Step by step isolated aortomesenteric bypass for chronic visceral ischemia
This video summarizes in 3 minutes all important steps to perform an isolated antegrade aortomesenteric bypass. The patient had a chronic occlusion of the superior mesenteric artery and underwent a primary stenting of a high-grade stenosis of the celiac trunk (CT). The endovascular recanalization of the SMA at that time was not feasible. The CT-stent occluded 8 months postimplantation with a complete thrombosis of the hepatic artery as well. The splenic artery arose from the aorta directly.
Hello Theodosios, congratulations for the great exposure of a unusual case.
I have couple of questions :
1. Is it easy to isolate enough aortic segment to perform an proximal anastomosis? Enough space to sit the clamps? Have you considered using a partial clamp?
2. How much aortic clamping time?
3. Do you think the disadvantages of a retrograde bypass surpasses the risk/benefit from an anterograde bypass?
Dear Ricardo, thank you for your comments.
Q1: Yes, in patients that they are not so obese, it is simple. You have to be gentle to the oesophagus and by vertically dividing the median arcuate ligament and the interdigitating fibers of the left and right crura over the anterior aortic surface. Keep in mind, the aorta is always deeper than you think. You do not need to clamp the total aorta. You can partially clamp with a Satinsky.
Q2: If the wall is of good quality, about 10-15 minutes.
Q3: Absolutely! I would prefer the retrograde bypass only in really obese patients or in an unfriendly enviroment (redo) at the level of the supraceliac aorta,