Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/1677-5449.202301482
Jornal Vascular Brasileiro
Artigo Original

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Revascularização aberta na isquemia mesentérica crônica durante a era endovascular: experiência de um centro quaternário e um algoritmo de tratamento

Bruno Pagnin Schmid; Vinícius Adorno Gonçalves; Lucas Marcelo Dias Freire; Felipe Nasser; Fábio Hüsemann Menezes

http://dx.doi.org/10.1590/1677-5449.202301482 J Vasc Bras, vol.23, e20230148, 2023
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Abstract

Background: Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

Objectives: To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Methods: Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan’s arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution’s experience and a review of recent literature.

Results: All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Conclusions: Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Keywords

mesenteric ischemia, superior mesenteric artery, mesenteric arteries, mesenteric vascular occlusion, blood vessel prosthesis

Resumo

Contexto: A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta.

Objetivos: Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição.

Métodos: Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C.

Resultados: Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos.

Conclusões: A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Palavras-chave

isquemia mesentérica, artéria mesentérica superior, artérias mesentéricas, oclusão vascular mesentérica, prótese vascular

Referências

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Submetido em:
16/10/2023

Aceito em:
16/12/2023

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