|Year : 2021 | Volume
| Issue : 2 | Page : 139-143
Retrograde mesenteric bypass with saphenous vein graft in chronic mesenteric ischemia in a resource-challenged setting
Anil Sharma, Sunil Dixit, Sourabh Mittal, Dhruva Sharma
Department of Cardiothoracic and Vascular Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
|Date of Submission||07-Jul-2020|
|Date of Decision||30-Jul-2020|
|Date of Acceptance||01-Sep-2020|
|Date of Web Publication||13-Apr-2021|
Department of Cardiothoracic and Vascular Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Chronic mesenteric ischemia is a pathophysiologic condition arising due to demand–supply mismatch of blood supply to bowel postprandially, resulting in chronic abdominal pain, food fear, and weight loss. The most common cause is atherosclerosis. Timely intervention in the form of mesenteric revascularization is the key to successful outcome. There are limited contemporary data on in-hospital outcomes of mesenteric revascularization via open versus endovascular therapy in a resource-challenged setting. Materials and Methods: This retrospective-prospective observational study included eight patients of chronic mesenteric ischemia who underwent open revascularization and were followed for a mean duration of 15 months. All patients were evaluated as per the institutional protocol, and retrograde mesenteric bypass with reverse saphenous vein graft was done in all cases. Outcomes were evaluated in terms of resolution of symptoms and confirmation of graft patency with duplex scan after 1 month and every 6 months thereafter. Results: Out of 8 patients, six patients were males. Predisposing factors for atheromatous diseases were present in all. All patients presented with postprandial abdominal pain and weight loss. Majority of patients ( n = 5) had involvement of all three mesenteric vessels (superior mesenteric artery, inferior mesenteric artery, and celiac axis). One patient was re-explored for bleeding in immediate postoperative period. One patient was admitted for small bowel obstruction in 1st month of follow-up after surgery and was managed conservatively. Two patients were lost to follow-up and six patients are symptom free and doing well on a close follow-up of 15 months. Conclusion: Open mesenteric revascularization, by reverse saphenous vein graft as conduit for bypass, performed by experienced surgeon gives promising results in terms of symptom-free duration and graft patency and can be preferred over endoscopic revascularization as a viable option in resource-challenged settings in developing nations.
Keywords: Chronic mesenteric ischemia, computed tomography aortogram, endoscopic revascularization, open revascularization, saphenous vein
|How to cite this article:|
Sharma A, Dixit S, Mittal S, Sharma D. Retrograde mesenteric bypass with saphenous vein graft in chronic mesenteric ischemia in a resource-challenged setting. Indian J Vasc Endovasc Surg 2021;8:139-43
|How to cite this URL:|
Sharma A, Dixit S, Mittal S, Sharma D. Retrograde mesenteric bypass with saphenous vein graft in chronic mesenteric ischemia in a resource-challenged setting. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jun 24];8:139-43. Available from: https://www.indjvascsurg.org/text.asp?2021/8/2/139/313573
| Introduction|| |
Chronic mesenteric ischemia (CMI) or intestinal angina or abdominal angina is an uncommon disease resulting from occlusion or stenosis (>70%) of at least two of three mesenteric vessels. Chronic abdominal pain after meals is the cardinal symptom of CMI.
The most common cause of CMI is atherosclerotic process which involves origin or proximal 2–3 cm of mesenteric arteries. It is a chronic progressive disease in which visceral arteries tend to increase blood flow through collateral circulation, but full compensation is not usually reached. CMI can become symptomatic in up to 85% of patients and can be life-threatening in up to 40% of patients.
Various diagnostic modalities, namely, duplex ultrasound, computerized tomography angiography, magnetic resonance angiography, or conventional aortography, are applied for the diagnosis of CMI. Diagnosis is often delayed in this particular condition because of low prevalence, misdiagnosis, or acute presentation in case of acute arterial thrombosis. Timely intervention is essential for better patient outcome.
