|Year : 2020 | Volume
| Issue : 3 | Page : 273-276
A case report of retrograde open mesenteric stenting for acute mesenteric ischemia
Ankur Aggarwal, Manju Bharat, Sunder Narasimhan
Department of Vascular Surgery, Apollo Hospital, Bengaluru, Karnataka, India
|Date of Submission||15-Sep-2019|
|Date of Acceptance||21-Oct-2019|
|Date of Web Publication||12-Sep-2020|
Department of Vascular Surgery, Apollo Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Occasionally, acute mesenteric ischemia cases present with vessels, which are very difficult to cannulate via the percutaneous method. Furthermore, there is a dire need to preserve as much bowel as possible in these cases. Another problem is the long operative time required for open revascularization in these cases and the associated risks. We present such a case of acute mesenteric ischemia with gangrenous distal ileum in an 87-year-old female with multiple comorbidities who was treated with retrograde open mesenteric stenting and resection and anastomosis of the gangrenous segment of the bowel. We recommend vascular surgeon involvement in all cases of laparotomies for acute mesenteric ischemia and we should consider retrograde open mesenteric stenting if cannulation of mesenteric arteries via percutaneous approach is not possible.
Keywords: Acute mesenteric ischemia, bowel gangrene management, mesenteric revascularization, retrograde open mesenteric stenting
|How to cite this article:|
Aggarwal A, Bharat M, Narasimhan S. A case report of retrograde open mesenteric stenting for acute mesenteric ischemia. Indian J Vasc Endovasc Surg 2020;7:273-6
|How to cite this URL:|
Aggarwal A, Bharat M, Narasimhan S. A case report of retrograde open mesenteric stenting for acute mesenteric ischemia. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Oct 22];7:273-6. Available from: https://www.indjvascsurg.org/text.asp?2020/7/3/273/294912
| Introduction|| |
Despite technological advancements, acute mesenteric ischemia has been traditionally found to be associated with high mortality (approximately 60%–90%).,, Some patients require immediate laparotomy for inspection as well as for resecting gangrenous bowel. In addition, percutaneous revascularization may not be possible in some cases due to extensive aortic wall or mesenteric artery origin atherosclerosis and calcification. In such cases, retrograde open mesenteric stenting is an important alternative to improve mesenteric circulation to the remaining viable bowel. We present a case of acute mesenteric ischemia, which was treated by retrograde open mesenteric stenting along with bowel resection.
| Case Report|| |
An 87-year-old female with diabetes, hypertension, and ischemic heart disease (past history of coronary artery bypass grafting) was admitted with sudden onset severe pain of the abdomen and obstipation for 1 day. On examination, she was tachypneic and tachycardic, and her abdomen was distended, tense, and tender. Contrast-enhanced computed tomography [CT] scan showed gas in the portal circulation, ischemic bowel, and calcified aorta at the origins of superior mesenteric artery (SMA) and celiac axis [Figure 1].
|Figure 1: Gas in portal circulation (a), Ischemic segment of bowel (b), Calcified aorta at the origin of the celiac artery and superior mesenteric artery (c)|
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In view of severe abdominal pain and features of peritonitis, emergency laparotomy followed by resection of gangrenous bowel and stoma/primary anastomosis was planned. Vascularity was planned to be restored by angioplasty – stenting or by bypass based on intraoperative findings.
Intraoperatively, distal ileal segment (approximately 15 cm) was found to be gangrenous [Figure 2].
Adjoining approximately 10 cm of the bowel was pale and had borderline vascularity. Therefore, it was decided to revascularize the bowel. The aorta was heavily calcified in the region of the mesenteric artery origins. In view of old age and high comorbidities, it was decided to go ahead with retrograde mesenteric stenting. The ileocolic artery was identified and cannulated. 5 Fr sheath was placed [Figure 3].
Angiogram showed severely calcified aorta with occluded SMA origin [Figure 4]. Angioplasty and stenting of the SMA was done, and angiogram showed good flows post stenting [Figure 5] and [Figure 6]. There was a significant change in the color of the previously borderline bowel from pale to pink, and the peristalsis improved. Then, gangrenous bowel resection and ileum–ascending colon anastomosis were done [Figure 7].
|Figure 4: Guidewire passed through the origin of superior mesenteric artery. Angio shoot showed occluded ostium|
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|Figure 5: 7 mm × 37 mm balloon mounted stent deployed at the origin of the superior mesenteric artery|
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|Figure 7: Resected distal ileum and proceeding for ileo–ascending colon anastomosis|
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The patient was started on oral feeds after the bowel function returned and was discharged on postoperatively day 12. The patient was seen after 2 months of discharge. She was healthy and tolerating solid oral feeds, and her bowel movements were regular.
| Discussion|| |
Very few reports of retrograde open mesenteric stenting have been reported in the literature.,,,,,, Most of these reports had very cachectic patients with severe comorbidities and high risk of death. This procedure has been found to be associated with high rates of mortality.,, Even our patient was very cachectic with high comorbidities and mortality risk.
