Multifocal Infarction Along the Alimentary Canal in the Context of Ostensible Salmonellosis: A Case Report.

Ischemic and/or infarction events of the alimentary canal are uncommon but potentially disastrous injuries of the digestive system that often portend a poor prognosis. Alimentary ischemia occurs when the vascular supply to one of the component conduit organs is disrupted or blocked, resulting in decreased tissue perfusion, subsequent necrosis, perforation, and even death if proper perfusion is not restored. We report a case here of a 67-year-old female who originally presented to the emergency department (ED) with nausea, vomiting, diarrhea, and progressively worsening abdominal pain. Conservative therapies that were initially employed failed to provide lasting symptom relief, and the patient was admitted for a more in-depth diagnostic workup and closer monitoring. During subsequent days of her resulting hospital stay, the patient had a positive result for Salmonella spp. on a stool PCR assay, an increasing leukocytosis, and the presence of several other worrisome laboratory abnormalities. Despite appropriate antibiotics and aggressive fluid resuscitation efforts, the patient's abdominal pain and laboratory profile continued to progressively worsen. At one point, the patient's condition perilously worsened, necessitating an emergent exploratory laparotomy. During the course of this surgery and subsequent surgeries, the patient was found to have multiple areas of infarction present including at her esophagus, stomach, duodenum, proximal jejunum, and right colon. Additionally, evidence of a metastatic neuroendocrine tumor of gastrointestinal (GI) origin was also incidentally found. Several subsequent surgical operations were required to repair the extensive tissue damage that the patient had sustained, and the patient's resulting hospital stay was complicated repeatedly by several different secondary infections and surgical complications. Attempts to determine the underlying cause for the ischemic events this patient experienced failed to yield definitive results, and no evidence for any arterial insufficiency or emboli was ever discovered. Despite this, a review of the histopathologic and laboratory findings from the tissue resected from the patient did find information to suggest that a relatively localized but severe venous thrombotic process likely occurred in the patient's alimentary vasculature that directly led to her presentation. Venous thrombosis of the mesenteric vessels and in the other vascular planes of the alimentary canal is often insidious in its presentation and poses a unique diagnostic challenge to clinicians. This case is significant because it illustrates the diagnostic complexity and difficulty imposed by mesenteric ischemia, especially cases resulting from mesenteric venous thrombosis (MVT) due to their often more indolent and atypical presentation. In short, a high level of clinical suspicion and familiarity with this ailment and its risk factors should be maintained because, in the absence of timely intervention, significant morbidity and/or mortality are likely to result.

Revision Surgery for Venous Graft Stenosis of SMA Bypass.

A 67-year-old male with postprandial abdominal pain for 4 months obtained medical attention for severe pain. He was diagnosed with small intestinal necrosis, secondary to chronic mesenteric ischemia by CT scan. We performed the surgery including a partial resection of the small intestine and left external iliac artery to the superior mesenteric artery bypass using saphenous vein graft. His symptoms improved after surgery. However, 5 months later, abdominal pain appeared after eating. A CT scan identified graft stenosis, leading to a revascularization. A synthetic vessel was used to perform the re-bypass surgery. Postoperatively, the patient's abdominal pain improved.

Mesenteric Ischemia.

Mesenteric ischemia occurs when perfusion of the visceral organs fails to meet normal metabolic requirements and subsequently results in abdominal symptoms such as diffuse postprandial pain, peritonitis, food fear, and weight loss. While generally divided into acute and chronic manifestations, mesenteric ischemia is commonly misdiagnosed at initial presentation due to the significant overlap with symptoms of other abdominal pathologies. Prompt recognition and diagnosis, mesenteric revascularization, and critical care management remain the mainstay of treatment in these patients for optimal outcomes. This review will highlight acute versus chronic mesenteric ischemia, their etiology, diagnostic criteria, treatment options, and will emphasize the joint role of the gastrointestinal and vascular surgeon in the timely management of this condition to prevent devastating outcomes.

Evaluation of non-occlusive mesenteric ischemia for burn patients - A matched-pair analysis and treatment algorithm.