Management involves mesenteric revascularization before onset of ischemic changes and deadly intestinal infarct. Numerous techniques have been described in literature to revascularize the mesenteric arteries, namely, angioplasty, endarterectomy, reimplantation, and antegrade or retrograde bypass grafting with autogenous or prosthetic grafts. Combined surgical and endovascular approach, using intraoperative retrograde superior mesenteric artery (SMA) stenting, is done for acute mesenteric ischemia as it is a surgical emergency. Due to high morbidity and invasiveness of the surgical intervention, endovascular stenting of the stenosed mesenteric vessel is the preferred modality worldwide. However, in our institution in view of low cost of surgical intervention as compared to stenting, along with good clinical outcomes, surgical intervention is the preferred treatment modality.
| Materials and Methods|| |
This retrospective-prospective observational study was conducted over a period of 3 years from January 2017 to December 2019 in a tertiary care center and teaching hospital in India. All patients were assessed and evaluated as per the institutional protocol (viz. complete history, physical examination, complete hemogram, renal function tests, liver function tests, pulmonary function tests, echocardiography, and radiological evaluation). Upper gastrointestinal (GI) endoscopy was performed to rule out other causes of abdominal pain. Other causes such as infectious, inflammatory, or autoimmune diseases were ruled out. Mesenteric stenosis of 70% or more was confirmed on CT aortogram. Patients were enrolled for elective surgery with the aim of mesenteric revascularization.
- Significant weight loss, cachexia
- No sign/symptom suggestive of intestinal infarction
- Insignificant coronary artery/renal artery disease.
- Asymptomatic on medical therapy
- Established intestinal gangrene
- Coronary lesions requiring intervention on priority
- Renal dysfunction on hemodialysis
- Median arcuate ligament syndrome
- Non occlusive mesenteric ischemia
- Previous laparotomy for segmental resection of intestine.
Retrograde mesenteric bypass with reverse saphenous vein graft was done in all cases. Saphenous vein graft has excellent tissue property, less thrombogenicity, and almost similar caliber without adding to the cost of procedure.
Patients were induced under general anesthesia. Central venous access was taken and arterial line was inserted for invasive BP monitoring. Nasogastric tube was inserted and lower limbs were prepared for vein harvesting. After laparotomy, gut was examined for any segmental gangrene and wrapped in warm sheet. Small bowel was retracted cephalad and toward right, retroperitoneum exposed. SMA was palpated along its course in small bowel mesentery and disease extent was identified. Site for distal anastomosis was chosen distal to middle colic branch near to right colic branch because of maneuverability. With the help of sharp dissection, retroperitoneum was entered, and the full extent of the aorta was exposed inferior to pancreatic border up to bifurcation of aorta. Aorta was dissected free and vascular controls were taken both proximally and distally. In cases where infrarenal aorta was not found suitable, common iliac artery was dissected and looped distally for iliomesenteric anastomosis in lazy “C” configuration [Figure 1]a. Peritoneum over SMA was incised, with careful dissection vascular loop passed; adjoining veins or lymphatics were ligated and cut. Heparin 150 U/kg was given and activated clotting time >200 was achieved. Vascular clamps were applied over SMA on both ends; arteriotomy was done over SMA; and end to side distal anastomosis with reverse saphenous vein graft was done. Retraction over small bowel was then removed and bowel was reposited in the right quadrants of the abdomen with assistant splaying distal anastomotic site. Appropriate length of vein graft was cut after identification of site for aortic anastomosis. Partial clamp was applied over infrarenal aorta, nondiseased portion. Neo-ostia were created with 6 mm aortic punch and vein was transected for appropriate length, beveled, and proximal anastomosis was completed [Figure 1]b. Intraoperatively, patency was checked with graft pulsations and any deterioration in bowel color was ruled out. Hemostasis was ensured and retroperitoneum was closed. Abdominal closure was done in layers and no drains were kept.
|Figure 1: Line diagram depicting operative procedure of mesenteric bypass: (a) Iliomesenteric anastomosis in lazy “C” configuration and (b) aortomesenteric bypass with distal anstomosis depicted in inset|
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Immediately after surgery, patients were shifted to ICU for watchful and intensive hemodynamic monitoring. Patients were kept on continuous nasogastric drainage. Intravenous heparin 10 U/kg/h was given to achieve desired anticoagulation with a targeted aPTT range of 60–80 s as per the institutional protocol. Patients were shifted toward when found hemodynamically stable and resumption of oral diet was done after return of bowel movements. Patients were switched over to oral anticoagulants for 6 months, along with antiplatelet drugs and statins. During follow-up, patients were evaluated clinically, and graft patency was confirmed with duplex scan after 1 month and every 6 months thereafter.
