Jornal Vascular Brasileiro
https://www.jvascbras.org/article/doi/10.1590/1677-5449.202301482
Jornal Vascular Brasileiro
Original Article

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Revascularização aberta na isquemia mesentérica crônica durante a era endovascular: experiência de um centro quaternário e um algoritmo de tratamento

Bruno Pagnin Schmid; Vinícius Adorno Gonçalves; Lucas Marcelo Dias Freire; Felipe Nasser; Fábio Hüsemann Menezes

Downloads: 1
Views: 70

Abstract

Background: Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

Objectives: To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Methods: Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan’s arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution’s experience and a review of recent literature.

Results: All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Conclusions: Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Keywords

mesenteric ischemia, superior mesenteric artery, mesenteric arteries, mesenteric vascular occlusion, blood vessel prosthesis

Resumo

Contexto: A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta.

Objetivos: Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição.

Métodos: Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C.

Resultados: Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos.

Conclusões: A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Palavras-chave

isquemia mesentérica, artéria mesentérica superior, artérias mesentéricas, oclusão vascular mesentérica, prótese vascular

References

1 Chandra A, Quinones-Baldrich WJ. Chronic mesenteric ischemia: how to select patients for invasive treatment. Semin Vasc Surg. 2010;23(1):21-8. http://dx.doi.org/10.1053/j.semvascsurg.2009.12.003. PMid:20298946.

2 Menezes FH. Angina abdominal e trombose mesentérica. In: Dragosavac D, Araújo S, editors. Protocolos e condutas em terapia intensiva. São Paulo: Atheneu; 2014. p. 571-9.

3 Erben Y, Jean RA, Protack CD, et al. Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia. J Vasc Surg. 2018;67(6):1805-12. http://dx.doi.org/10.1016/j.jvs.2017.10.071. PMid:29395425.

4 Gibbons CP, Roberts DE. Endovascular treatment of chronic arterial mesenteric ischemia: a changing perspective? Semin Vasc Surg. 2010;23(1):47-53. http://dx.doi.org/10.1053/j.semvascsurg.2009.12.006. PMid:20298949.

5 Kruger AJ, Walker PJ, Foster WJ, Jenkins JS, Boyne NS, Jenkins J. Open surgery for atherosclerotic chronic mesenteric ischemia. J Vasc Surg. 2007;46(5):941-5. http://dx.doi.org/10.1016/j.jvs.2007.06.036. PMid:17905561.

6 Sullivan TM, Oderich GS, Malgor RD, Ricotta JJ 2nd. Open and endovascular revascularization for chronic mesenteric ischemia: tabular review of the literature. Ann Vasc Surg. 2009;23(5):700-12. http://dx.doi.org/10.1016/j.avsg.2009.03.002. PMid:19541451.

7 Inoue Y, Sugano N, Iwai T. Long-term results of aorta-superior mesenteric artery bypass using a new route. Surg Today. 2004;34(8):658-61. http://dx.doi.org/10.1007/s00595-004-2793-6. PMid:15290394.

8 van Dijk LJ, van Noord D, Vries AC, et al. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J. 2019;7(2):179-88. http://dx.doi.org/10.1177/2050640618817698. PMid:31080602.

9 Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg. 2021;73(1S):87S-115S. http://dx.doi.org/10.1016/j.jvs.2020.10.029. PMid:33171195.

10 Björck M, Koelemay M, Acosta S, et al. Editor’s choice-management of the diseases of mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(4):460-510. http://dx.doi.org/10.1016/j.ejvs.2017.01.010. PMid:28359440.

11 Alahdab F, Arwani R, Pasha AK, et al. A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia. J Vasc Surg. 2018;67(5):1598-605. http://dx.doi.org/10.1016/j.jvs.2017.12.046. PMid:29571626.

12 Oderich GS, Bower TC, Sullivan TM, Bjarnason H, Cha S, Gloviczki P. Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg. 2009;49(6):1472-9. http://dx.doi.org/10.1016/j.jvs.2009.02.006. PMid:19497510.

13 Sharafuddin MJ, Nicholson RM, Kresowik TF, Amin PB, Hoballah JJ, Sharp WJ. Endovascular recanalization of total occlusions of the mesenteric and celiac arteries. J Vasc Surg. 2012;55(6):1674-81. http://dx.doi.org/10.1016/j.jvs.2011.12.013. PMid:22516890.

14 Arya S, Kingman S, Knepper JP, Eliason JL, Henke PK, Rectenwald JE. Open mesenteric interventions are equally safe as endovascular interventions and offer better midterm patency for chronic mesenteric ischemia. Ann Vasc Surg. 2016;30:219-26. http://dx.doi.org/10.1016/j.avsg.2015.07.038. PMid:26541970.

15 Lee RW, Bakken AM, Palchik E, Saad WE, Davies MG. Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease. Ann Vasc Surg. 2008;22(4):541-6. http://dx.doi.org/10.1016/j.avsg.2007.09.019. PMid:18620112.

16 Oderich GS, Gloviczki P, Bower TC. Open surgical treatment for chronic mesenteric ischemia in the endovascular era: when it is necessary and what is the preferred technique? Semin Vasc Surg. 2010;23(1):36-46. http://dx.doi.org/10.1053/j.semvascsurg.2009.12.005. PMid:20298948.

17 Biebl M, Oldenburg WA, Paz-Fumagalli R, McKinney JM, Hakaim AG. Endovascular treatment as a bridge to successful surgical revascularization for chronic mesenteric ischemia. Am Surg. 2004;70(11):994-8. http://dx.doi.org/10.1177/000313480407001113. PMid:15586513.

18 Pecoraro F, Rancic Z, Lachat M, et al. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg. 2013;27(1):113-22. http://dx.doi.org/10.1016/j.avsg.2012.05.012. PMid:23088809.

19 Ahanchi SS, Stout CL, Dahl TJ, Carty RL, Messerschmidt CA, Panneton JM. Comparative analysis of celiac versus mesenteric artery outcomes after angioplasty and stenting. J Vasc Surg. 2013;57(4):1062-6. http://dx.doi.org/10.1016/j.jvs.2012.10.081. PMid:23313180.

20 Flis V, Mrdža B, Štirn B, Milotič F, Kobilica N, Bergauer A. Revascularization of the superior mesenteric artery alone for treatment of chronic mesenteric ischemia. Wien Klin Wochenschr. 2016;128(3-4):109-13. http://dx.doi.org/10.1007/s00508-015-0897-1. PMid:26649404.

21 Jun HJ. Isolated bypass to the superior mesenteric artery for chronic mesenteric ischemia. Korean J Thorac Cardiovasc Surg. 2013;46(2):146-9. http://dx.doi.org/10.5090/kjtcs.2013.46.2.146. PMid:23614103.

22 Reis WP, Gaio J, Reis C Jr, et al. Prevalência da estenose aterosclerótica do tronco celíaco e da artéria mesentérica superior na arteriopatia oclusiva dos membros inferiores. J Vasc Bras. 2010;9(1):4-13. http://dx.doi.org/10.1590/S1677-54492010000100002.

23 Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung TK, Cambria RP. Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience. J Vasc Surg. 2007;45(6):1162-71. http://dx.doi.org/10.1016/j.jvs.2007.01.067. PMid:17467950.
 


Submitted date:
10/16/2023

Accepted date:
12/16/2023

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
65c50bd7a953950654108603 jvb Articles
Links & Downloads

J Vasc Bras

Share this page
Page Sections