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Antegrade Aorto-Celiac and Superior Mesenteric Bypass
William J. Quinones-Baldrich
UCLA Med Ctr, Dept of Surgery, Los Angeles, CA
This video presents the key elements of an antegrade aortoceliac and superior mesenteric artery bypass through a midline transperitoneal approach.
The patient is a 73-year-old female with eight-month history of severe postprandial pain and weight loss. GI workup included endoscopy, abdominal ultrasound. Magnetic resonance angiogram documented proximal occlusion of the celiac artery and significant proximal and mid superior mesenteric artery stenosis. The location of the mid superior mesenteric artery stenosis and occlusion of the celiac artery precluded an endovascular approach.
Through a midline incision, the supraceliac aorta was exposed after full mobilization of the left lobe of the liver. Important steps in exposure of the supraceliac aorta are demonstrated including division of the crux of the diaphragm, ligation of phrenic branches, and encircling of the aorta. Exposure of the proximal hepatic artery is performed emphasizing control of the left gastric artery. Identification of the location and exposure of the superior mesenteric artery at the base of the mesocolon is illustrated. Creation of an ante-pancreatic tunnel for the limb of the reconstruction to the superior mesenteric artery is demonstrated. Use of a single 8 mm graft as the origin with a side limb of a 6 mm graft to create a bifurcated graft is utilized in preference of an off-the-shelf bifurcated graft. The benefit of this approach is a smaller aortic anastomosis which is emphasized. Creation of the distal anastomosis of the 8 mm graft to the hepatic artery, and the 6 mm graft to the superior mesenteric artery is illustrated. Evaluation of the reconstruction with Doppler and observation of mesenteric pulsations is demonstrated. A postoperative duplex scan one month later showing patency of the reconstruction completes the presentation.
Experience with open revascularization of the celiac and superior mesenteric artery is limited as more patients are treated with endovascular intervention. Operative revascularization for patients who are not candidates for endovascular treatment is an important component in the armamentarium of vascular surgeons managing patients with chronic mesenteric ischemia. Antegrade aortoceliac and superior mesenteric bypass is a durable alternative and should be considered in younger, good risk patients.
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