Catching Two Birds with One Stone: A Primary Open Revascularisation First Approach in a Case Report of Chronic...

Symptomatic chronic mesenteric artery occlusive disease requires timely revascularisation. Although endovascular management is guideline endorsed as first line treatment, inferior mesenteric artery (IMA) revascularisation lacks evidence based guidance. This report presents a case in which an open repair first approach was selected with the IMA as the primary revascularisation target, aiming to provide long term benefit while enabling concomitant superior mesenteric artery (SMA) revascularisation.

A 60 year old woman, who was a smoker (40 pack/year), had a past medical history of hypertension and hypercholesterolemia, and a current body mass index of 17 kg/m², was diagnosed with chronic mesenteric ischaemia (CMI). Anatomically, while both the coeliac and SMA were occluded, severe stenosis of the IMA ostium was also present. An open revascularisation addressing the IMA disease with venous patch and concomitant aorta to SMA bypass was performed through a limited midline transperitoneal approach without adverse events. The patient was discharged two days post-operatively. At one year follow up, an asymptomatic bypass stenosis just after the IMA take off (approximately 2 cm from the proximal anastomosis) was identified on duplex ultrasound (peak systolic velocity 396 cm/second, end diastolic velocity 35 cm/second) and subsequently treated with a paclitaxel eluting balloon (5 x 60 mm) with angiographic resolution. No signs of IMA re-stenosis were detected. At the six month post-angioplasty follow up, no signs of clinical or haemodynamic recurrence were noted in the SMA bypass or IMA ostium.

In selected CMI patients, an open first revascularisation strategy may be performed with a low risk of adverse events.