CHAPTER 152 
Mesenteric Vascular Disease:
Chronic Ischemia
GUSTAVO S. ODERICH
Based on a chapter in the seventh edition by Thomas S. Huber and W. Anthony Lee
The first clinical and anatomic descriptions of intestinal
ischemia were recognized by Chienne in 1869 and
Councilman in 1894.1,2 Goodman in 1918 associated the
symptoms of postprandial abdominal pain with those of
patients with angina pectoris.3 Dunphy from the Peter Bent
Brigham Hospital reported in 1936 the correlation between
recurrent abdominal pain and fatal intestinal infarction
from occlusive mesenteric arterial disease.4 In that report,
60% of patients who died of intestinal infarction had a
history of recurrent abdominal pain that preceded the fatal
event by weeks, months, or years. Since then, the term
intestinal angina has been coined to describe the classic
symptom of chronic abdominal pain that occurs after meals,
which is the cardinal symptom of chronic mesenteric
ischemia.
BACKGROUND
Incidence
Current estimates indicate that chronic mesenteric ischemia
accounts for less than 1 per 100,000 hospital admissions
in the United States and less than 2% of all admissions
for gastrointestinal conditions.5 Since the first successful
mesenteric endarterectomy by Shaw and Maynard in 1958,
techniques of revascularization have greatly evolved.6
Advances in diagnostic imaging, medical therapy, surgical
techniques, and endovascular technology resulted in
improved outcomes. Balloon angioplasty was reported for
treatment of mesenteric arterial stenoses by Uflacker, Furrer,
Gruntzig, and colleagues in 1980.7,8 During the last decade,
mesenteric angioplasty and stenting gained widespread
acceptance and became the most frequently used treatment
of chronic mesenteric ischemia, relegating open surgery to
patients who fail to respond to endovascular therapy or
who have complex lesions unsuitable to it.9 This chapter
provides a comprehensive review of the pathophysiology,
clinical presentation, indications, techniques, and outcomes
of revascularization in patients with chronic mesenteric
ischemia.
Pathophysiology
Approximately 20% of the cardiac output goes through the
mesenteric arteries under normal conditions.10 Blood flow to
the gastrointestinal tract increases shortly after the ingestion
of a meal, remaining elevated at levels approaching 100% to
150% of normal (2000 mL/min) during the next 3 to 6
hours.11 This normal hyperemic postprandial response is
mediated by cardiovascular changes that accompany the
ingestion and digestion of food. These changes start with
anticipation of a meal and increase considerably with pres-
ence of food in the stomach and intestine, including an
increase in cardiac output, heart rate, and blood pressure.
Mesenteric vasodilatation starts 3 to 5 minutes after food
enters the intestine, reaching its maximum 30 to 90 minutes
later and lasting 4 to 6 hours. The latency and duration of
these responses depend on the type and quantity of a meal,
with high-fat and protein-containing foods producing the
most profound and sustained intestinal hyperemia.12
Postprandial mesenteric hyperemia is confined to organs
in which digestion is occurring but is not shared equally
within the same mesenteric arterial territory. The increased
blood flow in the superior mesenteric artery (SMA) territory
elicited by food in the intestine is associated with little or no
change in blood flow to the stomach, pancreas, and colon.
In conscious humans, Moneta et al13 have shown marked
increase in end-diastolic velocity in the SMA, with minimal
change in velocities in the celiac axis, presumably because of
the relatively low resistance on the splenic and hepatic cir-
culations at baseline. Portal venous and hepatic blood flow
also increase. At the level of the intestinal wall, blood flow
distribution favors the mucosa rather than the submucosa and
muscularis.14
Patients with mesenteric ischemia fail to achieve the post-
prandial hyperemic response that is required to supply oxygen
for the metabolic processes of secretion and absorption and
for increased peristaltic activity.15 Just as in the patient with
ischemic cardiomyopathy, in whom angina pectoris occurs
from inadequate supply of oxygen, intestinal angina results
from the relative imbalance between tissue supply and
2373
2374 SECTION 25  Mesenteric Vascular Disease
demand for oxygen and other metabolites. At the tissue and
cellular level, the lack of adenosine triphosphate metabolism
affects intestinal mucosa, muscularis, and visceral nerves,
causing failure of most intestinal mucosal transport pathways
and contracture of the muscle layer with inadequate relax-
ation, resulting in malabsorption and abdominal pain.16,17
The mesenteric circulation is rich in collateral networks
between the three main visceral artery territories (celiac
axis, SMA, and inferior mesenteric artery [IMA]) and the
internal iliac arteries (Fig. 152-1). Direction of blood flow
is contingent on the location of significant stenoses. The
gastroduodenal and pancreaticoduodenal arteries provide
collateralization between the celiac axis and SMA. The
marginal artery of Drummond and the arc of Riolan connect
the left colic artery (IMA) to the middle colic artery (SMA).