BACKGROUND: Burn injuries may cause gastrointestinal dysfunction leading to intestinal barrier dysfunction, abdominal compartment syndrome, and acute mesenteric ischemia. In the absence of major vascular occlusion, non-occlusive mesenteric ischemia (NOMI) often occurs in critically ill intensive-care burn patients. METHODS: A retrospective descriptive analysis of the burn registry of the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery of Hannover Medical School was performed from 1st January 2018 to 1st May 2024. Burn patients with NOMI were matched with burn patients who did not acquire acute mesenteric ischemia based on key variables and shared characteristics. RESULTS: A total of 20 patients were included in this study. Patients with NOMI showed a statistically significant elevation in serum lactate (p = 0.005) and were most likely to be in a shock state requiring vasopressors (p = 0.047). Overall prognosis was poor for the NOMI cohort, 80 % of whom had a fatal result (p = 0.024). A total of four patients received intra-arterial administration of alprostadil. CONCLUSIONS: NOMI represents a potentially fatal condition for the burn patient. The current lack of sensitive biomarkers and accurate diagnostic tools for the early detection of NOMI onset is a major factor behind the overall poor prognosis. We propose the intra-arterial administration of alprostadil as a novel approach to targeted treatment for NOMI.

Intestinal ischemia: A rare and less common complication after laparoscopic cholecystectomy-A case report and literature review.

Key Clinical Message: Patients with a history of persistent mesenteric ischemia should not undergo laparoscopy. Mesenteric ischemia must be kept in mind for patients who develop nonspecific abdominal symptoms following laparoscopic surgeries. Abstract: During laparoscopic cholecystectomy (LC), the rise in Intra-Abdominal Pressure due to carbon dioxide insufflation can reduce blood flow through splanchnic vessels, potentially leading to intestinal ischemia. A 72-year-old woman with a history of diabetes, hypertension, ischemic heart disease, and hyperlipidemia underwent LC. She was discharged but readmitted 4 days later due to peritonitis. Ischemic jejunum loops were found during surgery.

Intraoperative indocyanine green fluorescence for precise resection of nonocclusive mesenteric ischemia: a case report and diagnostic considerations based on pathology findings.

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) is characterized by intestinal ischemia caused by spasms in the peripheral intestinal vessels without organic obstruction in the main mesenteric vessels. NOMI can be fatal in case of delayed diagnosis and treatment. Although the use of indocyanine green (ICG) fluorescence in assessing intestinal viability during NOMI surgery is well recognized, there is a paucity of reported cases using this technique. Herein, we present a case of NOMI that was successfully managed through accurate diagnosis and resection of the ischemic intestines guided by ICG fluorescence. CASE PRESENTATION: An 81-year-old man presented with abdominal pain. Contrast-enhanced computed tomography revealed intrahepatic portal vein gas, superior mesenteric vein gas, and terminal ileal edema. Considering these findings, the patient was diagnosed with NOMI and emergency surgery was performed. Intestinal edema was observed 30 cm upstream of the terminal ileum without serosal discoloration. ICG fluorescence revealed areas of normal perfusion as well as mild and moderate hypoperfusion. The small bowel, including the hypoperfusion area, was resected. As no clinical signs of residual bowel ischemia were observed during the postoperative course, a second-look operation was deemed unnecessary. Intraoperative ICG fluorescence and histopathological findings indicated mucosal edema in the mildly hypoperfused area and mucosal necrosis in the moderately hypoperfused area. CONCLUSIONS: This case highlights the use of intraoperative ICG fluorescence in the disease. ICG fluorescence is invaluable in assessing the extent of bowel ischemia and guiding precise resection. Thus, future efforts should focus on identifying accumulation of cases and quantification of ICG fluorescence intensity to further improve diagnostic performance.

A case of non-occlusive mesenteric ischemia following hepatocellular carcinoma rupture.

Hepatocellular carcinoma (HCC) rupture is a severe complication, yet there is limited literature on cases complicated by subsequent non-occlusive mesenteric ischemia (NOMI). A 77-year-old man presented to our hospital with abdominal pain and shock. Arterial phase computed tomography (CT) hepatic arteriography revealed a 77-mm HCC in the left lobe with active extravasation, and the feeding artery was embolized. Although the abdominal pain initially subsided after the procedure, it recurred the next day. A contrast-enhanced CT scan revealed pneumatosis intestinalis and decreased enhancement of the small intestinal wall. The patient underwent resection of the affected segment of the small intestine and was ultimately diagnosed with NOMI based on pathological findings. This is the first reported case of NOMI following HCC rupture. Given the high mortality associated with these conditions, clinicians should be aware of this rare complication and ensure comprehensive evaluation and timely intervention to improve patient outcomes.

Chronic Ischemic Gastritis in a Patient With a History of Cancer and Atherosclerotic Disease.

