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Visceral artery reconstruction
Visceral JOHN L. KISER,
Artery
Reconstruction*
M.D. AND JOE R. UTLEY, M.D., St.
From the Department of Surgery, Washington School of Medicine, St. Louis, Missouri.
Unietersity
His past history revealed that he had been hospitalized twice for coronary insufficiency. He had had numerous previous operations including laminectomy and bilateral replacement of superficial femoral arteries. Examination revealed a wiry, chronically ill man with blood pressure of 150/90 mm. Hg. The abdomen was scaphoid and nontender. There was an epigastric bruit. The systolic blood pressure in the left arm was 50 mm. Hg below that in the right. Both femoral pulses were palpable. Gastrointestinal roentgenograms were normal. Translumbar aortogram showed complete occlusion of the superior mesenteric artery with delayed filling of the splenic and hepatic arteries. (Fig. 1.) The superior mesenteric artery was filled from the inferior mesenteric artery by a greatly enlarged marginal artery of Drummond. The following morning he had severe pain in the right lower quadrant, fever, and leukocytosis. At laparotomy, the superior mesenteric artery was pulseless and the cecum gangrenous. A saphenous vein graft was placed from the aorta to the superior mesenteric artery, and the ascending colon was resected, bringing the ends of the ileum and transverse colon out the wound. Forty-eight hours later, the patient was returned to the operating room and all bowel appeared viable. An ileotransverse colostomy was performed. The patient recovered uneventfully, ate well, gained weight, and was asymptomatic for two months. He was readmitted on January 3, 1967 for evaluation of pain of two months’ duration which was steady, epigastric in location, and not directly related to meals. He had no fever, colic, or bleeding. Gastrointestinal roentgenograms again revealed nothing abnormal. A translumbar arteriogram showed the bypass saphenous graft filling the superior mesenteric artery. The large inferior mesenteric artery was decreased in size. The hepatic artery filled less rapidly than the superior mesenteric and adjacent renal vessels. (Fig. 2.) The origin of the celiac axis was not visualized. The patient was discharged for further observation. Over the subsequent month, his symptoms increased; he lost additional weight and became anorexic. He had increased pain
purpose of this paper is to present a T HE unique example of the progression of visceral artery disease and to review the current status of surgery for arteriosclerosis of the visceral arteries. The celiac and superior mesenteric arteries have been reconstructed for a variety of lesions. These include mycotic aneurysm [1,2], arteriosclerotic aneurysm [3], compression of the celiac axis by the aortic hiatus [4,5], traumatic fistula [6,7], and neoplastic involvement. Direct surgical attack upon the arteries of the small intestine has developed in accordance with the rapid advances in arterial surgery in other areas. Mesenteric embolectomy was first reported by Klass IS] in 1951. Shortly thereafter, the first successful embolectomy (with bowel resection) was reported by Stewart et al. [9]. Elective surgery for arteriosclerotic narrowing of the celiac and mesenteric vessels has been performed since 1958 [IO]. The relationship of abdominal symptoms to chronic intestinal ischemia was recognized as early as 1901 by Schnitzler [II]. Fry and Kraft [IZ] described the “typical triad of pain following meals, weight loss, and intestinal dysfunction for varying periods before death.” The following case is reported to illustrate the manifestations and management of visceral artery disease. CASEREPORT The patient, a fifty year old man, was admitted on July 28, 1966 for evaluation of abdominal pain. Over the preceding ten months, incapacitating upper abdominal pain had developed after meals. He had lost 20 pounds and was eating only one meal per day. All forms of food promptly produced pain. * Presented
Louis, Missouri
at the Twentieth Annual Meeting of the Southwestern Denver, Colorado, April 22-25, 1968. 720
Surgical Congress,
The American
Journal of Surgery
Visceral Artery Reconstruction
laterals
are srnallcr.
