Revascularization of the superior mesenteric artery alone for treatment of chronic mesenteric ischemia.

BACKGROUND: Symptomatic patients with chronic mesenteric ischemia (CMI) should be treated without much delay because symptoms of CMI are present in 43% patients who present with acute mesenteric ischemia. There are few reported series with large numbers of patients undergoing surgery for CMI, and many controversies persist regarding the optimal surgical treatment. These controversies include the type of surgical repair (antegrade vs. retrograde bypass), and the number of arteries that should be treated (single- vs. multiple-vessel reconstruction). It was the aim of presented study to report our experience and long-term results with single-vessel bypass grafting from infrarenal aorta to superior mesenteric artery. METHODS: Patients who were admitted because of mesenteric ischemia at the surgical clinics of University Clinical Center Maribor between January 1999 and January 2009 were identified with a computerized medical data registry. Patients who underwent revascularization for CMI with retrograde synthetic aortomesenteric bypass were included in the study. Demographics, clinical characteristics, imaging, and operative data were obtained from the medical records. Significant superior mesenteric artery stenosis (> 70% diameter stenosis) was confirmed by spiral computed angiography. All patients underwent retrograde aortomesenteric arterial bypass with synthetic bypass graft originating from the infrarenal aorta. Doppler sonography combined with color Doppler was used to evaluate disease progression in patients at 3-month interval during the first year and from then at 6-month intervals. Endpoints of the study were occlusion of graft or death by any cause. RESULTS: Data are presented for a cohort of 19 women and 8 men with a mean age at admission 73 years (range 56-88 years). The mean duration of follow-up was 71 months (range 1-118 months). There was one early death (4%). Four patients died during the follow-up period, and three were lost for follow-up. None of the deaths was connected with mesenteric ischemia. During follow-up period none of the patients developed restenosis, and no occlusions were observed. There were no reinterventions. Symptom improvements were noted in 25 patients (93%). One patient (4%) referred to persistent pain despite successful revascularization, although during follow-up period weight gain was observed. At 71 months, freedom from recurrent symptoms, restenosis, and reinterventions was 78% ± 13.9%. CONCLUSIONS: Surgery for CMI can be safely performed with retrograde approach and single vessel anastomosis. Mortality rates and long-term survival compare favorably with other surgical approaches to treatment of CMI.

Delaying the superficial inferior epigastric artery flap: a solution to the problem of the small calibre of the donor artery.

BACKGROUND: Superficial inferior epigastric artery (SIEA) flap has a great advantage over other flaps of the area, that is, readily non-existent donor-site problems. The main reason why the SIEA flap has never been extensively used in breast reconstruction is the small diameter and variable anatomy of its donor artery. This study presents a possibility of enlarging the SIEA diameter using the delay-phenomenon mechanism. METHODS: A prospective clinical study of 26 patients was undertaken. Prior to surgery, ultrasound examinations were performed, measuring the diameter of SIEA and the velocity of blood flow in SIEA. The ipsilateral deep inferior epigastric artery (DIEA) was then ligated in all patients who had a measurable SIEA preoperatively. Two weeks later, measurements were repeated. The blood flow through SIEA was calculated and statistical analysis was applied. RESULTS: Twenty-one patients had an identifiable SIEA on preoperative measurements. On postoperative measurements, we confirmed ligation of DIEA in 19 patients, of these 17 patients had an augmentation in diameter (mean: 29%) and 18 in blood flow (mean: 127%). CONCLUSIONS: This study shows that ligating a single of the three main arteries (DIEA, SIEA and superficial circumflex iliac artery) irrigating skin/soft tissue of the lower abdomen, although the dominant one, results in widening of diameter and enlarging of blood flow of another artery (SIEA) supplying the same angiosome. The results of the present study might be used in future to increase the diameter and flow in SIEA when the vessel diameter found on preoperative imaging was too small for clinical microsurgical transfer. The drawback of the proposed delay procedure is the sacrifice of ipsilateral DIEA and an added operative procedure. STATEMENT: The clinical trial is registered with Clinical Trials (http://www.clinicaltrials.gov/). The clinical trial registration number is NCT01247129.

The measurement of stenosis of the internal carotid artery: comparison of doppler ultrasound, digital subtraction angiography and the 3D CT volume rendering technique.

OBJECTIVES: To determine the variability of measurement of stenosis of the internal carotid artery (ICA) using Doppler ultrasound, digital subtraction angiography (DSA) and the three-dimensional volume rendering technique (3D CT) in the high-grade stenosis band (70-100%). DESIGN: A prospective study of preoperative findings in 64 patients. MATERIAL AND METHODS: Doppler ICA stenosis was assessed according to combined Doppler acoustic standard criteria (CDASC) and peak systolic velocity (PSV). DSA and 3D CT stenosis were measured using the NASCET method. The results were compared using kappa statistics and Pearson's correlation coefficient. RESULTS: Agreement on the degree of ICA stenosis was statistically very good for DSA and 3D CT (kappa = 0.81, CI 0.69-0.93): Pearson's correlation coefficient was 0.88 (CI 0.76-0.90). The comparison of Doppler ultrasound with DSA showed good agreement (kappa 0.70, CI 0.58-0.82): Pearson's correlation coefficient was 0.61 (CI 0.43-0.74). The disagreement rate on occlusion was 3% between DSA and 3D CT and was rather high (10.9%) between Doppler ultrasound and DSA. CONCLUSIONS: The clinical decision to operate on an ICA stenosis will be strongly influenced by the diagnostic method used. DSA and 3D CT correlate well, whereas Doppler ultrasound tends to differ at the high end of the high-grade stenosis band (90% occlusion), underestimating (compared with DSA) the degree of stenosis.