewing them with a third author. Our outcomes of interest were loss of primary patency, restenosis, and symptom recurrence at the latest follow-up. Primary analysis was performed using random-effects models and heterogeneity was measured using the I2 statistic. We assessed the quality of observational studies using the Newcastle-Ottawa Scale. The predefined protocol was registered in PROSPERO. We double-screened a total of 502 articles, of which four observational studies (n = 432 patients, 511 vessels) were included (Fig 1). CS were used in 20.4% of vessels (n = 104). When compared with BMS, the use of CS was associated with lower odds of loss of primary patency (pooled odds ratio, 0.37; 95% confidence interval [CI], 0.15-0.90; P value = 0.029; I2 = 58.9%; n = 511 vessels) (Fig 2). CS were also associated with lower odds of restenosis (pooled odds ratio, 0.12; 95% CI, 0.06-0.23; P < 0.001; I2 = 0%; n = 280 patients). One study reported lower symptom recurrence associated with CS use (OR, 0.08; 95% CI, 0.02-0.23; P < 0.001; n = 189 patients). The length of follow-up varied across studies (median follow-up range, 16-31 months). Heterogeneity was high, and the overall quality of included studies was low owing to small sample sizes, single-center design, retrospective data collection, differential follow-up between treatment groups, and risk for systematic or selection bias. Available data comparing BMS with CS for use in patients with CMI are limited and of variable quality. Although endovascular treatment with CS was associated with lower odds of loss of primary patency and restenosis when compared with BMS, these results must be interpreted with caution. (PROSPERO CRD42021281294).Fig 2Pooled odds ratio (OR) for loss of patency at latest follow-up. 95%-CI, 95% confidence interval.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Long-Term Outcomes of Mesenteric Stenting and Analysis of In-Stent Restenosis Duplex Velocity Criteria

Endovascular therapy for chronic mesenteric ischemia (CMI) is the mainstay of treatment. Duplex velocity criteria within stented mesenteric vessels are not well established. We describe single-center outcomes of mesenteric stenting for CMI and analyze duplex velocities associated with in-stent restenosis (ISR). We performed a single-center retrospective review of patients undergoing mesenteric stenting for CMI (2012-2018). Primary outcome was reintervention for recurrence of CMI symptoms. Secondary outcomes were occlusion or bypass grafting. Duplex velocities in those with recurrent symptoms, corresponding with clinically significant ISR, were identified. Receiver operating characteristic (ROC) curves were created to identify velocity thresholds for ISR. Mesenteric stents were placed in 61 patients (71 arteries). Mean age was 72years (range, 49-92), and the majority were female (55%). Thirty-two (45%) celiac (CA) stents and 39 (55%) superior mesenteric artery (SMA) stents were placed. Ten patients had SMA and CA stents placed. Twenty-five stents were covered (35%). Freedom from reintervention at 1, 2, and 3years was 83%, 73%, and 60%. Freedom from occlusion or bypass grafting at 1, 2, and 3years was 100%, 86%, and 86%. No significant difference in patency was seen between covered and bare-metal stents (OR 0.45; 95% CI: 0.15-1.33; P=0.1383). Median survival was 6.1years. For CA stents, a peak systolic velocity (PSV) of 440cm/s corresponded with clinically significant ISR with 100% sensitivity and 86% specificity. For SMA stents, a PSV of 341cm/s corresponded with clinically significant ISR with only 80% sensitivity and 52% specificity. A PSV of 440cm/s for CA stents was indicative of clinically significant ISR with excellent sensitivity and specificity. This should be used in conjunction with clinical findings to identify patients that may benefit from repeat intervention. A similar threshold could not be identified for SMA stents and warrants further collaborative investigation.

Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is defined by stenoses or occlusions of the celiac artery, superior or inferior mesenteric artery. While it is mostly cause by atherosclerotic disease, less frequent cause in particular in younger patients are fibrowmuscular dysplasia or vasculitis. Risk factors include smoking, hypertension, dyslipidemia, higher age, and female sex. Symptomatic CMI only accounts for less than 5 % of intestinal ischemic events. The prevalence of asymptomatic CMI is unknown but may be as high as 15 % and is more frequent in peripheral artery disease (27 %) and abdominal aortic aneurysm (40 %). The celiac artery is mostly affected. Abdominal pain that is aggravated with food intake with preserved appetite, abdominal bruits, and severe malnutrition can be important clinical hints that raise the suspicion of CMI. The diagnostic modality of choice is duplex ultrasound that should be performed in specialized centers potentially together with functional test causally linking symptoms to relevant arterial stenosis or intestinal ischemia. Typically, a stenosis of only one artery is unlikely to cause CMI. The therapy of choice is revascularization. In most cases angioplasty potentially together with stenting is performed due to low post-interventional mortality in mostly multi-morbid patients with excellent technical and clinical success rates. Non-atherosclerotic CMI in particular in younger patients may require surgery. Similar to the treatment of patients with other cardiovascular diseases, atherosclerosis of mesenteric arteries requires life style modification and optimal medical therapy for risk reduction. Platelet inhibition is indicated after revascularization.

Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery

BackgroundEndovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation.Case presentationAn 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15–30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient’s symptoms.ConclusionsCMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.

3:00 PM Abstract No. 399 Percutaneous revascularization for chronic mesenteric ischemia: does a residual pressure gradient affect clinical outcomes?

Percutaneous revascularization has become a reliable option in the management of chronic mesenteric ischemia with much lower associated morbidity and mortality than surgical methods. Unlike peripheral arterial interventions, there are no quantitiative endpoints for to determine the success of mesenteric angioplasty. Complete angiographic patency or alleviation of an arterial pressure gradient across the stenosis are often not feasible. Furthermore, aggressive angioplasty is typicall avoided as the consequences of a dissection or acute occlusion can be catastrophic. Our purpose is to examine whether a residual arterial pressure gradient after percutaneous revascularization affects clinical outcomes and patient symptomatology. We present a single-institution retrospective observational study involving patients who underwent mesenteric revascularization between January 2009 and June 2017 for chronic mesenteric ischemia. Simultaneous intra-arterial pressures were obtained in the aorta and SMA or celiac trunk using an end-hole catheter with a pressure transducer. Patients who did not have post-angioplasty intra-arterial pressures recorded were excluded. Postprocedural vascular surgery clinic notes were reviewed to determine whether or not symptoms had improved. There were 20 revascularization procedures for which post-angioplasty arterial pressures are available: 14 SMA and 6 celiac trunk. Mean patient age was 69.3 years. All patients experienced post-prandial abdominal pain and most reported weight loss. All patients had at least one risk factor: hypertension, type 2 diabetes, coronary artery disease or stroke and smoking. Mean follow-up was 90.2 days (range, 33-218 days) Post-angioplasty gradients (systolic/mean) ranged from 4/0 - 65/28 mm Hg (mean 34.2/12.6 mm Hg). Minor complication rate was 8.6%. There were no deaths. Clinical improvement was reported in 100% of patients in follow-up. Three procedures were done prophylactically as the patients were asymptomatic but young with rising PSV on routine ultrasound. Percutaneous mesenteric revascularization can improve symptoms of chronic mesenteric ischemia despite a residual arterial pressure gradient.

Endovascular Management for Symptomatic Chronic Mesenteric Ischemia: A Single-Center Experience.

