Hybrid Approach to Chronic and Acute-on-Chronic Mesenteric Ischemia With Retrograde Stenting of the Superior Mesenteric Artery via Jejunal Arterial Access

Abstract

Since its introduction, endovascular stenting of the superior mesenteric artery (SMA) has been utilized as a technically feasible, safe, and efficient alternative to open surgery for patients with acute, chronic, and acute-on-chronic mesenteric ischemia resulting in significant reduction in both complication rates and perioperative mortality. Retrograde mesenteric stenting has been previously described; however, the need for formal laparotomy and arteriotomy represents a significant limitation of this approach, especially in elderly and malnourished patients. To this end, at our institution we developed and evaluated a novel hybrid approach to retrograde SMA revascularization via jejunal arterial access that requires a mini-laparotomy. Our initial experience shows that by mitigating the necessity for mesenteric dissection and formal laparotomy it is feasible to minimize the risks of extensive intra-abdominal surgery to this population.

VASCULAR DISEASE MANAGEMENT 2020;17(6):E113-E116

Historically, open surgical revascularization was the treatment of choice for patients with acute, chronic, and acute-on-chronic mesenteric ischemia.^1-7 However, this treatment approach was associated with significant postoperative complications and perioperative mortality, with respective rates that were as high as 54% and 10%.^3,5,8 Data from a systematic review that included a total of 1970 patients from 23 studies (acute mesenteric ischemia ranged from 8% to 60%) demonstrated a pooled operative mortality rate of 47%.⁹ High morbidity and mortality are predominantly due to the advanced age and significant comorbidities that frequently characterize these patients.¹⁰ More recently, favorable clinical results associated with endovascular approach combined with necessity for less invasive procedures in critically ill patients have shifted the focus from surgical to endovascular treatment modalities, whenever technically feasible.^11-14 Consequently this resulted in significant reduction in both complication rates and perioperative mortality during mesenteric ischemia treatment.^2,6,7,15,16

Despite the established benefits of endovascular approach, the morphology of the underlying lesion of the SMA has an important role in determining technical feasibility for antegrade approach. Notably, flush ostial atherosclerotic lesions as well patients with lack of “pushability” from the femoral or brachial access are not amenable to traditional antegrade endovascular access. In these patients, hybrid mesenteric revascularization using midline laparotomy followed by direct exposure of the SMA for retrograde endovascular access is preferred. Although retrograde cannulation of the SMA has been previously reported and evaluated, the formerly described techniques require a laparotomy, often followed by dissection and control of the proximal SMA segment. The need for formal laparotomy represents a significant limitation as it jeopardizes the management of mesenteric ischemia especially in elderly and malnourished patients, given that they are at greatest risk for complications from an open revascularization. To this end, at our institution we developed a novel hybrid approach to retrograde SMA revascularization via jejunal arterial access, which by mitigating the necessity for mesenteric dissection and formal laparotomy can minimize the risks of extensive intra-abdominal surgery to this population.¹⁷ 

Operative Technique

Following a mini-laparotomy, a segment of proximal jejunum is exteriorized through an incision. Only a single segment of jejunum needs to be eviscerated and the remainder of the abdominal contents can be left in situ. A 21-gauge micro-puncture needle is used to access an isolated, small segment (1 cm to 2 cm) of the distal branch of the SMA, approximately 5 cm from the bowel wall of the isolated jejunum. The initial access vessel is intraoperatively visualized and palpated, and findings of thrombosis or dissection of this initial vessel may prevent access and require selection of a second adjacent access vessel. In addition, if resistance is encountered during advancement of the micropuncture needle, another access vessel is selected. If compromised bowel viability is present or suspected, the case is converted to standard laparotomy incision. The ostial occlusion is traversed in a retrograde fashion using a hydrophilic microwire (0.014- to 0.035-in) passed through the needle. Next, the wire is snared in the aorta and exteriorized through a femoral or brachial sheath access. It is important to maintain tension on both ends of hydrophilic microwire as it creates a stable platform across the occlusion, allowing antegrade crossing of the occlusion from the brachial or femoral sheath and angioplasty and stenting (using balloon expandable, non-covered stents) of the SMA lesion for both acute-on-chronic and chronic disease. It is important to emphasize that applying excessive tension could lead to injury of the aorta, potentially resulting in aortic dissection. The stent size was determined based on angiographic assessment. At the conclusion of the procedure the small distal mesenteric access vessel is ligated, and a completion angiogram is performed for the assessment of the SMA patency. 