Meandering mesenteric or central anastomotic artery
describes marked enlargement that occurs in the arc of Riolan
in patients with high-grade stenosis or occlusion of the SMA
and collateralization via a patent IMA.18 This artery lies in
the mesentery close to the inferior mesenteric vein. Inad-
vertent ligation, division, or thrombosis of this important
collateral artery during aortic exposure or other operative
procedures may result in acute ischemia or bowel gangrene.
The internal iliac arteries provide a collateral pathway via
the hemorrhoidal branches.
Figure 152-1  Mesenteric artery circulation and common
collateral pathways in patients with severe occlusive mesen-
teric artery disease. Note severe disease at the celiac axis,
superior mesenteric artery (SMA), and inferior mesenteric
artery (IMA). Common collateral pathways include the arc of
Riolan between the left colic artery (IMA) and middle colic
artery (SMA). The celiac axis and SMA have collateralization via
the pancreaticoduodenal arcade (arc of Buhler) and the gas-
troduodenal arteries.
Because of the extensive collateral network, the majority
of patients with symptoms of chronic mesenteric ischemia
have significant stenosis or occlusion of at least two of the
three mesenteric arteries. In the last Mayo Clinic review of
229 mesenteric arteriograms, 98% of patients with chronic
mesenteric ischemia had two- or three-vessel involvement,
with occlusion or critical stenosis of the SMA in 92%.19
However, contrary to what has been propagated in many
surgical textbooks, this is not an absolute requirement.20,21
The clinical significance of ischemia correlates not only to
the extent of disease but also to the adequacy of collateral
pathways, acuteness of symptoms, and presence of arterial
steal; approximately 2% to 10% of patients with chronic
mesenteric ischemia have single-vessel disease, which affects
primarily the SMA in patients with poorly developed col-
laterals or more acute presentation, as might be predicted
from the postprandial hyperemic response.19
Etiology
The most common cause of chronic mesenteric ischemia is
atherosclerotic disease, accounting for more than 90% of
cases in most series. Atherosclerotic lesions usually affect the
origin or the proximal 2 to 3 cm of the mesenteric arteries,
frequently with associated plaque in the aorta and renal

arteries. The prevalence of mesenteric atherosclerotic disease
ranges from 6% to 10% in autopsy studies to 14% to 24% in
patients undergoing aortography for investigation of coronary
or peripheral arterial disease. Imaging studies typically dem-
onstrate stigmata of atherosclerosis (e.g., calcified plaque,
atheromatous debris) in multiple vascular beds, notably the
coronary, carotid, renal, and aortoiliac arteries.
Nonatherosclerotic lesions can also affect the mesenteric
arteries and tend to occur in younger patients. A variety of
diagnoses merit investigation, including vasculitis (giant cell
arteritis, Takayasu’s disease, and polyarteritis nodosa), sys-
temic lupus erythematosus, Buerger’s disease, mesenteric or
aortic dissection, fibromuscular dysplasia, neurofibromatosis,
radiation arteritis, mesenteric venous stenosis or occlusion,
and drug-induced arteriopathy from cocaine or ergot use.
Abdominal aortic coarctation or midaortic syndrome can also
be manifested with symptoms of mesenteric ischemia.
Natural History
The natural history of mesenteric arterial disease has not
been completely defined. It is generally accepted that asymp-
tomatic lesions carry a benign course, not justifying prophy-
lactic revascularization. Nonetheless, the observation that
15% to 50% of patients who present with bowel gangrene
have thrombosis of preexisting lesions with no antecedent
warning signs suggests that these lesions are not entirely
benign.22,23 The likelihood of symptom progression seems to
depend on the extent of disease. Wilson et al24 reported a
large prospective cohort study of 553 elderly patients who
were screened for mesenteric artery disease with duplex ultra-
sound. The prevalence of mesenteric stenosis greater than
70% or occlusion was 18%. After a follow-up period of 7
years, none of the patients developed symptoms of mesenteric
ischemia, but most had single-vessel disease, only 14% had
SMA stenoses, and none had three-vessel involvement.