after meals and at night. Xrteriogram was repeated and showed severe stenosis at the origin of the celiac artery. (Fig. 3.) Iaparotomy was performed on February 22. I9GY’. The celiac axis was approached through the lesser omentum. The celiac vessels were dissected. Direct celiac artery pressure was 85:‘4(1 mm. Hg when the systemic pressure was l-IO/90 mm. Hg. An endarterectomy of the. origin of this vessel was performed. A Dacro# patch graft was applied over the arteriotomy. Immediate direct arterial pressure was the same as the systemic pressure. The postoperative course was uneventful. During the first six weeks, the patient complained of diarrhea. This has ceased; he is pain-free and has regained his original weight. r\ faint upper abdominal bruit has been present since surgery. COMMENTS
The symptoms and physical findings of visceral artery disease are well known. Pain typically follows meals and may be relieved by diarrhea1 bowel movements [12]. Lapiccirella [13] showed the postprandial meteorism and somnolence were often the initial symptoms. These symptoms frequently precede the symptoms of coronary arteriosclerosis and abdominal angina by many years. The duration of symptoms is variable, but most patients with mesenteric thrombosis due to arteriosclerosis have antecedent symptoms. In an autopsy series reported from the University of Michigan [12], Vcl. 116,
November
196X
sixteen oi twenty patients had symptoms preceding mesenteric thrombosis. These varied in duration from three weeks to two vears. Generalized arteriosclerosis frequently ‘is manifest in other areas prior to the development of visceral angina. m’eight loss is common and may be severe. An upper abdominal bruit is an important physical finding, but it is not present in all cases and should not be expected in some of the patients with extreme stenosis or complete occlusion [IF]. No bruit was preent in at least five of the patients in Table I. Definitive diagnosis depends upon tiemonstration of the origin of the celiac and superior mesenteric arteries in a lateral aortogram [15]. Advanced arteriosclerosis is usually present in all three visceral abdominal arteries before symptoms occur. It has become axiomatic that at least two of the vessels are severely diseased before symptoms develop. This depends upon the development of collateral flow during the slow evolution of arteriosclerosis since sudden occlusion of one vessel, for example, occlusion due to embolus, can produce necrosis. The viability of the intestine can be maintained in spite of complete obstruction of all three visceral vessels [16,17]. Patients may be asymptomatic with occlusion of both celiac and superior mesenteric arteries [18]. Isolated stenosis of the celiac artery has been
'722
Kiser and Utley After the demonstration of arterial narrow ing, surgery should be prompt to circumvent the development of gangrene. In addition to developing in our patient, gangrene has developed in two reported p,atients after arteriography
1251.
FIG. 3. Lateral view- showing the origin of the celiac artery to be almost completely occluded by a short plaque.
discussed in two papers with the conclusion that isolated stenosis is not symptomatic [19,20]. The upper abdominal pain in most of this group of patients was due to other disease. Two patients were unimproved after resection of the stenosed segment. However, symptoms apparently may be produced by constriction of the celiac artery at the aortic hiatus by the crura of the diaphragm [4,5]. This occurs most commonly in women prior to the age of severe arteriosclerosis. These symptoms due to celiac artery compression have been treated with good results by division of the constricting band and resection of the narrowed segment [4,5 1. Isolated occlusion of the inferior mesenteric artery may be asymptomatic, may cause acute infarction, or may cause a chronic fibrosis and stenosis of the descending colon [Zl ] Gangrene of the descending colon occurs in about 1 per cent of patients after aneurysmectomy [ZZ]. Aneurysmectomy or aortography may precipitate visceral angina due to interference with the inferior mesenteric artery [5,23]. In three of the patients with reported cases of superior mesenteric artery bypass visceral angina developed after aneurysmectomy [24].
