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Objective: Acute mesenteric ischemia is a life threatening vascular emergency associated with a very high mortality rate. The current standard of care for acute mesenteric artery thrombosis is mesenteric arterial bypass grafting, but the perioperative mortality has been reported to be as high as 45%. A hybrid technique that employs an exploratory laparotomy, canalization of the distal superior mesenteric artery (SMA), and stent deployment across the atherosclerotic lesion was first described in 2004 for the treatment of acute on chronic mesenteric ischemia. We report 5 cases where acute on chronic mesenteric ischemia was treated with exploratory laparotomy and retrograde SMA stent placement. The purpose of this study is to describe this novel technique and to present our clinical outcomes, with regard to mortality, re-operation rate, and symptom resolution.
Methods: This is a retrospective review of 5 cases of acute on chronic mesenteric ischemia that required emergent revascularization. Each patient in the study had a diagnosis of chronic mesenteric ischemia based on imaging that revealed atherosclerosis of the SMA, food intolerance or aversion, and a history of weight loss. In each case, a balloon mounted covered stent (iCAST^TM, Atrium Medical Corp.) was directly placed in the SMA in a retrograde fashion during exploratory laparotomy. A completion angiogram was performed in each case to ensure patency. All operations were performed at a single institution between 20011-2013.
Results: The mean age of the patients in the study was 83±8.6 with an average APACHE II score of 14.5±2.6 upon presentation. Of the 5 patients reviewed, 3 had necrotic bowel necessitating resection, and 4 patients required ICU admissions. All attempts at SMA stenting were successful without technical complications as verified by completion angiogram. Overall, 4 of 5 patients survived the hospitalization and were discharged tolerating PO diet without symptoms. Re-interventions were required in 2 cases, one patient died of overwhelming sepsis within 24hrs of presentation.
Conclusions: The hybrid technique of exploratory laparotomy and retrograde SMA stenting is a viable revascularization option for the treatment of acute on chronic mesenteric ischemia. The preliminary results in this study for this novel technique have been promising with regards to patient mortality, when compared to that of mesenteric arterial bypass surgery.