Thomas et al25 reviewed 980 aortograms and found 60
patients (6%) with significant mesenteric artery disease
(>50% stenosis). Of these, 15 had involvement of all three
visceral arteries. During follow-up of 2.6 years, four patients
(27%) developed symptoms, three had successful revascular-
ization, but one died of acute ischemia.
The natural history of patients with symptoms of chronic
mesenteric ischemia is even less well understood because
revascularization is typically recommended. There are no
cohort studies with a control or medical treatment arm.
It is generally accepted that once a patient develops symp-
toms of chronic ischemia, there is considerable risk of
progression to cachexia or bowel gangrene, and revascu-
larization is indicated.
DIAGNOSTIC EVALUATION
The diagnosis of chronic mesenteric ischemia is suggested by
clinical history and confirmed by one or more diagnostic
studies, such as duplex ultrasonography, magnetic resonance
angiography (MRA), computed tomography angiography
(CTA), or conventional aortography. Endoscopy with
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2375
24-hour or exercise tonometry, if it is available in centers
SECTION 25 MESENTERIC VASCULAR DISEASE
with established protocols, can be useful in the differential
diagnosis of patients with atypical symptoms, single-vessel
disease, or median arcuate ligament syndrome. Tests of intes-
tinal absorptive and excretory function have not been useful.26
Clinical Presentation
The typical patient with chronic mesenteric ischemia is
female with a median age of 65 years, with age ranging from
40 to 90 years.9,19,27 Most studies quote a 3 : 1 or 4 : 1 female-
to-male ratio. A survey of the Nationwide Inpatient Sample
examining the outcomes of mesenteric revascularizations in
22,413 patients reported a mean age of 66 years and that 76%
of the patients were women.9 In patients with nonatheroscle-
rotic lesions, the female-to-male ratio varies from 1 : 1 or 1 : 2
for coarctation and neurofibromatosis to 5 : 1 for vasculitis.
Most patients with nonatherosclerotic disease are in their
third or fourth decade of life.28-30
The classic symptoms of chronic mesenteric ischemia
include abdominal pain, weight loss, and “food fear.” The
abdominal pain is often postprandial and begins within a few
minutes to 30 minutes after meals, persisting for as long as 5
to 6 hours. It is usually midabdominal in location and crampy
or dull. Patients may describe intolerance to certain types of
food, and consequently they alter their eating habits to avoid
foods that precipitate symptoms. In fact, some patients do not
report any pain at time of presentation because of their adap-
tive strategies to reduce or to relieve it. Unintentional weight
loss progresses to malnutrition and cachexia, which is often
present at the time of intervention. In the last review of the
Mayo Clinic, which included 357 consecutive patients
treated by revascularization since 1990, abdominal pain was
present in 96% (postprandial in 74%) and weight loss in
84%. Duration of symptoms, or time delay, before revascular-
ization averages 15 months. The pattern of symptoms often
changes and progresses in intensity, frequency, and severity.
Subacute mesenteric ischemia is characterized by progression
of pain from intermittent to unremitting or continuous during
the course of days or a few weeks, warranting immediate
revascularization. Physical examination is nonspecific, does
not commonly reveal any pathognomonic findings, but can
point to the diagnosis. Many individuals are thin at the onset
of their symptoms and progress to cachexia, particularly those
with significant delay at time of diagnosis. These patients
have obvious signs of malnutrition, muscle wasting, and a flat
or scaphoid abdomen. Pain may be present but not localized
or aggravated by abdominal palpation; the finding of pain out
of proportion to physical findings should point toward the
diagnosis of mesenteric ischemia. An abdominal bruit may be
noted in up to 50% of patients; it differs from the bruit caused
by compression of the celiac axis by the median arcuate liga-
ment, which is elicited by deep expiration and elevation of
the diaphragm. A complete vascular examination may elicit
a diminished ankle-brachial index or absent peripheral pulses
and bruit in other vascular beds (e.g., carotid, subclavian, and
iliacs). Laboratory test results are nonspecific or unremark-
able in the absence of acute symptoms but may demonstrate
2376 SECTION 25  Mesenteric Vascular Disease
malnutrition (decreased serum albumin, transferrin, and pre-
albumin levels), systemic inflammation (e.g., vasculitis), and
elevation of L-lactate and D-dimer after meal challenge.31
The clinical presentation can be less specific in some
patients. Vague abdominal pain, nausea, vomiting, or change
in bowel habits, without the classic postprandial component
to the pain, can make the diagnosis difficult to ascertain; in
these patients, 24-hour gastric tonometry has been useful if
it is available.32-39 Liver function abnormalities or endoscopic
evidence of diffuse small ulcerations in the stomach or proxi-
mal duodenum or patchy areas of ischemia in the colon are
not uncommon. A previous history of smoking and the diag-
noses of hypertension and hyperlipidemia are documented in
60% to 70%.19,40,41 Consequently, patients often have other
manifestations of atherosclerotic disease affecting the coro-
nary (50% to 70%), cerebrovascular (20% to 45%), and
peripheral (20% to 35%) arteries. Concomitant renal artery
disease with difficult to control hypertension or ischemic
nephropathy is not uncommon.42 The presence of severe
aortic or peripheral arterial occlusive disease represents a
challenge in terms of source of inflow for bypass, access for
percutaneous procedures, or sequence of revascularization in
patients with limb-threatening ischemia.