Chronic mesenteric ischemia is an uncommon disease presenting with nonspecific symptoms. The large number of differential diagnoses may result in diagnostic delays and progression to acute mesenteric ischemia. A 74-year-old woman with a history of breast cancer and carotid atherosclerosis complained of postprandial abdominal pain, vomiting, and weight loss. Endoscopic examination showed active chronic gastritis Helicobacter pylori negative. Contrast-enhanced computed tomography revealed stenosis in the mesenteric arterial district. Chronic gastritis resistant to treatment in a patient complaining of postprandial abdominal pain and weight loss should be investigated for chronic mesenteric ischemia, although history of cancer could be a misleading factor.

Successful endovascular treatment of chronic mesenteric ischemia in a patient with variant celiacomesenteric trunk anatomy.

The celiacomesenteric trunk (CMT) is a rare anatomical variant where the celiac axis and superior mesenteric artery share a common origin. Despite its rarity, CMT has significant implications across various medical fields, particularly in surgical planning and interventional procedures. We report a case of chronic mesenteric ischemia owing to atherosclerotic stenosis at the CMT bifurcation, necessitating a complex interventional approach. Kissing covered stent angioplasty was successfully performed, resulting in revascularization, symptom resolution, and no restenosis at 1-year follow-up. This report highlights the feasibility and effectiveness of the kissing stent technique in managing complex CMT bifurcation obstructions in patients with chronic mesenteric ischemia.

Chronic mesenteric ischemia, renovascular hypertension and critical limb threatening ischemia treated with thoraco-visceral and lower extremity bypass: Major open surgical techniques will remain essential.

A 68-year-old female with extensive medical and surgical history, including open and endovascular procedures, presented with chronic limb-threatening ischemia, hypertension, and chronic mesenteric ischemia. A computed tomographic angiogram showed significant paravisceral aortic atherosclerosis involving the celiac, superior mesenteric, and renal arteries. She underwent an open descending aorta to superior mesenteric artery, left renal artery, and left common femoral artery bypass with a "trifurcated" ringed polytetrafluoroethylene graft. Nine months after surgery, she was progressing with significant improvement of her symptoms. Open surgical approaches in aortoiliac disease are reserved for patients with unfavorable anatomy or previous failed endovascular attempts. Detailed preoperative planning and careful patient selection are imperative for optimal outcomes.

Acute primary mesenteric venous thrombosis: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Mesenteric vein thrombosis (MVT) is a pathological condition characterized by the obstruction of blood flow caused by the formation of new thrombi in the mesenteric veins, resulting in the development of intestinal ischemia due to the absence of collateral circulation. The insidious onset, clinical manifestations and lack of specificity of laboratory tests are significant factors that impede the timely diagnosis of MVT in clinical setting. CASE PRESENTATION: This article critically examined the pathogenesis, diagnosis and treatment of a 60-year-old male patient with MVT, while also exploring the etiology, clinical manifestations, diagnostic approaches and management advancement with MVT. CLINICAL DISCUSSION: We determined that CT angiography serves as a pivotal method for early detection of MVT. Proactive anticoagulation strategy utilizing unfractionated heparin or low molecular weight heparin can notably decrease the mortality rate of patients afflicted with MVT and enhance the clinical outcome. CONCLUSION: Surgery is generally not endorsed as the preferential therapeutic intervention for mesenteric venous thrombosis, barring patients with concurrent intestinal necrosis or perforation.

Somatostatin peptides prevent increased human colonic epithelial permeability induced by hypoxia.

Mesenteric ischemia increases gut permeability and bacterial translocation. In human colon, chemical hypoxia induced by 2,4-dinitrophenol (DNP) activates basolateral intermediate conductance K+ (IK) channels (designated KCa3.1 or KCNN4) and increases paracellular shunt conductance/permeability (GS), but whether this leads to increased macromolecule permeability is unclear. Somatostatin (SOM) inhibits IK channels and prevents hypoxia-induced increases in GS. Thus, we examined whether octreotide (OCT), a synthetic SOM analog, prevents hypoxia-induced increases GS in human colon and hypoxia-induced increases in total epithelial conductance (GT) and permeability to FITC-dextran 4000 (FITC) in rat colon. The effects of serosal SOM and OCT on increases in GS induced by 100 µM DNP were compared in isolated human colon. The effects of OCT on DNP-induced increases in GT and transepithelial FITC movement were evaluated in isolated rat distal colon. GS in DNP-treated human colon was 52% greater than in controls (P = 0.003). GS was similar when 2 µM SOM was added after or before DNP treatment, in both cases being less (P < 0.05) than with DNP alone. OCT (0.2 µM) was equally effective preventing hypoxia-induced increases in GS, whether added after or before DNP treatment. In rat distal colon, DNP significantly increased GT by 18% (P = 0.016) and mucosa-to-serosa FITC movement by 43% (P = 0.01), and 0.2 µM OCT pretreatment completely prevented these changes. We conclude that OCT prevents hypoxia-induced increases in paracellular/macromolecule permeability and speculate that it may limit ischemia-induced gut hyperpermeability during abdominal surgery, thereby reducing bacterial/bacterial toxin translocation and sepsis.NEW & NOTEWORTHY Somatostatin (SOM, 2 µM) and octreotide (OCT, 0.2 µM, a long-acting synthetic analog of SOM) were equally effective in preventing chemical hypoxia-induced increases in paracellular shunt permeability/conductance in isolated human colon. In rat distal colon, chemical hypoxia significantly increased total epithelial conductance and transepithelial movement of FITC-dextran 4000, changes completely prevented by 0.2 µM OCT. OCT may prevent or limit gut ischemia during abdominal surgery, thereby decreasing the risk of bacterial/bacterial toxin translocation and sepsis.

