Peripheral Vascular Surgery Society
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Peripheral Vascular Surgery Society |
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#14 ACUTE MESENTERIC ISCHEMIA WITH SEVERE AORTORENAL OCCLUSIVE DISEASE: REPAIR USING A TRIFURCATED AORTO/MESENTERIC/RENAL BYPASS AND BIFURCATED AORTOILIAC BYPASS
Mordechai F. Twena, MD and Jeffrey L. Ballard, MD
Loma Linda University Medical Center Loma Linda, CA
A 70-year-old female presented as an emergency with severe acute and chronic abdominal pain. Pain had been postprandial, associated with weight loss and was present for 10 weeks. She was in moderate distress with normal vital signs and temperature. Physical examination revealed a discrepancy between her complaints of abdominal pain and lack of palpable tenderness. Her WBC was 7.700, CO2-26 and creatinine-1.0. Arteriography demonstrated severe infradiaphragmatic aortic occlusive disease, celiac and superior mesenteric artery occlusion, a patent IMA with proximal 50% stenosis and large central anastomotic and marginal arteries. In addition, there was proximal stenosis of the remaining left renal artery. Previously, complications after failed renal artery angioplasty had resulted in right nephrectomy.
This complex vascular problem became more vexing with the unexpected intraoperative finding of a large supraceliac aortic bleb that was threatening imminent rupture. Therefore, mesenteric/renal artery disease was reconstructed by a combination of SMA endarterectomy and creation of aorto-inferior mesenteric/left renal/superior mesenteric artery bypass using a trifurcated 12 x 6 mm PTFE graft that originated from the side of the lower thoracic aorta. Aortobiiliac reconstruction, using an in-line 18 x 9 mm PTFE graft, excluded the entire abdominal aorta below the trifurcated graft and completed the procedure. The diminutive celiac artery was ligated at its origin. IMA, SMA and left renal artery ischemia times were 10, 14, and 10 minutes, respectively. Respiratory failure and transient renal insufficiency complicated the postoperative course. However, the patient recovered well without coagulopathy or intestinal dysfunction and was discharged home 3 weeks after surgery with near normal renal function.
This case teaches the value of maintaining visceral and renal perfusion through 1) tangential thoracic aortic clamping, 2) individual aortic branch vessel reconstruction, and 3) separate distal revascularization.
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Last updated January 10, 1999