Diagnostic Tests
It is not infrequent for patients with chronic mesenteric
ischemia to experience significant delay in diagnosis or to
undergo an extensive evaluation to rule out other causes of
chronic abdominal pain and weight loss. The differential
diagnosis is extensive, including inflammatory, infectious,
and malignant disease. The investigation often includes
upper and lower gastrointestinal endoscopy and cross-
sectional imaging of the abdomen with either computed
tomography or magnetic resonance imaging. Often, the
finding of mesenteric artery stenosis in an imaging study is
the first clue to the diagnosis. If chronic mesenteric ischemia
Figure 152-2  Mesenteric duplex ultrasound with normal and abnormal waveform patterns during the fasting state. IMA, Inferior mesenteric
artery; PSV, peak systolic velocity; SMA, superior mesenteric artery.
is suspected on clinical examination, mesenteric duplex
ultrasound is the most frequently used screening study. None-
theless, the author recommends obtaining additional cross-
sectional imaging of the abdomen and mesenteric arteries
before proceeding with an intervention. Because abdominal
pain and unintentional weight loss are common presenta-
tions of other conditions (e.g., cancer, inflammatory bowel
disease, infections), imaging of the abdomen and pelvis may
help rule out other diagnoses and identify nonatherosclerotic
causes of mesenteric disease. Most important, anatomic detail
about the number of vessels affected and lesion characteristics
(diameter, length, presence of occlusion, calcification, throm-
bus, or tandem lesions) are key factors that affect selection
of the type of revascularization.
Mesenteric Duplex Ultrasound
Mesenteric duplex ultrasound is an excellent screening study
in patients with abdominal pain or an epigastric bruit in
whom mesenteric artery disease is suspected (Fig. 152-2). A
negative duplex ultrasound study essentially excludes the
diagnosis of mesenteric artery disease. In preparation for the
study, patients undergo a minimum 6- to 8-hour fast. A com-
plete study should include B-mode images, spectral analysis,
and velocity measurements. In the celiac axis, velocity mea-
surements are also obtained with deep inspiration and deep
expiration; an increase in peak systolic velocity with deep
expiration is indicative of compression of the celiac axis by
the median arcuate ligament. Mesenteric ultrasound can be
technically challenging because of body habitus, bowel gas,
or unusual anatomy.
Since the original work by Nicholls et al43 from the Uni-
versity of Washington, the criteria for significant mesenteric
artery stenosis have been established by retrospective studies
and validated by prospective comparison with mesenteric
angiography.44-47 In 1993, Moneta et al48 from Oregon Health
Science University reported the first prospective validation of
mesenteric diagnostic criteria in 100 patients. In that study,

the most accurate criteria to indicate a stenosis of 70% or
greater were a peak systolic velocity of more than 275 cm/s
for the SMA and more than 200 cm/s for the celiac axis (see
Fig. 152-2).48 As a criterion for SMA stenosis of 70% or
greater, a peak systolic velocity of more than 275 cm/s had a
sensitivity of 92%, specificity of 96%, positive predictive
value of 80%, and negative predictive value of 99%. A veloc-
ity of 200 cm/s in the celiac axis as a predictor of a stenosis of
70% or greater had somewhat lower values. The Bowersox
criteria,45 later validated prospectively by the Dartmouth
group,47 are based on 50% or greater arterial stenosis. For the
SMA, an end-diastolic flow velocity of 45 cm/s or higher had
90% sensitivity, 91% specificity, 90% positive predictive
value, 91% negative predictive value, and 91% accuracy. For
the celiac axis, reversal of blood flow in the hepatic artery was
100% predictive of stenosis. An end-diastolic velocity higher
than 55 cm/s or no flow signal had the best overall accuracy
(95%) with high sensitivity (93%) and specificity (94%).
