This document describes a case of a 31-year-old male patient who presented with chronic abdominal pain and pain in both lower limbs for 6 months. Investigations revealed complete occlusion of the infrarenal aorta and celiac and superior mesenteric arteries. The patient underwent an open surgical bypass grafting procedure involving an aorto-mesenteric graft to restore blood flow to the celiac and superior mesenteric arteries. The procedure was technically successful and the patient was discharged after an uneventful post-operative recovery. Chronic mesenteric ischemia can be treated through open surgical or endovascular methods, with endovascular interventions demonstrating better long-term outcomes in many cases.

1. Chronic Mesenteric Ischaemia
with
Peripheral Arterial Disease
Dr SD Sanyal
Post Doctoral Trainee
Dept of CTVS
IPGME&R

2. History
• 31 yr old male
• Chronic smoker x 10yrs ( 10 pack years)
• Presented with c/o:
- Pain abdomen x 6 months
- Pain b/l Lower limbs
• Abdominal pain subsequently subsided after
being administered:
- Antiplatelet agents
- Statins
- Vasodilators

3. History
• No past h/o any significant illness
• No relevant family history
• He is a:
- Reformed chronic smoker
- Does not consume alcohol
- On mixed diet

4. Examination
• Avgly built and poorly nourished
• BP:142/86mmHg Pulse: 94/min/reg
• Clubbing +
• Chest: B/L vesicular breath sounds
• CVS: S1S2 normal, no murmurs
• P/A: Soft, non tender
No organomegaly
• CNS: NAD

5. Examination
• Bilateral lower limb pulses:
• Temp: Normal Colour: Normal
• CRT= 3secs Venous refilling: 5 secs
• Hairloss+, Nails brittle
• Ulcer over left great toe
Vessel Right Left
Femoral ABSENT ABSENT
Popliteal ABSENT ABSENT
ATA ABSENT ABSENT
PTA ABSENT ABSENT
ADP ABSENT ABSENT

6. Investigations
• US Doppler:
- Monophasic sluggish flow in B/L Femoral
artery and downwards
- Diffuse atherosclerotic changes
- Complete occlusion of b/l Iliac arteries with
normal veins

7. Investigations
• CT Angiogram:
- Complete occlusion of the infra-renal aorta
- Complete occlusion of Coeliac and SMA

8. CT Angiogram

9. Operative Steps
• Midline laparotomy upto Xiphisternum superiorly
and to 3cms below umbilicus
• Stomach retracted inferiorly
• Supra-coeliac aorta, Coeliac artery at the
trifurcation dissected
• Kocherization of duodenum done
• SMA dissected at the root of the mesentery
• Tunnel formed by blunt dissection below 3rd &
4th part of the duodenum and behind the root
the mesentery.

10. Operative steps
• Heparinisation done, 100U/kg
• Side biting clamp applied over the supra-coeliac
aorta
• 12-6 mm Dacron Y graft anastomosed with 5-0
continuous prolene sutures
• A piece of 6mm Dacron graft was anastomosed
end to side to the stem of the Y limb
• The distal end of the 6mm graft was
anastomosed at the point of branching of the
coeliac artery into common hepatic artery with 6-
0 prolene continuous

11. Operative steps
• The stem along with the 2 limbs tunneled behind
2nd part, inferior to the 3rd and 4th parts of
duodenum and behind the root of mesentery
• One limb was anastomosed to SMA anteriorly,
curving the Ligament of Treitz, with 6-0 prolene
• Common Iliac artery(L) dissected but it was
completely occluded
• Other limb was tunneled through the sigmoid
mesocolon , lateral pelvic wall along the root of
the iliac vessels behind the inguinal ligament and
anastomosed to the left femoral artery anteriorly
with 6-0 prolene(end to side)

12. Operative steps
• Dacron to dacron anastomosis with 6-0
prolene done, taking separate 6mm graft was
tunneled subcutaneously and anastomosed to
right femoral artery anteriorly

20. Post operative status
• RT feeds started on POD 1
• RT removed on POD 3
• Oral feeds started on POD 3
• Drain removed on POD 5
• Discharged on POD 8
• Suture removal done on POD 14

21. Post-operative Angiogram
• Patent grafts with normal flow to the target
vessels

22. Medications at Discharge
• Tab Acitrome 2mg OD
• Tab Ecospirin 75mg OD
• Tab Atorvastatin 20mg HS
• Tab Pantoprazole 40mg ODAC

23. DISCUSSION

24. Chronic Mesenteric Ischaemia
• Chronic mesenteric ischemia is a rare
condition that was first described in 1918 as
“abdominal angina” by Goodman
• Late presentation due to presence of
collaterals
• Diagnosis requires a high degree of clinical
suspicion compounded with imaging

25. Clinical Presentation
• Post prandial abdominal pain
• Weight loss
• Nausea, vomiting
• Diarrhoea
• Abdominal distension
• Constipation
• Occult blood in stool

26. Clinical Presentation
• Pain:
- Diffuse
- Onset 15-45 mins after meals
- Severity: Degree of occlusion & size of meals
- Early onset: Coeliac trunk occlusion