Treatment outcomes in non-occlusive mesenteric ischemia and post-treatment return to social activities.

PURPOSE: To investigate the treatment outcomes of patients with non-occlusive mesenteric ischemia (NOMI) at our institution, we focused on their post-treatment return to social activities. METHODS: This study included patients with suspected NOMI who were referred to our department between 2011 and 2023. In-hospital mortality was also investigated as a prognostic factor. The Glasgow-Pittsburgh Outcome Categories (GPOC) score was used to evaluate the return to social activities. The relationship between in-hospital mortality and GPOC scores and patient background and treatment factors was examined. RESULTS: Eighty-two patients were included in the study. Among them, 54 (65.9%) died during hospitalization. Only 9 patients (11%) returned to their social activities. In the multivariate analysis, non-surgical management was found to be the only independent factor for in-hospital mortality. Positive portal venous gas on computed tomography, no open abdomen, no pre-onset catecholamine administration, platelet count < 100,000/µL, lactate level < 5 mmol/L, APTT < 46 s, and Sequential Organ Failure Assessment score < 11 were factors significantly associated with an increased likelihood of return to social activities. CONCLUSION: This is the first study to assess the post-treatment return to social activities among patients with NOMI. Our findings highlight the concerning reality that survivors may face prolonged dependence on medical care.

Retroperitoneal approach for ilio-superior mesenteric artery bypass: Technique and case series.

In patients with chronic mesenteric ischemia, options for revascularization include endovascular angioplasty, stenting and open surgery, with the latter typically favored in patients who have failed or who are not candidates for endovascular intervention. Here we describe a retroperitoneal approach for open surgical revascularization in patients with a hostile abdomen. We present a case series of five patients from our institution. The median age was 72 years, the mean operative time was 143.6 minutes and 90-day mortality rate was 0. This case series demonstrates the technical feasibility, success, and safety of this approach in patients with anatomic factors that would render a traditional open surgical approach for revascularization technically difficult.

Isquemia intestinal con antecedente de infección por SARS COV2. Reporte de un caso / Intestinal ischemia with a history of SARS COV2 infection. Report of a case

El virus y la enfermedad COVID-19 no solo afectan los pulmones, sino que también pueden dañar otros sistemas de órganos, además de causar coagulopatía, esta coagulopatía se puede prolongar a largo plazo siendo ésta una de las secuelas más importantes. La ausencia de factores predisponentes importantes para la formación de tromboembolismo en este paciente sugirió una relación causal entre el antecedente COVID-19 y la isquemia intestinal.

The virus and the COVID-19 disease not only affect the lungs, but can also damage other organ systems, in addition to causing coagulopathy, this coagulopathy can be prolonged in the long term, this being one of the most important sequelae. The absence of important predisposing factors for the formation of thromboembolism in this patient suggested a causal relationship between a history of COVID-19 and intestinal ischemia. Post Acute Syndrome of COVID-19

Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

BACKGROUND: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. METHODS: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. RESULTS: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. CONCLUSIONS: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies.

PURPOSE: To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT. MATERIALS AND METHODS: From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients. RESULTS: Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively. CONCLUSION: Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis.

OBJECTIVE: This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI). METHODS: This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence. RESULTS: A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031). CONCLUSIONS: Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.

Preoperative risk factors for 90-day postoperative mortality outcome in patients with non-occlusive mesenteric ischemia.