A recent meta-analysis showed that mortality in acute mesenteric ischemia is approximately 17% in patients undergoing an endovascular procedure and approximately 25% in patients undergoing open surgery. However, when revascularization was necessary in the open surgery cohort, the mortality rate rose to 40%–54%. Therefore, in such high-risk patients, it would be prudent to minimize the time of and dissection during surgery.
Second, most of these patients have a significant length of the bowel that has a borderline vascularity. Improving the vascular supply can save these segments. This would reduce complications of the short gut syndrome and further requirement of intestinal transplantation. This would also reduce the need for stoma formation and avoid another surgery to close the stoma, apart from reducing the consequences of stoma formation (stoma leak, malnutrition, etc.). Healing of primary anastomosis, if done, would also increase dramatically. Apart from these advantages, operating time would be reduced, procedure-related mortality and morbidity will come down, and financial advantages will be huge.
Retrograde mesenteric endovascular interventions can help a great deal while dealing with patients who have very tight and nonnegotiable mesenteric vessel origins. In these patients, percutaneous methods of revascularization may not be very helpful. When compared with the open method of revascularization, it would reduce dissection and operating time, and therefore, minimize consequent morbidity and mortality in a great way. Therefore, this procedure can be considered while doing laparotomy for acute mesenteric ischemia to improve the blood supply to the remaining bowel.
Another suggestion would be to involve vascular surgeons for all exploratory laparotomies done for acute limb ischemia. This would go a long way in selecting a subgroup of cases, in which improving the blood supply to the gut shall allow the stoma or the anastomosis to heal and also reduce the length of gut resected. Furthermore, C-arm facilities with digital substraction angiography (DSA) should be readily available in the theater so that retrograde or percutaneous mesenteric revascularization can be performed.
Finally, age, comorbidities, and vessel/bowel status on CT scan should not be the deciding factors in revascularization. In this aspect, hybrid techniques of revascularization could help to reduce the complications of open revascularization that would be expected in these extremely sick and highly morbid patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
It is my pleasure to thank Dr. Sunder Narasimhan for his valuable support and inputs in managing this case and guiding me through this case and writing this case report. I would also like to thank Dr. Manju Bharat for constant help in creating this case report. Last, but not the least, I would like to thank my patient for allowing me to publish her details.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP, et al.
Acomparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg 2011;53:698-704.
Park WM, Gloviczki P, Cherry KJ Jr., Hallett JW Jr., Bower TC, Panneton JM, et al.
Contemporary management of acute mesenteric ischemia: Factors associated with survival. J Vasc Surg 2002;35:445-52.
Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: A clinical review. Arch Intern Med 2004;164:1054-62.
Sonesson B, Hinchliffe RJ, Dias NV, Resch TA, Malina M, Ivancev K. Hybrid recanalization of superior mesenteric artery occlusion in acute mesenteric ischemia. J Endovasc Ther 2008;15:129-32.
Wyers MC, Powell RJ, Nolan BW, Cronenwett JL. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. J Vasc Surg 2007;45:269-75.
Moyes LH, McCarter DH, Vass DG, Orr DJ. Intraoperative retrograde mesenteric angioplasty for acute occlusive mesenteric ischaemia: A case series. Eur J Vasc Endovasc Surg 2008;36:203-6.
Stout CL, Messerschmidt CA, Leake AE, Veale WN, Stokes GK, Panneton JM. Retrograde open mesenteric stenting for acute mesenteric ischemia is a viable alternative for emergent revascularization. Vasc Endovascular Surg 2010;44:368-71.
Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemia – A case report. Vasc Endovascular Surg 2004;38:89-91.
Do N, Wisniewski P, Sarmiento J, Vo T, Aka PK, Hsu JH, et al.
Retrograde superior mesenteric artery stenting for acute mesenteric arterial thrombosis. Vasc Endovascular Surg 2010;44:468-71.
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.e7-11.
Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S, et al.
Revascularization for acute mesenteric ischemia. J Vasc Surg 2012;55:1682-9.
Wyers MC. Acute mesenteric ischemia: Diagnostic approach and surgical treatment. Semin Vasc Surg 2010;23:9-20.
Adaba F, Askari A, Dastur J, Patel A, Gabe SM, Vaizey CJ, et al.
Mortality after acute primary mesenteric infarction: A systematic review and meta-analysis of observational studies. Colorectal Dis 2015;17:566-77.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]