The IMA is the smallest of the mesenteric arteries and
usually gains significance in advanced cases of chronic mes-
enteric ischemia, in which it provides collateral flow into the
SMA via the meandering mesenteric artery. Because of its
small size, difficult visualization, and minimal clinical impor-
tance, this vessel has gained little attention in the mesenteric
duplex literature. The evaluation of the IMA is indicated in
situations in which colonic ischemia is the predominant
clinical finding. AbuRahma reported the duplex ultrasound
criteria for greater than 50% stenosis in 85 patients with
paired duplex ultrasound and angiography.49 The most
Figure 152-3  Computed tomography
angiography with three-dimensional re-
construction in a patient with severe three-
vessel mesenteric occlusive disease.
A, Note occlusion of the celiac axis and su-
perior mesenteric artery (SMA), with collat-
eral flow via a large inferior mesenteric
artery (IMA) and meandering artery. Collat-
eralization from the IMA to SMA via arc of
Riolan (curved arrow) and marginal artery of
Drummond (arrowhead) and from the SMA
to celiac axis via a large gastroduodenal
artery (straight arrow). B, Axial view of the
SMA demonstrates occlusion with a small A B
stump (double arrow).
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2377
accurate peak systolic velocity was higher than 250 cm/s,
SECTION 25 MESENTERIC VASCULAR DISEASE
with sensitivity of 90%, specificity of 96%, and overall accu-
racy of 95%. A ratio of IMA to aortic peak systolic velocity
above 4.0 had overall accuracy of 93%. There have been no
studies with prospective validation of duplex criteria for
the IMA.
Comparison of preprandial and postprandial blood flow
velocities is not specific enough to distinguish physiologi-
cally appropriate from inappropriate blood flow responses.
Despite a large quantity of data from healthy individuals,
there is little evidence that postprandial testing adds to
the fasting duplex examination.13 Gentile et  al50 compared
fasting and postprandial duplex ultrasound velocities with
angiographic stenosis measurements in the SMA of healthy
controls and those with peripheral arterial disease. Combin-
ing fasting and postprandial duplex results increased specific-
ity and positive predictive value slightly but did not improve
overall accuracy.
Multidetector Computed Tomography and
Magnetic Resonance Angiography
Although there is little question about the accuracy of mes-
enteric duplex ultrasound as a screening study, cross-sectional
imaging of the abdomen is often needed to rule out other
causes of abdominal pain and to provide anatomic analysis to
plan revascularization.51-53 The choice of CTA or MRA is
somewhat related to individual expertise at the institution.
Most centers use CTA, which allows analysis with three-
dimensional reformatting techniques (Fig. 152-3), maximum
2378 SECTION 25  Mesenteric Vascular Disease

intensity projection, and volume rendering. Images can be
analyzed in multiple planes (sagittal, coronal, and axial), and
centerline of flow measurements can be obtained for accurate
measurement of lengths. Multidetector computed tomogra-
phy technology is readily available in most centers, combin-
ing multiple rows of detection with narrow collimation.54
Multidetector computed tomography has the highest spatial
resolution and finest image detail and is considered by most
the best study to evaluate anatomic characteristics (calcifica-
tion, thrombus, diameters, and lengths) that are important to
plan mesenteric interventions (Fig. 152-4). In patients with
classic symptoms, CTA may supplement or even replace
duplex ultrasound, and it is often the only imaging study that
is obtained before intervention. It is also useful to objectively
assess patency of grafts and stents. Limitations include radia-
tion exposure, cost, risk of complications related to the con-
trast agent (e.g., nephropathy, allergic reactions), and, in
some cases, difficult assessment of luminal diameter due to
significant vessel calcification or prior stents.