Chronic mesenteric ischemia (CMI) is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to classical intestinal ischemia, although a clear pathophysiology has yet to be elucidated. Here, we have presented our institution's experience in the management of symptomatic CMI. From February 2007 to February 2016, a retrospective study was performed of all consecutive patients with symptomatic CMI managed by endovascular treatment (ET). We reviewed these patients' demographics, comorbidities, clinical presentations, and treatment modalities. Perioperative and midterm outcomes included technical success, clinical symptom relief, complications, symptomatic recurrence, mortality, restenosis, and reintervention. Thirty-five mesenteric arteries (74.3% stenotic/25.7% occluded) identified in 32 patients (12 females, 20 males) were treated with endovascular procedures. There were no 30-day deaths; the perioperative complication rate was 12.5%. Overall, the median postprocedural time to symptom relief was 7.6 days (range: 1-30 days). Twenty-two (68.8%) had complete remission of symptom, whereas 7 (21.9%) had partial improvement in symptom after ET. After a mean follow-up of 35.4 (25.9) months, 5 (15.6%) patients developed recurrent symptoms, with 4 requiring reinterventions. The primary patency was 93.7%, 82.6%, and 73.1% at 12, 24, and 36 months, respectively, and the freedom from symptomatic recurrence was 90.6%, 84.0%, 84.0%, and 84.0% at 6, 12, 24, and 36 months, respectively. Endovascular treatment for patients with CMI had a high technical success rate and satisfactory clinical outcomes. Symptomatic recurrence was not frequent but found mainly within 12 months following the initial procedure.

Revascularization by Percutaneous Transluminal Angioplasty for Chronic Mesenteric Ischemia: Results and One-Year Follow-up in a Single Center

Although the prevalence of mesenteric artery stenosis is high, symptomatic chronic mesenteric ischemia (CMI) is rare; the collateral network in the mesenteric circulation serves to prevent most cases of ischemia. The number of affected vessels is the major determinant in CMI development and most subjects with single vessel mesenteric stenosis do not develop ischemic complaints.

Surgery for acute exacerbation of chronic mesenteric ischemia: a case report.

BackgroundChronic mesenteric ischemia (CMI) is a rare disease; however, symptomatic CMI has a risk of acute exacerbation without timely revascularization.Case presentationA 54-year-old man who had had postprandial pain for 6 months was admitted to our hospital because of vomiting and diarrhea. Although the celiac and superior mesenteric arteries were occluded at the proximal portion, contrast enhancement of the bowel wall was good in contrast-enhanced computed tomography (CECT). Endoscopic examination revealed only a healed gastric ulcer and slight mucosal erosions in the colon. He was diagnosed as having acute enteritis or inflammatory digestive disease and observed with conservative therapy, which improved his acute symptoms. On hospitalization day 42, he suddenly complained of lower back pain. CECT showed abdominal free air, which indicated gastrointestinal perforation. Emergency surgery was performed for jejunum resection. Two days later, a second operation was performed for a leak in the anastomotic site of the jejunum. Necrotic change in the small intestinal serosa was also observed and required broad resection of the small intestine. He was diagnosed with acute exacerbation of CMI, and we performed surgical retrograde bypass to the gastroduodenal artery using a saphenous vein graft as the third operation. After the surgery, he was free from digestive symptoms and was discharged.ConclusionsWhen patients complain of chronic and gradual digestive symptoms, we should always consider symptomatic CMI. Timely mesenteric revascularization is important for symptomatic CMI before severe complications occur.

Percutaneous transluminal angioplasty and stenting in the management of chronic mesenteric angina: A single center experience.

Introduction:The objective of our study was to review the results of percutaneous angioplasty (PTA)/stenting in the treatment of patients who presented with symptoms and angiographic findings of chronic mesenteric ischemia (CMI).Materials and Methods:We performed a retrospective analysis of 13 consecutive patients from a single institution who underwent PTA/stenting for the treatment of symptoms suggestive of CMI.Results:All 13 patients in our study were men, and most common presenting symptoms were weight loss and postprandial pain. Atherosclerosis was the most common cause. PTA and stenting was performed in 9 patients and PTA alone was done in 4 patients. Primary technical success rate was 92% with complete resolution of symptoms within 2 weeks in all patients. No statistical difference was noted in primary clinical success rate based on the number of vessels treated or the method of treatment. However, in patients whom SMA was treated had longer duration of symptom-free survival as compared to other vessels.Conclusion:PTA and stenting are very effective therapeutic options for patients presenting with CMI symptoms. It should be considered as the first-line of management in such patients.

