Polling Station

Poll 01/03/2019 – 31/03/2019

The chronic mesenteric ischemia

Patient’s characteristics

 

Gender: Female

Age: 69 years old

Comorbidity: Arterial hypertension, Dyslipidemia, coronary heart disease (DES deployment 2 years ago)

Symptoms:  Postprandial pain

Previous abdominal operations: None

DUS: Occlusion of the superior mesenteric artery

Question #1

Do you think that isolated SMA occlusion can cause mesenteric ischemia?
  • Yes

  • No

The expert: Raphaël Coscas, MD
Although the Mikkelsen rule is that at least two of the three intestinal vessels (celiac artery [CT], superior mesenteric artery [SMA] and inferior mesenteric artery [IMA]) need to be severely stenosed/occluded to cause mesenteric ischemia [1], the truth can be different in the daily practice. Chronic mesenteric ischemia can be caused can an isolated SMA occlusion, especially if the collateral network is weak (prior abdominal/colic surgery) or if the disease extends to the distal SMA. Acute mesenteric ischemia can of course be caused by an isolated SMA occlusion.
Question #2

Which would be your primary SMA revascularization method?
  • Endovascular

  • Surgery

  • Hybrid

The expert: Raphaël Coscas, MD
It is hard to give a clear answer based on one single CT view. However, endovascular therapy seems here feasible since there is a short stump of patent SMA. Also, the lesion is not calcified at all. In contrast, open surgery might be challenging since the supraceliac and the infrarenal aorta are heavily calcified – probably so are the iliacs – which complicates clamping. SMA transposition in the infrarenal aorta should be kept in mind but with the same clamping issues. However, we recently communicated on a surgical technique of clampless aortic anastomosis in such cases (see the case in the polling station). If there is need to open the abdomen (symptoms/blood tests with suspicion of acute mesenteric ischemia onset), retrograde open mesenteric stenting (ROMS) would be then my preferred option [2].
Question #3

In case of endovascular therapy, which is your primary access vessel
  • Common femoral

  • Upper extremity

The expert: Raphaël Coscas, MD
When I finished my residency, I was sure that the upper extremity was the easiest solution to access the intestinal vessels. Nevertheless, risks associated with arch navigation (stroke) are real in these patients with a generally multilevel atherosclerotic disease. The common femoral access generally allows to catheterize most SMA lesions, even in case of SMA occlusion. It is paramount to use specific material (45/55 cm pre-curved sheath and VS1 catheter on the table). In case of very acute SMA-to-aorta angle (as for the present case), directional steerable sheaths/catheter can be of great help.
Question #4

Which is your primary endovascular treatment option?
  • Bare Metal Stent

  • Stent Graft

  • Drug eluting stent

  • Plain Angioplasty

  • Drug coated balloon angioplasty

  • Vessel prep and drug coated balloon angioplasty

The expert: Raphaël Coscas, MD
I generally use balloon-expandable covered stents in the SMA. It allows a very precise placement to avoid covering collaterals and protects from emboli secondary to the angioplasty. When the disease extends more distally, I then add a self-explandable uncovered bare metal stent to avoid mesenteric kinking. This would be necessary in this case. I never use balloon angioplasty without stenting and this is in accordance with recent ESVS guidelines [3]. These guidelines represent an important document that vascular surgeons should read and know.
Question #5

Which conduit do you prefer for surgical reconstructions?
  • Great saphenous vein

  • Synthetic conduit

The expert: Raphaël Coscas, MD
Synthetic conduits avoid bypass kinking, especially when you perform a retrograde bypass from the infrarenal aorta or the iliacs. I generally use grafts reinforced with external rings. It is paramount to cover the graft with the omentum at the end of the procedure. There are 2 exceptions: septic context (bowel necrosis) and small diameter (<4mm) of the outflow vessel. A conduit not proposed here but that can be of interest (if the saphenous vein is not available) is the autologous SFA.
Question #6

In case of severe calcification of the aorta which surgical revasculariation option do you favor?
  • Antegrade bypass

  • Iliac-mesenteric bypass

  • Hybrid revascularization (retrograde endo treatment)

The expert: Raphaël Coscas, MD
Retrograde open mesenteric stenting (ROMS) is a great, fast and simple technique that avoids any clamping with high technical success rates and promising results [2]. The technique of clampless anastomosis we recently communicated on (see polling station) is also an option is such cases.