27. Etiopathogenesis
• Risk factors:
- Family history
- Smoking
- Hypercholestrolaemia
- Hypertension
- Female sex

28. Etiopathogenesis
• Types:
- Atherosclerotic: More common
- Non atherosclerotic:
1. Inflammatory arterial disease
2. Middle aortic syndrome
3. Median arcuate ligament syndrome
4. Neurofibromatosis
5. Fibromuscular dysplasia
6. Coarctation of aorta
7. Aortic dissection

29. Evaluation
• Physical examination:
- Signs of malnutrition
- Epigastric bruit
- Evidence of:
1. Coronary artery disease
2. Peripheral arterial disease

30. Evaluation
• Laboratory studies:
- Blood picture: Lekopaenia, anaemia
- Dyselectrolytaemia
- LFT: Hypoalbuminaemia
- Coagulation profile

31. Evaluation
• Imaging:
1. US Duplex scan:
- Promising results
- Fasting duplex criteria:
* SMA velocity> 275 cm/s
* Coeliac velocity> 200 cm/s
- Limitations: Body habitus, bowel gas,
operator dependence
Mitchell E L, Moneta G L. Mesenteric duplex scanning. Perspect Vasc Surg Endovasc
Ther. 2006;18:175–183. [PubMed]

33. Evaluation
2. MDCT:
- Used to evaluate for stenosis or occlusion within the
mesenteric vasculature
- Sequelae of ischemia: bowel wall thickening,
pneumatosis, or peritoneal fluid
- Can be timed to acquire images in both the arterial
and venous phases
- 3-D imaging allows evaluation of collateral pathways
- Superior to normal CT because of its fast scanning
speeds (0.5 seconds) and narrow collimation (1 mm),
Chronic Mesenteric Ischemia: Diagnosis and Treatment
Eric J. Hohenwalter, M.D. Semin Intervent Radiol. 2009 Dec; 26(4): 345–351

35. Evalution
3. MRA:
- Multiplanar imaging capability to evaluate
for stenoses within the mesenteric vessels
- Disadvantage: potential inability to
accurately evaluate the Inferior mesenteric
artery
- Advantage: Ability to image without
radiation

36. Evaluation
4. Angiography:
- Gold standard
- Performed to assist with treatment planning,
including angioplasty or stent placement
- Selective catheterization and pressure
measurement across a stenosis to determine
the hemodynamic significance of questionable
lesions
Ujiki M, Kibbe M R. Mesenteric ischemia. Perspect Vasc Surg Endovasc
Ther. 2005;17:309–318.[PubMed]

38. Treatment
• Medical management:
- Reserved for patients who are not healthy
enough to be treated, either surgically or
endovascularly
- Long-term anticoagulation : warfarin
- Nitrates provide temporary relief
- Not curative

39. Treatment
• Open surgical repair:
- Procedures: Transaortic endarterectomy, Direct re-
implantation on the aorta, and Antegrade or
Retrograde bypass grafting
- Series on surgical repair have reported success rates
and symptom improvement in 90 to 100% of patients*
- Associated with significant morbidity (5 to 30%) and
mortality (5 to 12%)**
- Weight loss, malnutrition & low albumin which are
predictors of increased morbidity and mortality after
major surgery***

40. Treatment
• Open surgical repair:
- Recurrent symptoms and reintervention rate >in
patients treated endovascularly compared to those
treated with open surgery.****
*Kihara T K, Blebea J, Anderson K M, Friedman D, Atnip R G. Risk factors and outcomes
following revascularization for chronic mesenteric ischemia. Ann Vasc Surg. 1999;13:37–
44.
**/****Atkins M D, Kwolek C J, LaMuraglia G M, Brewster D C, Chung T K, Cambria R P.
Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a
comparative experience. J Vasc Surg. 2007;45:1162–1171.
*** Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri S F. Preoperative serum albumin
level as a predictor of operative mortality and morbidity: results from the National VA
Surgical Risk Study. Arch Surg. 1999;134:36–42

41. Treatment
• Endovascular repair:
- Angioplasty and/or stent placement of lesions within
the mesenteric vasculature
- Alternative to surgery was first described in 1980*
- Meta-analysis data:**
Clinical success rate: 80-100%
Technical success rate: 90-100%
Complication rate: 9%
30 day mortality rate: 3%
Re-intervention rate: 27%

42. Treatment
• Endovascular repair:
- Review of the literature indicates better
patency rate with mesenteric artery stenting
when compared with angioplasty alone***
*Treatment of abdominal angina with percutaneous dilatation of an arteria
mesenterica superior stenosis. Preliminary communication.Furrer J, Grüntzig A,
Kugelmeier J, Goebel N.Cardiovasc Intervent Radiol. 1980; 3(1):43-4.
** Management of chronic mesenteric ischemia. The role of endovascular
therapy.Kougias P, El Sayed HF, Zhou W, Lin PHJ Endovasc Ther. 2007 Jun;
14(3):395-405.
*** Percutaneous management of chronic mesenteric ischemia: outcomes after
intervention.Landis MS, Rajan DK, Simons ME, Hayeems EB, Kachura JR,
Sniderman KW .J Vasc Interv Radiol. 2005 Oct; 16(10):1319-25

43. Follow up
• US duplex at 1,3 and 6 months initially and
then at 6-12 months.
• Antiplatelet agents and statins
• Smoking cessation and life style modification
• Management of risk factors for atherosclerosis

44. THANK YOU