The surgical approach depends upon the physique of the patient and the nature of the lesion. The celiac axis arises from between the crura of the diaphragm or even from above the diaphragm. Thoracoabdominal incisions have commonly been recommended [12]. In our reconstruction of the celiac axis, preparation was made for a thoracoabdominal incision, but proved unnecessary when adequate exposure was obtained through an upper abdominal incision. Exposure of the origin of the celiac artery can usually be achieved through the lesser omentum. The best exposure of the superior mesenteric artery is by reflecting the contents of the left upper quadrant downward and to the right. Vascular reconstruction is facilitated by the localized distribution of these lesions. The occluding plaques NilI generally be within the first 2.5 cm. of the celiac or superior mesenteric arteries. They are most commonly found at the origin from the aorta [26]. In a rare patient, reconstruction may be impossible because of involvement of peripheral branches of the superior mesenteric artery [12]. In Table I the reported cases of elective arterial reconstruction for arteriosclerotic occlusive disease are summarized. The reported results of reconstruction have been remarkably successful both technically and symptomatically. Endarterectomy, bypass, and reimplantation have all produced good results. Bypass can be carried out without exposing the origin of the superior mesenteric artery and may be warranted for that reason in poor risk patients. Nevertheless, it seems advisable to measure pressure differentials between the aorta and the celiac and superior mesenteric arteries whenever possible. When large gradients exist, reconstruction of both the superior mesenteric artery and celiac artery should be performed. This has been reported four times [2,5,34]. Failure to reconstruct both arteries may require a secondary operation as became necessary in our patient. In three patients, symptoms recurred after being initially relieved by surgical correction of the lesion in a single artery; symptoms were again relieved by operation upon a second visceral artery [5,10]. The American
Jouvnal of Surgery
\‘isceral
Artery
;2:3
Reconstruction
TABLE I ELECTIVE VISCERAL ARTERY RECOSSTR~CTIOS
Type
No. of Operations
Survivors
No. with Total Occlusion of Both Celiac and Superior Mesenteric Arterie
References
--___ Superior mesenteric endarterectomy Superior mesenteric reimplant Superior mesenteric bypass Celiac endarterectomy Celiac reimplant Celiac bypass5 Inferior mesenteric endarterectomy Reconstruction of both celiac and superior mesenteric artery Reconstruction of visceral artery and aortoiliac system Total
9 3* 6
9 3
6t 1
4
10 44
1
_
_-. _
[~,~0.22,‘7~30..?4]
I)
[I8 31,321
0
[12:14,23,33] Present case
04 81
0 1 0
1
0
IlO1
4
3
[2,5,34]
t%!5,12.31,3%,
10** 1 [2,5,12,3-371 4% operationstt 40 patients (two patients had two operations)
* One patient was asymptomatic preoperatively despite complete occlusion of both celiac and superior mesenteric arteries. t Symptoms were unchanged in a forty-one year old woman who had had superior mesenteric endarterectomy. All other patients had great improvement postoperatively. 3 Death was due to occlusion of the collateral vessels in the presence of complete occlusion of superior mesenteric artery. $ In three cases, the splenic artery was implanted in the aorta to form a bypass. 11One patient had occlusion of the celiac axis with supradiaphragmatic aneurysm of the celiac axis. ll Mortality due to postoperative hemorrhage. ** In one patient, symptoms recurred, requiring celiac resection. tt In one patient with superior mesenteric bypass at the time of aortic aneurysmectomy, celiac bypass was performed two years later for recurrent symptoms.
Thus, when surgery is performed, pressure measurements are important to assess the severity of the block and the therapeutic result [19]. Ten of the aforementioned case reports contain pressure measurements. Symptomatic obstruction is associated with a pressure gradient of 50 to 100 mm. Hg. These gradients may be present in both the celiac and superior mesenteric arteries. One patient had only 35 mm. Hg mean arterial pressure in both of these vessels [26]. Reconstruction of the inferior mesenteric artery for visceral angina is recorded only once in the surgical literature. This was reported in 1958 by Shaw and Maynard as part of the first description of eIective surgery for visceral angina [IQ]. Vol. 116, November 1968
SUMMARY
The mortality from thrombosis of the superior mesenteric artery remains very high. Most of these patients have prodromal symptoms of visceral angina. Elective surgical reconstruction of visceral arteries has been remarkably successful both immediately and in long-term relief of these symptoms. A case presentation illustrates the course of this disease. As physicians become more generally aware of this syndrome an increasing number of these patients will be treated. REFERENCES 1. ALVARES,J.F.,PARSONNET,V.,~~~ BRIEF, D.K. Mycotic aneurysms of the superior mesenteric artery.Am. J. Surg., 111: 237 1966.