| Results|| |
Eight patients ( n = 8) underwent surgery for CMI over a period of 3 years from 2017 to 2019. Baseline characteristic of patients are shown in [Table 1] and presenting complaints in [Table 2]. While postprandial pain and weight loss were common to all, other bowel symptoms were also present. Disease was more common in males with male: female ratio of 3:1. Predisposing factors, namely, smoking, diabetes mellitus, hypertension, dyslipidemia, chronic obstructive pulmonary disease, and coronary artery disease for atheromatous disease, were present.
Pattern of involvement of mesenteric vessels in enrolled patients is shown in [Table 3] with most common being involvement of all three vessels (62.5%). Aortic atheromatous lesions were also seen in three patients for which common iliac artery was used as inflow vessel.
As shown in [Table 4], out of eight patients, only one patient was re-explored for bleeding in immediate postoperative period. One patient was admitted for small bowel obstruction in the 1st month of follow-up after surgery and was managed conservatively. Three patients experienced prolonged ileus in immediate postoperative period and were kept on nasogastric drainage for 4–5 days. However, there was spontaneous resumption of bowel activity.
The mean duration of hospital stay was 10 days (range, 7–14 days). There was no reporting of postprandial pain at time of discharge. These patients were evaluated clinically and radiologically (duplex scan) at 1 month and biannually thereafter. Subsequently, oral warfarin was withheld at 6 months interval and antiplatelets and statins were continued.
All patients were relieved of abdominal pain. Two patients were lost to follow-up after 1 year, and the rest six patients were asymptomatic till recent follow-up with patent graft as seen on duplex scan. The mean duration of follow-up was 15 months ranging from 8 months to 25 months. There was no recurrence of symptoms and nutritional status also improved.
| Discussion|| |
Mesenteric vessel stenosis is seen in 17.5% of routine aortic angiograms performed in patients older than 65 years, but due to collateral blood flow, they are predominantly asymptomatic. Although CMI has been described with female preponderance, in our series, it was more prevalent in males. Probable explanation for this could be more prevalence of atheromatous disease, hypertension,tobacco chewing and smoking in males in our country. There is often significant delay between onset of symptoms and subsequent treatment. In our series, average duration of symptoms was 8 months ranging from 4 to 14 months. All patients had postprandial abdominal pain and significant weight loss with food fear and dietary modifications to avoid pain. They had episodes of bloating and diarrhea, but none reported symptoms suggestive of GI bleeding.
Patients have already undergone physical examination, laboratory workup, upper and lower GI endoscopy, and imaging studies to exclude other causes of weight loss and pain before referral to our side. We did preoperative CT aortogram to look for other vessels' involvement, aortic pathologies (atheroma, calcifications, and iliac artery involvement), tandem lesions of SMA and origin and extent of stenosis of celiac, SMA, and inferior mesenteric artery. Certain investigations such as gut exercise tonometry have shown to aid in the diagnosis of CMI. It was not done in our institute because of nonavailability of this modality.
The goal of revascularization in patients with CMI is to relieve associated symptoms, improve nutritional status, and prevent any acute ischemic episode, resulting in bowel necrosis. Prophylactic revascularization is not warranted in asymptomatic patients. There has been upsurge in the management of CMI with percutaneous methods to establish revascularization. Complete revascularization has been advocated in various series as single graft thrombosis did not result into recurrence of symptom; however, it has been seen that physiological postprandial intestinal hyperemia is limited to SMA, so revascularization of SMA should suffice to abate symptoms of intestinal angina.,
There are no definitive guidelines as such for the management of splanchnic ischemia either by open or percutaneous method. Type of intervention done varies with the institute, referral, and expertise of vascular surgeon or intervention physician. However, in government institution like ours, where patients are not covered under any health insurance and compliance is poor, open revascularization (OR) still holds major role for the treatment of such conditions.
