CURRENT RESULTS OF SURGICAL THERAPY FOR CHRONIC MESENTERIC ISCHEMIA

Background: Although recognition of chronic mesenteric ischemia has in creased in recent years, this disorder has continued to present diagno stic and therapeutic challenges. Objective: To examine the modern resu lts of surgical revascularization for chronic mesenteric ischemia. Des ign: Retrospective review. Setting: University medical center. Patient s: The management of 24 consecutive patients (mean+/-SEM age, 58+/-3 y ears; 5 men, 19 women) who were undergoing surgical treatment of chron ic mesenteric ischemia between 1986 and 1996 was reviewed. Interventio n: Surgical mesenteric revascularization. Main Outcome Measures: Posto perative course, longterm graft patency rate, and long-term symptom-fr ee survival rate. Results: The most frequent presenting symptoms were postprandial abdominal pain (18 patients [75%]) and weight loss (14 pa tients [58%]). Less specific complaints included nausea and vomiting ( 8 patients [33%]), diarrhea (7 patients [29%]), and constipation (4 pa tients [17%]). Atherosclerotic risk factors were common, including tob acco use (20 patients [83%]), coronary artery disease (10 patients [42 %]), and hypertension (10 patients [42%]). The cause was identified as atherosclerosis in 21 patients, median arcuate ligament compression i n 2 patients who were monozygotic twins, and Takayasu arteritis in 1 p atient. Lesions were localized to all 3 major visceral vessels (celiac artery, superior mesenteric artery [SMA], and inferior mesenteric art ery) in 8 patients, celiac artery and SMA in 13, SMA alone in 2, and S MA and inferior mesenteric artery in 1. Seventeen patients underwent a ntegrade reconstructions from the supraceliac aorta to the SMA and/or celiac artery; 7 patients underwent revascularization by use of a retr ograde bypass that originated from the infrarenal aorta or a prostheti c graft. There were no perioperative deaths although I patient died in the hospital 6 weeks after early graft failure and sepsis (overall in -hospital mortality, 4%). Follow-up ranged from 3 months to 10 years ( median, 2.4 years). The mean+/-SEM 5-year primary graft patency rate, as objectively documented by use of contrast angiography or duplex sca nning in 19 of 24 patients, was 78%+/-11%. Primary failure was documen ted in 3 patients (at 3 weeks, 5 months, and 7 months). Two patients r equired a thrombectomy; I of these patients subsequently died of an in testinal infarction. The mean+/-SEM 5-year survival rate by use of lif etable analysis was 71%+/-11%. No patient with a patent graft experien ced a symptomatic recurrence. Conclusions: Chronic mesenteric ischemia is usually a manifestation of advanced systemic atherosclerosis. Symp toms almost always reflect midgut ischemia in the distribution of the SMA. An antegrade bypass from the supraceliac aorta can be performed w ith acceptable operative morbidity and is currently the preferred reco nstructive technique. Surgical revascularization affords long-term sym ptom-free survival in a majority of patients with chronic mesenteric i schemia.