724
Kiser and Utley
2. MORRIS, A. C., CRAWFORD, E. S., COOLEY, D. il., and DEBAKEY, M. E. Revascularization of the celiac and superior mesenteric arteries. Arch. Surg., 84: 95, 1962. 3. PAPADOPOULOS, C. and STASKO, A. Successful repair of multiple arterial lesions including an aneurysm of the celiac artery. Am. J. Swg., 112: 116, 1966. 4. DUNBAR, J. D., MOLNAR, W., BEMAN, F. F., and MARABLE, S. A. Compression of the celiac trunk and abdominal angina. Am. J. Roentgenol., 95: 731 1965. 5. STONEY, R. J. and WYLIE, E. J. Recognition and surgical management of visceral ischemic syndromes. Ann. Surg., 164: 714, 1966. 6. TAYLOR, R. M. DOUGLAS, A. P., HACKING, P. M., and WALKER, F. C. Traumatic fistula between a main branch of the superior mesenteric artery and vein. Am. J. Med., 38: 641, 1965. 7. SHIRKEY, A. L., QWAST, D. C., and JORDAN, G. L. Superior mesenteric artery division and intestinal function. J. Trauma, 7: 7, 1967. 8. KLASS, A. A. Embolectomy in acute mesenteric occlusion. Ann. Surg., 134: 913, 1951. 9. STEWART. G. D.. SWEETMAN. W. R.. WESTPHAL. K., and WISE,‘R. A. Superior mesenteric artery embolectomy. Ann. Swg., 151: 274, 1960. 10. SHAW, R. S. and MAYNARD, E. P. Acute and chronic thrombosis of the mesenteric arteries associated with malabsorption: a report of two cases successfully treated by thromboendarterectomy. New England J. Med., 258: 874, 1958. 11. SCHNITZLER, J. Zur Symptomatologie des Darmarterien-verschlusses. B’ien. med. l~chnschr., 51: 506, 567, 1901. 12. FRY, W. J. and KRAFT, R. 0. Visceral angina. Surg. Gynec. & Obst., 117: 417, 1963. 13. LAPICCIRELLA, V. Mesenteric insufficiency. Am. J. Cardiol., 16: 912, 1965. 14. MAVOR, G. C. and LYALL, A. D. Superior mesenteric artery stenosis treated by iliac-mesenteric arterial bypass. Lancet, 2: 1143, 1962. 15. Editorial. Visceral angina. Brit. J. Med., 5392: 1199, 1964. 16. BLALOCK, A. and LEVY, S. E.: Gradual complete occlusion of coeliac axis, the superior and inferior mesenteric arteries with survival af animals: effects of ischemia on blod pressure. Surgery, 5: 175, 1939. 17. CHEINE, J. Complete obliteration of celiac and mesenteric viscera receiving their arteries: blood supply through the extraperitoneal system of vessels. J. Anat. Physiol., London 3 (second series), 65, 1868-69. 18. BROLIN, L. and HANSSON, L. 0. Thrombotic occlusions of both the coeliac axis and superior mesenteric artery. Acta. chir. Scandinav, 128: 261, 1964. 19. DRAPANAS, T. and BRON, K. M. Stenosis of coeliac artery. Ann. Surg., 164: 1085, 1966. 20. REUTER, S. R., and OLIN, T. Stenosis of the celiac artery. Radiology, 85: 617, 1965. 21. HANNAN, J. R., JACKSON, B. F., and PIPIK, P.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34. 35.