For patients who present with subacute or acute symptoms,
multidetector computed tomography has the advantage of
showing additional imaging signs that are not visible with
catheter angiography. Bowel wall changes indicative of isch-
emia include circumferential thickening with low (edema)
or high (hemorrhage) attenuation, increased or delayed
enhancement in the bowel wall due to hyperemia, and frank
bowel infarction or perforation with pneumatosis intestinalis,
portal venous air, or pneumoperitoneum. Another potential
application of multidetector computed tomography is the
evaluation of venous thrombosis or narrowing affecting the
mesenteric veins and portal venous system.
Gadolinium-enhanced MRA has advanced in recent years
to provide improved imaging resolution with shorter acqui-
sition times. This imaging modality is used to a lesser
extent but affords many of the same advantages as CTA.55,56
The overall sensitivity and specificity for detection of sig-
nificant mesenteric artery disease is more than 95% compared
with contrast angiography.57 MRA provides functional infor-
mation by integrating flow dynamics and blood oxygen
saturation techniques with the anatomic detail, which can
be useful in patients with questionable diagnosis of chronic
mesenteric ischemia.58,59 The study is limited in patients

Focal Disease Complex Disease

A B
Figure 152-4  Computed tomography angiography is the most useful imaging study to plan revascularization. Anatomic characteristics of the
superior mesenteric artery can be used to identify patients with focal disease (A), for which angioplasty and stenting are favored, and patients
with complex disease (B), for which endovascular therapy is technically more challenging. Lesions with unfavorable anatomy for stenting include
heavily calcified occlusions, long-segment occlusions, and long-segment stenosis involving multiple branches.

with prior stents or excessive calcification. Until recent
reports of complications from gadolinium, MRA was the
preferred imaging modality in patients with chronic kidney
disease. The complication of systemic fibrosis due to gado-
linium has significantly decreased its use in this patient
population. Time-of-flight imaging, without gadolinium, has
proved to be inaccurate to estimate the degree of mesenteric
stenosis.
Contrast Arteriography
Diagnostic catheter-based arteriography is considered the
“gold standard” diagnostic study for evaluation of mesenteric
artery disease in patients with chronic mesenteric ischemia.
During the last decade, its role as a confirmatory test and for
planning revascularization diminished in favor of the afore-
mentioned noninvasive modalities. Since 2002, the use of
contrast arteriography to plan mesenteric reconstructions at
the Mayo Clinic decreased from 97% to 57%, with an increase
in the use of CTA (55% to 88%) and MRA (12% to 33%).60
Mesenteric arteriography is rarely needed to confirm the diag-
nosis, and it typically does not add anatomic detail to plan
an intervention. More frequently, angiography is obtained in
conjunction with a planned endovascular intervention.
Exceptions are patients with suboptimal imaging studies and
A B
Figure 152-5  Abdominal aortogram with right anterior oblique view demonstrates a large patent inferior mesenteric artery (IMA). Selective
IMA angiography confirms collateralization to the superior mesenteric artery via the arc of Riolan (arrow) and collateralization to the celiac axis
via the gastroduodenal artery (arrow).
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2379
those with extensive calcification, small vessels, or multiple
SECTION 25 MESENTERIC VASCULAR DISEASE
prior stents causing metallic artifact.
A diagnostic study includes biplane abdominal aortogra-
phy with anterior-posterior and lateral projections. A lateral
view is imperative to provide visualization of the origins
of the celiac axis and SMA. A right anterior oblique view
(Fig. 152-5) demonstrates the origin of the IMA. For better
visualization of ostial lesions and quantification of the degree
of stenosis, selective catheterization of the visceral arteries
is necessary. In patients who had prior CTA or MRA,
abdominal aortography may be avoided, unless it is needed
to identify the origin of a vessel before selective catheteriza-
tion. However, if CTA or MRA has not been performed,
biplane aortography is recommended to define the location,
severity, and extent of visceral artery involvement, to identify
the presence of concomitant lesions in the renal or iliac
arteries, and to indicate the suitability of the supraceliac or
infrarenal aorta as an inflow site if open reconstruction is
contemplated.
Selective catheterization is often performed to provide
anatomic detail about the extent of disease, presence of
tandem lesions, aberrant anatomy, and collateral patterns. It
is not infrequent to find small, flow-related aneurysms in col-
lateral branches, specifically the pancreaticoduodenal arcades,
2380 SECTION 25  Mesenteric Vascular Disease
combined with occlusion of the celiac axis and extensive
collateralization via the SMA.
