Mesenteric revascularization in a contaminated abdomen: a case report
R M Young1, J J Hoballah, W J Sharp
1Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
Abstract:
The management of acute mesenteric ischemia in the contaminated abdomen may require the use of an autogenous graft to achieve mesenteric revascularization. The authors present a case of an ischemic small bowel perforation in a 62-year-old-woman whose preoperative angiogram demonstrated occlusion of the celiac, superior mesenteric, and inferior mesenteric arteries. Vein mapping of the right greater saphenous vein demonstrated a dual saphenous system whose individual diameters were more than 4 millimeters. Exploratory laparotomy revealed a diffusely ischemic small bowel and liver, as well as abdominal sepsis from the perforated small bowel. Revascularization was accomplished by using saphenous vein in a nonreversed orientation as a bifurcated conduit from the supraceliac aorta to the hepatic and superior mesenteric arteries. Following revascularization, the liver and small bowel immediately regained a normal perfused appearance and the perforated segment of small bowel was resected and reanastomosed. She returned for a follow-up clinic visit 5 months later and was found to have an asymptomatic 6 cm aneurysm involving the proximal mesenteric vein bypass. The aneurysmal aspect of the vein bypass was replaced with a polytetrafluoroethylene interposition graft originating from the supraceliac aorta. On follow-up 3 months later, her aortomesenteric bypass is patent without aneurysmal recurrence, and she is clinically asymptomatic from any symptoms of mesenteric ischemia.
Insights
This case study demonstrates successful mesenteric revascularization using a saphenous vein graft in a patient with acute mesenteric ischemia and abdominal sepsis. A subsequent aneurysm in the graft was successfully managed with a polytetrafluoroethylene interposition graft.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Abdominal Surgery
Background:
- Acute mesenteric ischemia (AMI) with abdominal sepsis presents a complex surgical challenge.
- Autogenous grafts are often necessary for mesenteric revascularization in contaminated abdominal cases.
Observation:
- A 62-year-old woman presented with AMI and small bowel perforation, involving occlusion of major mesenteric arteries.
- Preoperative evaluation revealed a suitable dual right greater saphenous vein system for grafting.
- Exploratory laparotomy confirmed diffuse bowel and liver ischemia, and abdominal sepsis.
Findings:
- Mesenteric revascularization was achieved using a nonreversed bifurcated saphenous vein graft from the supraceliac aorta to the hepatic and superior mesenteric arteries.
- Immediate reperfusion of the bowel and liver was observed post-revascularization.
- A 6 cm aneurysm developed in the saphenous vein graft 5 months postoperatively, necessitating replacement with a polytetrafluoroethylene (PTFE) interposition graft.
- The PTFE graft remained patent without recurrence at 3-month follow-up, with the patient remaining asymptomatic.
Implications:
- Saphenous vein grafts can be a viable option for mesenteric revascularization in complex AMI cases.
- Monitoring for and managing potential complications like aneurysms in autogenous mesenteric bypass grafts is crucial.
- PTFE grafts offer a durable alternative for managing complications in mesenteric bypass surgery.