Results

To assess safety and efficacy of our initial experience with this approach we retrospectively reviewed charts of 7 patients treated at our institution. The patients ranged from 51 to 85 in age (71.1 ± 11.5 years [mean ± SD]). Five patients presented with chronic mesenteric ischemia and 2 patients presented with acute-on-chronic mesenteric ischemia that required formal laparotomy. Symptom duration ranged from 1 day to 5 years. There were no cases of acute mesenteric ischemia due to an embolic source. Preoperative imaging demonstrated multi-vessel visceral stenosis or occlusion in all the patients. 

Data showed technical success, defined as perfusion restoration in the SMA on completion angiography, in 85.7% cases (6 out of 7 patients). In 1 patient, endovascular approach was converted to surgical approach due to inability to cross the SMA occlusion and to re-enter the true lumen of the aorta. This patient underwent surgical aorto-SMA bypass. Operative time ranged from 73 to 212 minutes (163 ± 44 minutes [mean ± SD]). Table 1 demonstrates a summary of operative details. Symptom relief, defined as improvement in pain and ability to tolerate nutrition orally, was seen in all the patients. Despite the advanced age, deconditioning, and significant comorbidity in our cohort of patients, there was no perioperative or 30-day mortality. There was one case of stent migration within 30 days and another case of in-stent restenosis 180 days after index procedure. The first case required intervention for stent extension and the second case required conversion to a splenic artery-SMA bypass. None of the patients required bowel resection at the time of revascularization. Outcomes and complications are summarized in Table 2. 

Discussion

Milner et al. first reported (in 2004) a retrograde approach for SMA revascularization in a critically ill 85-year-old female with acute mesenteric ischemia due to an occluded celiac axis and a high-grade SMA stenosis.¹⁸ Retrograde approach has subsequently been described in several case series from single institution studies.^19-21  

Studies with a larger number of patients also demonstrated technical feasibility and efficacy of a retrograde approach. In the largest multicenter series to date, Oderich et al. treated 54 patients, 13 male and 41 female (mean age: 72 ± 11 years), with retrograde open mesenteric stenting.²² Indications for treatment were acute mesenteric ischemia and acute-on-chronic mesenteric ischemia with flush mesenteric occlusion in 44 patients (81%) and in 10 patients (19%), respectively. The SMA was the primary target artery in 52 patients (96%). The retrograde approach alone was used in 70% of cases (38 patients) and the remaining 30% of cases (16 patients) required concomitant anterograde brachial access due to inability to re-enter the aorta using retrograde access. Data from their study demonstrated freedom from mesenteric stent re-intervention of 74% ± 8% at 1-year and 74% ± 8% at 2-year follow-up. Data also showed primary stent patency in 76% ± 8% cases at 1-year follow-up and 76% ± 8% cases at 2-year follow-up. Secondary stent patency rate was 97% ± 3% at 1-year and 90% ± 8% at 2-year follow-up. Authors also reported the 30-day (or in-hospital) mortality rate of 39% (21 patients). Out of these, 20 patients had acute mesenteric ischemia and 1 patient had acute-on-chronic ischemia. The most common complications included persistent bowel ischemia in 13 patients (24%), respiratory failure in 9 (17%), acute renal insufficiency in 10 (19%), and cardiac ischemia in 5 (9.3%) patients. One-year and 2-year survival rates for the entire cohort of patients were 55% ± 7% and 43% ± 9%, respectively.²² Relatively recently, in 2019, Roussel et al. analyzed the safety and efficacy of retrograde approach in 25 patients (14 men and 11 women; mean age: 64.9 ± 11.6 years) with occlusive thrombotic acute mesenteric ischemia.²³ Data from this multicenter (3 tertiary centers) analysis showed a 92% technical success rate and a 30-day operative mortality rate of 25%. The overall 1-year survival rate was 65%. In 2 patients, retrograde approach was not feasible due to a failure to re-enter the aortic lumen. These 2 patients underwent mesenteric bypass. Blauw et al. analyzed outcomes in 10 females and 5 males with median age of 66 years (interquartile range: 54-73 years) with acute mesenteric ischemia treated with retrograde open mesenteric stenting.¹⁵ Data showed identical mortality rates of 20% at 30 days and 6 and 12 months follow-up. Authors reported that in these 3 patients who died, the procedure was technically successful but the extent of the splanchnic ischemia and reperfusion damage was irreversible. Data showed a 1-month primary patency rate of 92% (11 of 12 patients). At 6 and 12 months, primary patency rates remained the same at 83% (10 of 12 patients). Data also demonstrated primary assisted patency rates of 92% (11 of 12 patients), 91% (10 of 11 patients) and 91% (10 of 11 patients) at 1, 6, and 12 months, respectively. Secondary patency was identical, approximately 92%, at 1, 6, and 12 months. Authors reported clinical efficacy (defined as relief or improvement of presenting symptoms) at 1 month in 11 out of 15 patients (73%). At 6 and 12 months, it was identical, and it was seen in 10 out of 15 patients (67%).¹⁵