36.
37.
Fibrosis and stenosis of the descending colon and sigmoid following occlusion of the inferior mesenteric artery. ,4m12.J. Roentgenol, 91: 826, 1964. YOUNG, J. R., HUMPHRIES,A. W., DEWOLFE, V. G., and LEFEVRE, F. A. Complications of abdominal aortic surgery: intestinal ischernia. Arch. Suvg., 86: 51, 1963. KREMENCHWZKY, M., STEIMBERG, M., KRYNSKI, Z., and PORTUGALLI, J. Colonic cotnplications of aortography. Prensa med. urgent., 52: 2324, 1965. ROB, C. and SNYDER, M. Chronic intestinal ischemia: a complication of surgery of the abdominal aorta. Surgery., 60: 1141, 1966. CONNOLLY, J. E. Discussion: recognition and surgical management of visceral ischemic syndrome. Ann. Surg., 164: 721, 1966. DERRICK, J. R., POLLARD, H. S.. and MOORE, R. M. The pattern of arteriosclerotic narrowing of the coeliac and superior mesenteric arteries. Ann. Surg., 149: 684, 1959. GULDHAMMER, E. H., LUND, F., POULSEN, T. and SCHIOLER, H. Chronic intestinal ischemia. Acta. chir. Scandinav., 131: 366, 1966. MIKKELSEN, W. P. and SARO, J. A., JR. Intestinal angina: report of a case with pre-operative diagnosis and surgical relief. New England J. Med., 260: 912, 1959. LARSON, R. E., SPITTELL, J. A., and KIRKLIN, J. W. Insufficiency of superior mesenteric artery (socalled intestinal angina): report of a patient successfully treated by endarterectomy. Proc. Sta# Meet. Mayo Cl%., 38: 436, 1963. CONNOLLY, J. E., ABRAMS, H. L., and KIERALDO, J. H. Observations on the diagnosis and treatment of obliterative disease of the visceral branches of the abdominal aorta. Arch. Surg., 90: 596, 1965. HIVET, M. and BOGNEL, J. C. Abdominal angina: report of three cases treated by mesenteric and spleno-aortic anastomosis. Dis. Chest, 47: 549, 1965. VOLLMAR, J., HARTERT, H., HASSE, H. M., SHRODER K., and COERPER, H. G. The chronic obstructive syndrome of the visceral arteries. Arch. klin. Chir., 305: 473, 1964. RANGER, I. and SPENCE, M. P. Superior mesenteric artery occlusion treated by ileocolic aortic anastomosis. Brit. J. Med., 5297: 95, 1962. MIKKELSEN, W. P. and BERNE, C.J. Intestinal angina. S. Cl&.. North America, 42: 1321, 1962. HEJHAL, L., FIRT, P., MICHAL, V., and HEJNAL, J. Some interesting case reports in the field of reconstructive vascular surgery. J. Card&ax. Swg., 6: 409, 1965. STARZL, T. E. and TRIPPEL, 0. H. Reno-mesenteroaorto-iliac thromboendarterectomy in a patient with malignant hypertension. Surgery, 46: 556, 1959. HEARD, G., JEFFRIES, J. D., and PETERS, D. K. Chronic intestinal ischemia: successful aorta/ superior-mesenteric bypass. Lancet, 2: 975, 1963.
The American Journal oj Surgery
Artery
Reconstruction*
M.D. AND JOE R. UTLEY, M.D., St.
From the Department of Surgery, Washington School of Medicine, St. Louis, Missouri.