Revascularization of the superior mesenteric artery alone for treatment of chronic mesenteric ischemia

Symptomatic patients with chronic mesenteric ischemia (CMI) should be treated without much delay because symptoms of CMI are present in 43% patients who present with acute mesenteric ischemia. There are few reported series with large numbers of patients undergoing surgery for CMI, and many controversies persist regarding the optimal surgical treatment. These controversies include the type of surgical repair (antegrade vs. retrograde bypass), and the number of arteries that should be treated (single- vs. multiple-vessel reconstruction). It was the aim of presented study to report our experience and long-term results with single-vessel bypass grafting from infrarenal aorta to superior mesenteric artery. Patients who were admitted because of mesenteric ischemia at the surgical clinics of University Clinical Center Maribor between January 1999 and January 2009 were identified with a computerized medical data registry. Patients who underwent revascularization for CMI with retrograde synthetic aortomesenteric bypass were included in the study. Demographics, clinical characteristics, imaging, and operative data were obtained from the medical records. Significant superior mesenteric artery stenosis (> 70% diameter stenosis) was confirmed by spiral computed angiography. All patients underwent retrograde aortomesenteric arterial bypass with synthetic bypass graft originating from the infrarenal aorta. Doppler sonography combined with color Doppler was used to evaluate disease progression in patients at 3-month interval during the first year and from then at 6-month intervals. Endpoints of the study were occlusion of graft or death by any cause. Data are presented for a cohort of 19 women and 8 men with a mean age at admission 73 years (range 56-88 years). The mean duration of follow-up was 71 months (range 1-118 months). There was one early death (4%). Four patients died during the follow-up period, and three were lost for follow-up. None of the deaths was connected with mesenteric ischemia. During follow-up period none of the patients developed restenosis, and no occlusions were observed. There were no reinterventions. Symptom improvements were noted in 25 patients (93%). One patient (4%) referred to persistent pain despite successful revascularization, although during follow-up period weight gain was observed. At 71 months, freedom from recurrent symptoms, restenosis, and reinterventions was 78% ± 13.9%. Surgery for CMI can be safely performed with retrograde approach and single vessel anastomosis. Mortality rates and long-term survival compare favorably with other surgical approaches to treatment of CMI.

Successful endovascular treatment of severe chronic mesenteric ischemia by concurrent triple-vessel mesenteric artery revascularization

A 52-year-old man presenting with severely symptomatic chronic mesenteric ischemia had proximal occlusion of the celiac and superior mesenteric arteries and critical stenosis of the inferior mesenteric artery ostium. Concurrent percutaneous revascularization with stenting of all three mesenteric arteries was successfully achieved using techniques tailored to each lesion. Complete clinical recovery was observed at the six-month post-procedure follow-up.

Recanalization of Chronic Total Occlusions of the Superior Mesenteric Artery in Patients with Chronic Mesenteric Ischemia: Technical and Clinical Outcomes

PurposeTo evaluate the safety and outcomes of endovascular recanalization of chronic total occlusions (CTOs) of the superior mesenteric artery (SMA) in patients with chronic mesenteric ischemia (CMI). Materials and MethodsA single-institution retrospective review was performed of 47 consecutive patients (18 male, 29 female) who underwent endovascular stent placement for CTOs of the SMA between February 2006 and November 2012. All patients had symptoms of CMI. Procedural and follow-up data were collected for assessment of technical success, safety, and outcome. ResultsTechnical success was achieved in 41 of 47 patients (87%). Forty-two of the 47 procedures were performed from a femoral approach. Fifteen patients underwent concurrent revascularization of the celiac artery. All patients who underwent successful recanalization reported symptomatic improvement. Kaplan–Meier analysis revealed primary freedom from symptomatic recurrence of 95% at 12 months and 78% at 24 months. Symptomatic recurrence was observed in seven patients, all of whom underwent successful assisted or secondary endovascular procedures. Secondary freedom from symptomatic recurrence rates were 100% at 12 months and 88% 24 months. There were three (7%) minor access-related complications and no major complications. ConclusionsEndovascular stent-assisted recanalization of chronic SMA occlusions is safe and effective, with an acceptable rate of technical success and excellent midterm clinical outcomes.