The operative technique aspects of the retrograde mesenteric revascularization procedure are mostly consistent between studies. Most frequently, authors use a formal laparotomy followed by mesenteric dissection to cannulate and access the proximal SMA. This approach requires both creation and closure of a formal arteriotomy of the SMA. Although this approach is technically feasible, and by mitigating the need for a surgical bypass can avoid the placement of prosthetic material into a contaminated operative field, the extent of intra-abdominal mobilization required to isolate and control the proximal SMA can be challenging and time consuming particularly in the presence of extensive adhesions and/or in patients who are critically ill. To this end, based on data from our analysis, we suggest that modification of retrograde technique used at our institution and described above improves existing techniques for the following reasons: the mobilization, manipulation, and discretion of intra-abdominal viscera can be significantly minimized by use of distal branches for accessing the mesenteric vasculature. Secondly, this approach mitigates the necessity for a formal laparotomy as adequate exposure and the access of the target vessel can be gained via a relatively small mini-laparotomy incision. This is particularly important in patients who are critically ill. In addition, this technical modification can eliminate the need for repair or reconstruction of the proximal SMA as the access branches are controlled by ligation at the end of the case. Lastly, these modifications allow the opportunity for faster revascularization and reduction of total operative time. Karkos et al. also showed that jejunal access was technically feasible in a 72-year-old patient who previously underwent unsuccessful antegrade SMA stenting via the left axillary approach.²⁴ Although the authors used formal laparotomy (instead of mini-laparotomy) for jejunal access, there were no intraoperative and postoperative complications and the patient remained asymptomatic with radiologic evidence of SMA patency at the 6-month follow-up. 

Conclusion

Data from our study showed that hybrid retrograde mesenteric stenting via jejunal arterial access provides a feasible technical alternative for revascularization in patients with ostial SMA occlusions not amenable to antegrade endovascular intervention. By minimizing the intra-abdominal exploration and avoiding the need for exposure, manipulation, arteriotomy, and repair of the proximal SMA—this modification suggests improvement of previously described methods of retrograde mesenteric revascularization. Although initial results are promising, statistically the study is not powered enough due to a small number of patients. Further clinical studies with larger number of patients and longer follow-up times are needed for wider application and significant change in practice as well as for a more detailed assessment of this treatment modality.  n

Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Jovan N. Markovic, MD

Department of Surgery

Duke University School of Medicine

Box 3538, Durham, NC 27710

Phone: 919-681-2915

Fax: 919-681-3563 

Email: jovan.markovic@duke.edu

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