Unietersity
His past history revealed that he had been hospitalized twice for coronary insufficiency. He had had numerous previous operations including laminectomy and bilateral replacement of superficial femoral arteries. Examination revealed a wiry, chronically ill man with blood pressure of 150/90 mm. Hg. The abdomen was scaphoid and nontender. There was an epigastric bruit. The systolic blood pressure in the left arm was 50 mm. Hg below that in the right. Both femoral pulses were palpable. Gastrointestinal roentgenograms were normal. Translumbar aortogram showed complete occlusion of the superior mesenteric artery with delayed filling of the splenic and hepatic arteries. (Fig. 1.) The superior mesenteric artery was filled from the inferior mesenteric artery by a greatly enlarged marginal artery of Drummond. The following morning he had severe pain in the right lower quadrant, fever, and leukocytosis. At laparotomy, the superior mesenteric artery was pulseless and the cecum gangrenous. A saphenous vein graft was placed from the aorta to the superior mesenteric artery, and the ascending colon was resected, bringing the ends of the ileum and transverse colon out the wound. Forty-eight hours later, the patient was returned to the operating room and all bowel appeared viable. An ileotransverse colostomy was performed. The patient recovered uneventfully, ate well, gained weight, and was asymptomatic for two months. He was readmitted on January 3, 1967 for evaluation of pain of two months’ duration which was steady, epigastric in location, and not directly related to meals. He had no fever, colic, or bleeding. Gastrointestinal roentgenograms again revealed nothing abnormal. A translumbar arteriogram showed the bypass saphenous graft filling the superior mesenteric artery. The large inferior mesenteric artery was decreased in size. The hepatic artery filled less rapidly than the superior mesenteric and adjacent renal vessels. (Fig. 2.) The origin of the celiac axis was not visualized. The patient was discharged for further observation. Over the subsequent month, his symptoms increased; he lost additional weight and became anorexic. He had increased pain
purpose of this paper is to present a T HE unique example of the progression of visceral artery disease and to review the current status of surgery for arteriosclerosis of the visceral arteries. The celiac and superior mesenteric arteries have been reconstructed for a variety of lesions. These include mycotic aneurysm [1,2], arteriosclerotic aneurysm [3], compression of the celiac axis by the aortic hiatus [4,5], traumatic fistula [6,7], and neoplastic involvement. Direct surgical attack upon the arteries of the small intestine has developed in accordance with the rapid advances in arterial surgery in other areas. Mesenteric embolectomy was first reported by Klass IS] in 1951. Shortly thereafter, the first successful embolectomy (with bowel resection) was reported by Stewart et al. [9]. Elective surgery for arteriosclerotic narrowing of the celiac and mesenteric vessels has been performed since 1958 [IO]. The relationship of abdominal symptoms to chronic intestinal ischemia was recognized as early as 1901 by Schnitzler [II]. Fry and Kraft [IZ] described the “typical triad of pain following meals, weight loss, and intestinal dysfunction for varying periods before death.” The following case is reported to illustrate the manifestations and management of visceral artery disease. CASEREPORT The patient, a fifty year old man, was admitted on July 28, 1966 for evaluation of abdominal pain. Over the preceding ten months, incapacitating upper abdominal pain had developed after meals. He had lost 20 pounds and was eating only one meal per day. All forms of food promptly produced pain. * Presented
Louis, Missouri
at the Twentieth Annual Meeting of the Southwestern Denver, Colorado, April 22-25, 1968. 720
Surgical Congress,
The American
Journal of Surgery
Visceral Artery Reconstruction
laterals
are srnallcr.