8:32 AM Abstract No. 16 - ■ FEATURED ABSTRACT Stenting of superior mesenteric artery chronic total occlusions in patients with chronic mesenteric ischemia: technical and clinical outcomes

Purpose While endovascular treatment of chronic mesenteric arterial stenosis is well accepted, management of chronic total occlusions (CTO) remains controversial with historical mainstays of treatment consisting of bypass or endarterectomy. Our goal is to evaluate the clinical and technical outcomes of endovascular recanalization and stenting of CTOs of the superior mesenteric artery (SMA). Materials and Methods We performed a retrospective review of 46 patients (18 M, 28 F) who underwent endovascular stenting of CTOs of the SMA between February 2008 and July 2012. All patients had symptoms of chronic mesenteric ischemia. Procedural and follow-up data were collected for assessment of technical success, safety and outcomes. Technical success was defined as the ability to traverse and stent the SMA occlusion without significant residual stenosis. Patency and freedom from symptom recurrence were calculated by Kaplan Meier analysis. Results Technical success was achieved in 40 of 46 patients (87%). Twelve patients underwent concurrent stenting of the celiac artery. Of the 6 technical failures, 2 were referred for bypass, 3 underwent celiac artery stenting, and 1 was lost to followup. Within 24 hours of the procedure, complete symptomatic relief was reported by 39 of 40 (97%) patients, while 1 patient (3%) reported partial improvement. No patients reported stable or worsening of symptoms. Imaging followup (22 US, 8 CTA) was obtained in 30 of 40 (75%) patients with a mean followup of 11.2 months. Kaplan Meier analysis revealed a primary patency of 100% at 3mo, 96% at 6mo, 80% at 1yr, and 72% at 2yrs. Symptomatic recurrences, which was observed in 5 patients, correlated to restenosis/reocclusion on imaging. All 5 patients underwent successful assisted or secondary PTA and/or stenting procedures. Kaplan Meier analysis of freedom from symptom recurrence showed primary and assisted rates of 80% and 100% at 1 year, and 77% and 97% at 2 years. There were 3 (7%) minor access-related complications and no major complications. Conclusion Endovascular stenting of CTOs of the SMA is a safe and effective procedure with an acceptable technical success rate and excellent mid-term clinical outcomes.

Endovascular Treatment of Chronic Mesenteric Ischemia by Crossing of Two Stents in a Patient with Celiacomesenteric Trunk

Chronic mesenteric ischemia (CMI) is an uncommon disorder caused by atherosclerotic occlusion or stenosis of the mesenteric arteries (1). CMI symptoms classically develop when there is significant stenosis or occlusion of at least two of the three mesenteric arteries (2). Endovascular therapy is increasingly accepted as the first line of therapy for CMI due to its lower morbidity and mortality rate and similar outcome compared with open surgery (1-5). In celiacomesenteric trunk (CMT), the celiac artery (CA) and superior mesenteric artery (SMA) arise from a common origin (6). Patients with CMT variation develop CMI when atheromatous disease causes occlusion of both the proximal CA and SMA at their common trunk. We report a case of CMT variant with severe stenosis of the trunk ostium and a totally occluded SMA that was successfully treated with overlapping CA and SMA stents in the trunk portion.

Endovascular treatment of stenoses in a pediatric patient with incomplete aortic duplication, mesenteric ischemia, and renovascular hypertension

Variations in abdominal aortic anatomy may have significant implications in various surgical procedures. We report here a pediatric patient with symptoms of chronic mesenteric ischemia, labile hypertension, and lower extremity claudication. Angiography revealed a partially duplicated aorta with the anterior aorta containing the splanchnic and renal arteries and the posterior segment perfusing the lower extremities. She was successfully treated with balloon angioplasty of two focal stenoses and is normotensive without abdominal symptoms at 1-year follow-up. To our knowledge, this is the first report of a successful endovascular intervention in a partially duplicated aorta.