There has been significant debate regarding superiority of endovascular revascularization (ER) over OR with low perioperative morbidity and mortality and length of hospital stay. However, rate of recurrent stenosis is higher with ER ranging from 17% to 65% as compared to 10%–20% at 3 years. The symptom recurrence is also frequently seen with ER (15%–35%) as compared to OR (6%–24%). This results in increase in reintervention in primary ER patients negating the advantage seen in terms of morbidity.,,
Zacharias et al. in their study, on 116 patients, demonstrated failure of ER in 23% of patients. Primary patency at 3 years in OR was 91% as compared to 74% in endoscopic group. They found lesions > 2 cm, close to SMA origin and higher rate of aortic occlusive disease as risk factor for failure of ER.
In our series of patients, perioperative morbidity was seen in 12.5% ( n = 1), which required repeat hospitalization within 30 days and average length of stay was 10 days. There was no mortality reported in group of patients and all patients were relieved of postprandial pain in postoperative period. However, prolonged ileus was seen in 37.5% ( n = 3 ) in immediate postoperative period, which required prolonged nasogastric drainage and relieved subsequently. Kruger et al., in 39 consecutive patients, found perioperative morbidity of 12.2% with primary patency of 92%. Rawat et al., in multicenter study with primary bypass on 40 patients, found perioperative morbidity of 32% with primary patency of 80% at 1 year. Lejay et al. in their 10-year follow-up had 30 days morbidity and mortality rates of 13.9% and 3.5%, respectively. Patency at 10 years was close to 90% despite incomplete vascularization and freedom from symptoms was 80% in complete vascularization group.
Sivamurthy et al. in their comparative study found that though endovascular approach is less morbid than open vascularization, but symptomatic benefit was not achieved. They concluded that endovascular approach be reserved for patients who cannot undergo OR.
Site of aortic anastomosis was chosen based on aortogram findings in collaboration with intraoperative inspection and palpation of vessel. There have been equivalent results of both antegrade and retrograde mesenteric bypass. However, Huerta et al. have suggested that direct retrograde bypass is preferable to antegrade bypass for open mesenteric revascularization. Our preferred approach was also retrograde, as there is no need for total aortic occlusion although if the need arises it does not affect renal blood flow. None developed postoperative renal dysfunction. Right-sided common iliac artery was used in three patients for inflow. Ease of procedure was significant as per surgeon's perspective as compared to aorta.
Type of conduit, vein or prosthetic, has been topic of debate with nonsuperiority of one over the other. We chose saphenous vein with caliber at least 4 mm electively as it is autogenous, less thrombogenic, and it does not add to the cost of procedure. Davenport et al. found that saphenous vein has been used in emergent situations and contaminated field resulting in high mortality/morbidity rate, otherwise both prosthetic and vein graft are expected to function equally well. Modrall et al. have suggested that superficial femoral vein (SFV) yields acceptable clinical outcomes for mesenteric arterial bypass, compared with saphenous vein, making SFV a viable alternative when autogenous conduit is desired for mesenteric arterial reconstruction. However, we found 20–30 min of additional operative time for harvesting of SFV prohibitive and preferred saphenous vein in all patients. Excellent saphenous vein patency up to 10 years has been described in coronary artery bypass grafting which can be extrapolated in mesenteric bypass.
Davies et al. found 100% patency at 2-year follow-up in their surgical group of patients. In our series, all patients had patent grafts till their last follow-up. All patients showed weight gain and relief from postprandial pain was reported; however, bloating sensation and frequent bowel movements were seen in 25% ( n = 2).
Patients with median arcuate ligament or nonocclusive mesenteric ischemia were not part of treatment group as these patients are younger and free from significant intraluminal occlusive disease process and their treatment is different.
| Conclusion|| |
Our series demonstrated that open mesenteric revascularization, by reverse saphenous vein graft as conduit for bypass, performed by experienced surgeon, gives promising results in terms of symptom-free duration and graft patency. Certainly, endovascular revascularization seems to be promising option in old age and high surgical risk cases that have low life expectancy. However, in a developing nation like ours, where cost of the procedure goes to the patient as maximum patients do not have health insurance, OR is cost-effective with better results and is a viable option.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]