after meals and at night. Xrteriogram was repeated and showed severe stenosis at the origin of the celiac artery. (Fig. 3.) Iaparotomy was performed on February 22. I9GY’. The celiac axis was approached through the lesser omentum. The celiac vessels were dissected. Direct celiac artery pressure was 85:‘4(1 mm. Hg when the systemic pressure was l-IO/90 mm. Hg. An endarterectomy of the. origin of this vessel was performed. A Dacro# patch graft was applied over the arteriotomy. Immediate direct arterial pressure was the same as the systemic pressure. The postoperative course was uneventful. During the first six weeks, the patient complained of diarrhea. This has ceased; he is pain-free and has regained his original weight. r\ faint upper abdominal bruit has been present since surgery. COMMENTS
The symptoms and physical findings of visceral artery disease are well known. Pain typically follows meals and may be relieved by diarrhea1 bowel movements [12]. Lapiccirella [13] showed the postprandial meteorism and somnolence were often the initial symptoms. These symptoms frequently precede the symptoms of coronary arteriosclerosis and abdominal angina by many years. The duration of symptoms is variable, but most patients with mesenteric thrombosis due to arteriosclerosis have antecedent symptoms. In an autopsy series reported from the University of Michigan [12], Vcl. 116,
November
196X
sixteen oi twenty patients had symptoms preceding mesenteric thrombosis. These varied in duration from three weeks to two vears. Generalized arteriosclerosis frequently ‘is manifest in other areas prior to the development of visceral angina. m’eight loss is common and may be severe. An upper abdominal bruit is an important physical finding, but it is not present in all cases and should not be expected in some of the patients with extreme stenosis or complete occlusion [IF]. No bruit was preent in at least five of the patients in Table I. Definitive diagnosis depends upon tiemonstration of the origin of the celiac and superior mesenteric arteries in a lateral aortogram [15]. Advanced arteriosclerosis is usually present in all three visceral abdominal arteries before symptoms occur. It has become axiomatic that at least two of the vessels are severely diseased before symptoms develop. This depends upon the development of collateral flow during the slow evolution of arteriosclerosis since sudden occlusion of one vessel, for example, occlusion due to embolus, can produce necrosis. The viability of the intestine can be maintained in spite of complete obstruction of all three visceral vessels [16,17]. Patients may be asymptomatic with occlusion of both celiac and superior mesenteric arteries [18]. Isolated stenosis of the celiac artery has been
'722
Kiser and Utley After the demonstration of arterial narrow ing, surgery should be prompt to circumvent the development of gangrene. In addition to developing in our patient, gangrene has developed in two reported p,atients after arteriography
1251.
FIG. 3. Lateral view- showing the origin of the celiac artery to be almost completely occluded by a short plaque.
discussed in two papers with the conclusion that isolated stenosis is not symptomatic [19,20]. The upper abdominal pain in most of this group of patients was due to other disease. Two patients were unimproved after resection of the stenosed segment. However, symptoms apparently may be produced by constriction of the celiac artery at the aortic hiatus by the crura of the diaphragm [4,5]. This occurs most commonly in women prior to the age of severe arteriosclerosis. These symptoms due to celiac artery compression have been treated with good results by division of the constricting band and resection of the narrowed segment [4,5 1. Isolated occlusion of the inferior mesenteric artery may be asymptomatic, may cause acute infarction, or may cause a chronic fibrosis and stenosis of the descending colon [Zl ] Gangrene of the descending colon occurs in about 1 per cent of patients after aneurysmectomy [ZZ]. Aneurysmectomy or aortography may precipitate visceral angina due to interference with the inferior mesenteric artery [5,23]. In three of the patients with reported cases of superior mesenteric artery bypass visceral angina developed after aneurysmectomy [24].
