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Isolated inferior mesenteric artery revascularization for chronic visceral ischemia
D B Schneider1, N A Nelken, L M Messina
1Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA, USA.
Insights
Isolated inferior mesenteric artery (IMA) revascularization can be a lifesaving option for chronic visceral ischemia when other visceral arteries cannot be treated. This procedure offers symptom relief in select patients with adequate collateral circulation.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Interventional Cardiology
Background:
- Complete visceral artery revascularization is standard for chronic visceral ischemia.
- Revascularization of the celiac or superior mesenteric artery (SMA) is not always feasible.
- Isolated inferior mesenteric artery (IMA) revascularization is a rare alternative.
Purpose of the Study:
- To report the experience of isolated IMA revascularization over three decades.
- To evaluate the efficacy and safety of isolated IMA revascularization in chronic visceral ischemia.
Main Methods:
- Retrospective review of 11 patients with chronic visceral ischemia undergoing isolated IMA revascularization.
- Patients had symptomatic disease documented by arteriography.
- Techniques included bypass grafting, endarterectomy, reimplantation, and patch angioplasty.
Main Results:
- 10 of 11 patients had improved or cured conditions at discharge; one perioperative death.
- One acute thrombosis was successfully reoperated.
- Median follow-up was 6 years, with patent IMA repairs in 8 patients at 1 year; no late deaths from bowel infarction.
Conclusions:
- Isolated IMA revascularization is a viable option when other visceral arteries cannot be revascularized.
- Adequate IMA collateral circulation is crucial for success.
- This procedure can relieve symptoms and be lifesaving in select patients.
Purpose:
Complete visceral artery revascularization is recommended for the treatment of chronic visceral ischemia. However, in rare cases, it may not be possible to revascularize either the celiac or superior mesenteric (SMA) arteries. We have managed a series of patients with isolated revascularization of the inferior mesenteric artery (IMA) and now report our experience gained over a period of three decades.
Methods:
Records were reviewed from 11 patients with chronic visceral ischemia who underwent isolated IMA revascularization (n = 8) or who, because of failure of concomitant celiac or SMA repairs, were functionally left with an isolated IMA revascularization (n = 3). All the patients had symptomatic chronic visceral ischemia documented with arteriography. Five patients had recurrent visceral ischemia after failed visceral revascularization, and two patients had undergone resection of ischemic bowel. The celiac or the SMA was unsuitable for revascularization in five cases, and extensive adhesions precluded safe exposure of the celiac or the SMA in five cases. IMA revascularization techniques included: bypass grafting (n = 4), transaortic endarterectomy (n = 4), reimplantation (n = 2), and patch angioplasty (n = 1).
Results:
There was one perioperative death, and the remaining 10 patients had cured or improved conditions at discharge. One IMA repair thrombosed acutely but was successfully revascularized at reoperation. The median follow-up period was 6 years (range, 1 month to 13 years). Two patients had recurrent symptoms develop despite patent IMA repairs and required subsequent visceral revascularization; interruption of collateral circulation by prior bowel resection may have contributed to recurrence in both patients. Objective follow-up examination with arteriography or duplex scanning was available for eight patients at least 1 year after IMA revascularization, and all underwent patent IMA repairs. There were no late deaths as a result of bowel infarction.
Conclusion:
Isolated IMA revascularization may be useful when revascularization of other major visceral arteries cannot be performed and a well-developed, intact IMA collateral circulation is present. In this select subset of patients with chronic visceral ischemia, isolated IMA revascularization can achieve relief of symptoms and may be a lifesaving procedure.