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Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta
VASCULAR IMAGES
Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta Daniel Silverberg, MD, and Moshe Halak, MD, Tel Hashomer, Israel
A 60-year-old man with a history of chronic mesenteric ischemia and chronic aortic occlusion presented with diffuse abdominal pain. On admission he was hypotensive and acidotic. A computed tomography angiogram revealed occlusion of his entire infrarenal aorta to the femoral arteries, an occluded celiac trunk and inferior mesenteric artery (previously stented), and severe stenosis of his superior mesenteric artery (SMA; A). He underwent explorative laparotomy, during which three segments of gangrenous small bowel were resected. The rest of the small bowel appeared ischemic but viable. Endovascular attempts to recanalize the SMA were unsuccessful. Owing to his hemodynamic instability and metabolic status, we performed a hybrid procedure. Under fluoroscopy, the thrombosed aorta was punctured. A wire and catheter were introduced into the thoracic aorta. After intraluminal position was confirmed, a 14F peel-away sheath was placed. A 6-mm hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz) was introduced (10-cm nitinol reinforced section and a 50-cm nonringed graft). The sheath was removed and the visible end of the nitinol section, which protruded through the aorta, was secured with stitches to the aortic wall. (model, B) An 8-mm ringed polytetrafluoroethylene graft was placed over the 6-mm graft to prevent kinking and the graft was anastomosed to the SMA. The remaining bowel improved immediately. Postoperative computed tomography angiography showed the hybrid graft was patent, with filling of the SMA (C and D/Cover). DISCUSSION Patients with acute mesenteric ischemia commonly present with hemodynamic instability and in a metabolically compromised state. Urgent surgical revascularization is frequently necessary in the acute setting but is time consuming and carries significant morbidity, with mortality rates as high as 52%.1 Standard endovascular revascularization of the visceral vessels through an antegrade approach is an a attractive alternative but is not always possible due to inability to recanalize the target vessels. Retrograde open mesenteric stenting of the SMA has also been described.2,3 A hybrid approach, as described above, is an attractive alternative. Benefits include rapid revascularization of the bowel, no SMA recanalization is required, and no aortic cross-clamping is performed.
From the Chaim Sheba Medical Center. Author conflict of interest: none. E-mail: [email protected] The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;62:1071-2 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.03.285
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1072 Silverberg and Halak
REFERENCES 1. Thomas DP, Robert HR. Hypercoagulability in venous and arterial thrombosis. Ann Intern Med 1997;126:638-44. 2. Pisimisis GT, Oderich GS. Technique of hybrid retrograde superior mesenteric artery stent placement for acute-on-chronic mesenteric ischemia. Ann Vasc Surg 2011;25:132.e7-132. e11. 3. Do N, Wisniewski P, Sarmiento J, Vo T, Aka PK, Hsu JH, Tayyarah M. Retrograde superior mesenteric artery stenting for acute mesenteric arterial thrombosis. Vasc Endovascular Surg 2010;44:468-71. Submitted Mar 25, 2014; accepted Mar 30, 2014.
JOURNAL OF VASCULAR SURGERY October 2015
Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta Daniel Silverberg, MD, and Moshe Halak, MD, Tel Hashomer, Israel
A 60-year-old man with a history of chronic mesenteric ischemia and chronic aortic occlusion presented with diffuse abdominal pain. On admission he was hypotensive and acidotic. A computed tomography angiogram revealed occlusion of his entire infrarenal aorta to the femoral arteries, an occluded celiac trunk and inferior mesenteric artery (previously stented), and severe stenosis of his superior mesenteric artery (SMA; A). He underwent explorative laparotomy, during which three segments of gangrenous small bowel were resected. The rest of the small bowel appeared ischemic but viable. Endovascular attempts to recanalize the SMA were unsuccessful. Owing to his hemodynamic instability and metabolic status, we performed a hybrid procedure. Under fluoroscopy, the thrombosed aorta was punctured. A wire and catheter were introduced into the thoracic aorta. After intraluminal position was confirmed, a 14F peel-away sheath was placed. A 6-mm hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz) was introduced (10-cm nitinol reinforced section and a 50-cm nonringed graft). The sheath was removed and the visible end of the nitinol section, which protruded through the aorta, was secured with stitches to the aortic wall. (model, B) An 8-mm ringed polytetrafluoroethylene graft was placed over the 6-mm graft to prevent kinking and the graft was anastomosed to the SMA. The remaining bowel improved immediately. Postoperative computed tomography angiography showed the hybrid graft was patent, with filling of the SMA (C and D/Cover). DISCUSSION Patients with acute mesenteric ischemia commonly present with hemodynamic instability and in a metabolically compromised state. Urgent surgical revascularization is frequently necessary in the acute setting but is time consuming and carries significant morbidity, with mortality rates as high as 52%.1 Standard endovascular revascularization of the visceral vessels through an antegrade approach is an a attractive alternative but is not always possible due to inability to recanalize the target vessels. Retrograde open mesenteric stenting of the SMA has also been described.2,3 A hybrid approach, as described above, is an attractive alternative. Benefits include rapid revascularization of the bowel, no SMA recanalization is required, and no aortic cross-clamping is performed.
From the Chaim Sheba Medical Center. Author conflict of interest: none. E-mail: [email protected] The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2015;62:1071-2 0741-5214 Copyright Ó 2015 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvs.2014.03.285
1071
1072 Silverberg and Halak
REFERENCES 1. Thomas DP, Robert HR. Hypercoagulability in venous and arterial thrombosis. Ann Intern Med 1997;126:638-44. 2. Pisimisis GT, Oderich GS. Technique of hybrid retrograde superior mesenteric artery stent placement for acute-on-chronic mesenteric ischemia. Ann Vasc Surg 2011;25:132.e7-132. e11. 3. Do N, Wisniewski P, Sarmiento J, Vo T, Aka PK, Hsu JH, Tayyarah M. Retrograde superior mesenteric artery stenting for acute mesenteric arterial thrombosis. Vasc Endovascular Surg 2010;44:468-71. Submitted Mar 25, 2014; accepted Mar 30, 2014.
JOURNAL OF VASCULAR SURGERY October 2015