The surgical approach depends upon the physique of the patient and the nature of the lesion. The celiac axis arises from between the crura of the diaphragm or even from above the diaphragm. Thoracoabdominal incisions have commonly been recommended [12]. In our reconstruction of the celiac axis, preparation was made for a thoracoabdominal incision, but proved unnecessary when adequate exposure was obtained through an upper abdominal incision. Exposure of the origin of the celiac artery can usually be achieved through the lesser omentum. The best exposure of the superior mesenteric artery is by reflecting the contents of the left upper quadrant downward and to the right. Vascular reconstruction is facilitated by the localized distribution of these lesions. The occluding plaques NilI generally be within the first 2.5 cm. of the celiac or superior mesenteric arteries. They are most commonly found at the origin from the aorta [26]. In a rare patient, reconstruction may be impossible because of involvement of peripheral branches of the superior mesenteric artery [12]. In Table I the reported cases of elective arterial reconstruction for arteriosclerotic occlusive disease are summarized. The reported results of reconstruction have been remarkably successful both technically and symptomatically. Endarterectomy, bypass, and reimplantation have all produced good results. Bypass can be carried out without exposing the origin of the superior mesenteric artery and may be warranted for that reason in poor risk patients. Nevertheless, it seems advisable to measure pressure differentials between the aorta and the celiac and superior mesenteric arteries whenever possible. When large gradients exist, reconstruction of both the superior mesenteric artery and celiac artery should be performed. This has been reported four times [2,5,34]. Failure to reconstruct both arteries may require a secondary operation as became necessary in our patient. In three patients, symptoms recurred after being initially relieved by surgical correction of the lesion in a single artery; symptoms were again relieved by operation upon a second visceral artery [5,10]. The American
Jouvnal of Surgery
\‘isceral
Artery
;2:3
Reconstruction
TABLE I ELECTIVE VISCERAL ARTERY RECOSSTR~CTIOS
Type
No. of Operations
Survivors
No. with Total Occlusion of Both Celiac and Superior Mesenteric Arterie
References
--___ Superior mesenteric endarterectomy Superior mesenteric reimplant Superior mesenteric bypass Celiac endarterectomy Celiac reimplant Celiac bypass5 Inferior mesenteric endarterectomy Reconstruction of both celiac and superior mesenteric artery Reconstruction of visceral artery and aortoiliac system Total
9 3* 6
9 3
6t 1
4
10 44
1
_
_-. _
[~,~0.22,‘7~30..?4]
I)
[I8 31,321
0
[12:14,23,33] Present case
04 81
0 1 0
1
0
IlO1
4
3
[2,5,34]
t%!5,12.31,3%,
10** 1 [2,5,12,3-371 4% operationstt 40 patients (two patients had two operations)
* One patient was asymptomatic preoperatively despite complete occlusion of both celiac and superior mesenteric arteries. t Symptoms were unchanged in a forty-one year old woman who had had superior mesenteric endarterectomy. All other patients had great improvement postoperatively. 3 Death was due to occlusion of the collateral vessels in the presence of complete occlusion of superior mesenteric artery. $ In three cases, the splenic artery was implanted in the aorta to form a bypass. 11One patient had occlusion of the celiac axis with supradiaphragmatic aneurysm of the celiac axis. ll Mortality due to postoperative hemorrhage. ** In one patient, symptoms recurred, requiring celiac resection. tt In one patient with superior mesenteric bypass at the time of aortic aneurysmectomy, celiac bypass was performed two years later for recurrent symptoms.
Thus, when surgery is performed, pressure measurements are important to assess the severity of the block and the therapeutic result [19]. Ten of the aforementioned case reports contain pressure measurements. Symptomatic obstruction is associated with a pressure gradient of 50 to 100 mm. Hg. These gradients may be present in both the celiac and superior mesenteric arteries. One patient had only 35 mm. Hg mean arterial pressure in both of these vessels [26]. Reconstruction of the inferior mesenteric artery for visceral angina is recorded only once in the surgical literature. This was reported in 1958 by Shaw and Maynard as part of the first description of eIective surgery for visceral angina [IQ]. Vol. 116, November 1968
SUMMARY
The mortality from thrombosis of the superior mesenteric artery remains very high. Most of these patients have prodromal symptoms of visceral angina. Elective surgical reconstruction of visceral arteries has been remarkably successful both immediately and in long-term relief of these symptoms. A case presentation illustrates the course of this disease. As physicians become more generally aware of this syndrome an increasing number of these patients will be treated. REFERENCES 1. ALVARES,J.F.,PARSONNET,V.,~~~ BRIEF, D.K. Mycotic aneurysms of the superior mesenteric artery.Am. J. Surg., 111: 237 1966.
724
Kiser and Utley
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