PURPOSE: The mortality rate for non-occlusive mesenteric ischemia remains high even after patients survive the acute postoperative period with tremendous treatment efforts, including emergency surgery, which is challenging. The aim of this study was to explore the preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. METHODS: This single-center, retrospective cohort study included patients diagnosed with non-occlusive mesenteric ischemia who underwent emergency surgery between August 2014 and January 2023. All patients were divided into survival-to-discharge and mortality outcome groups at the 90-day postoperative follow-up. Preoperative factors, including comorbidities, preoperative status of vital signs and consciousness, blood gas analysis, blood test results, and computed tomography, were compared between the two groups. RESULTS: Twenty patients were eligible, and 90-day mortality was observed in 10 patients (50%). The mortality outcome group had significantly lower HCO3- (20.9 vs. 14.6, p = 0.006) and higher lactate (4.4 vs. 9.4, p = 0.023) levels than did the survival outcome group. The median postoperative time to death was 19 [2-69] days, and five patients (50%) died after postoperative day 30, mainly because hemodialysis was discontinued because of hemodynamic instability in patients requiring hemodialysis. CONCLUSION: Low preoperative HCO3- and high lactate levels may be preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. However, patients on hemodialysis die from discontinuing hemodialysis even after surviving the acute postoperative phase. Therefore, indications for emergency surgery in patients with risk factors for postoperative mortality should be carefully determined.

Un caso complejo de isquemia mesentérica crónica: Reporte de caso y revisión de la literatura / A complex case of chronic mesenteric ischemia: Case report and literature review

Introducción. La isquemia mesentérica crónica es una entidad infrecuente, con una prevalencia de 0,03 %, donde más del 90 % son debidas a enfermedad arterioesclerótica que compromete principalmente la arteria mesentérica superior. Sus síntomas son dolor abdominal crónico y pérdida de peso, asociado a alteraciones imagenológicas que hacen el diagnóstico. El tratamiento depende de las condiciones clínicas del paciente y el número de vasos comprometidos. Es claro que la enfermedad multivaso sintomática requiere revascularización. Caso clínico. Mujer de 67 años, fumadora activa con antecedentes de hipertensión arterial y dislipidemia, con cuadro de crisis hipertensiva tipo urgencia que requirió manejo en Unidad de Cuidados Intensivos. Se hizo diagnóstico de aneurisma toracoabdominal Crawford IV, oclusión aorto-ilíaca (TASC D) y oclusión crónica del tronco celíaco y la arteria mesentérica superior. Por los síntomas de isquemia mesentérica crónica fue llevada a tratamiento quirúrgico con baipás aorto-bifemoral más baipás retrógrado a la arteria mesentérica superior por vía abierta. Resultado. La paciente tuvo mejoría de la sintomatología y aumentó 13 % del peso al seguimiento a los 3 meses. Conclusión. La isquemia mesentérica crónica es una condición subdiagnosticada, marcador de riesgo cardiovascular, con alta carga de morbilidad y mortalidad, en la cual, con una identificación temprana se puede ofrecer una terapia de revascularización, sea por vía endovascular o abierta, con el fin de mejorar la calidad de vida y la ganancia de peso, y evitar la necrosis intestinal.

Introduction. Chronic mesenteric ischemia is a rare entity, with a prevalence of 0.03%, where more than 90% are due to arteriosclerotic disease that mainly affects the superior mesenteric artery. Its symptoms are chronic abdominal pain and weight loss, associated with imaging alterations that make the diagnosis. Treatment depends on the patient's clinical conditions and the number of vessels involved. It is clear that symptomatic multivessel disease requires revascularization. Clinical case. A 67-year-old woman, an active smoker with a history of high blood pressure and dyslipidemia, presented with an emergency-type hypertensive crisis that required management in the Intensive Care Unit. A diagnosis of Crawford IV thoracoabdominal aneurysm, aorto-iliac occlusion (TASC D), and chronic occlusion of the celiac trunk and superior mesenteric artery was made. Due to the symptoms of chronic mesenteric ischemia, she underwent surgical treatment with aorto-bifemoral bypass plus retrograde bypass to the superior mesenteric artery via an open approach. Result. The patient had improvement in symptoms and gained 13% weight at 3-month follow-up. Conclusion. Chronic mesenteric ischemia is an underdiagnosed condition, a marker of cardiovascular risk, with a high burden of morbidity and mortality, in which, with early identification, revascularization therapy can be offered, either endovascularly or open, in order to improve quality of life and weight gain, and avoiding intestinal necrosis.