Endoscopy
Endoscopy is often obtained as part of the investigation of
abdominal pain. It can demonstrate inflammatory and isch-
emic changes, most noticeable in the stomach, duodenum, or
right colon. Erosive ischemic gastritis, gastroduodenitis, or
ischemic colitis noted on endoscopy has been described in
association with chronic mesenteric ischemia.61 In a study of
55 patients treated for mesenteric ischemia, endoscopy dem-
onstrated ischemic duodenitis in 38% of patients and isch-
emic colitis in 57%.62 Clinical experience from European
centers has shown that endoscopy can be useful to assess
mucosal perfusion, to confirm ischemia, and to differentiate
causes of abdominal pain in patients with atypical symptoms
of chronic mesenteric ischemia.32-34,36-39,63-70
Gastric Tonometry
Gastric tonometry has been shown to be a valuable diagnostic
test to assess intestinal perfusion. The initial concept was
described in 1965 and later developed into clinical protocols
in the late 1980s.32-34,36-39,61 The study is based on the premise
that PCO2 levels rise above normal from reduced carbon
dioxide washout in the ischemic tissue. Higher PCO2 levels
measured in the gastric, jejunal, or colonic mucosa correlate
with poor mucosal perfusion. Tonometry can be performed as
part of a 24-hour monitoring study during the fasting and
postprandial states or as an exercise test using a small naso-
gastric tonometry catheter with serial PCO2 measurements in
the stomach, duodenum, or upper jejunum.33,35,38 Most
recently, jejunal tonometry has been used with additional
diagnostic value.37 For exercise tonometry, the patient uses a
bicycle ergometer and the gastric-arterial PCO2 gradient is
measured at incremental workloads.36 Excessive or inadequate
exercise can result in false-positive or false-negative results.
Whereas several studies have shown the clinical utility of
tonometry for diagnosis of ischemia, this modality has not
gained widespread acceptance in the United States.32-39
Oxygen Light Spectroscopy
Visible light spectroscopy is a new technique that enables
noninvasive measurements of mucosal capillary hemoglobin
oxygen saturation during endoscopy with use of white light
from a fiberoptic probe. The technique relies on differences
in absorption spectra of oxygenated and deoxygenated hemo-
globin; oxygen saturation reflects mucosal perfusion. Pilot
studies and recent clinical correlation have shown promising
results.65,70
TREATMENT STRATEGIES
There is no role for a conservative approach with chronic
parenteral nutrition and noninterventional therapy in pa-
tients with symptomatic mesenteric artery disease. Excessive
delays in proceeding with definitive revascularization and the
use of parenteral nutrition alone have been associated with
clinical deterioration, bowel infarction, and risk of sepsis from
catheter-related complications.71,72
Indications for Revascularization
Revascularization is indicated in all patients with symptoms
of chronic mesenteric ischemia. Treatment goals are to relieve
symptoms, to restore normal weight, and to prevent bowel
infarction. The indication of prophylactic revascularization
in patients with asymptomatic disease remains controversial.
Based on the report by Thomas et al,25 there may be a role
for prophylactic revascularization in patients with severe
three-vessel disease, particularly for those with difficult access
to medical care who live in remote or underserved areas. Our
approach in these patients has been close surveillance and
counseling about symptoms of mesenteric ischemia, with a
low threshold to proceed with revascularization if any gastro-
intestinal symptoms (e.g., bloating, diarrhea, atypical pain)
arise. Revascularization has been advised in asymptomatic
patients with severe three-vessel disease undergoing aortic
reconstructions for other indications.
Choice of Open versus Endovascular
Revascularization
Treatment selection has evolved in most centers. The number
of mesenteric revascularizations has increased 10-fold in the
United States in the last decade, largely because of improved
diagnosis and decreased morbidity of endovascular therapy.
In most centers, angioplasty with stenting surpassed open
bypass as the first option and is currently used in more than
70% to 80% of the patients treated for chronic mesenteric
ischemia.9,19,51 These changes in treatment paradigm have
occurred despite the lack of prospective randomized compari-
sons between the two techniques. Endovascular revascular-
ization has been associated with decreased morbidity, length
of stay, and convalescence time but similar mortality com-
pared with open repair in single-institution studies.19,73 A
larger population-based study suggests a possible mortality
benefit with endovascular treatment, but this may be limited
by selection bias.9 Mesenteric bypass offers improved patency,
with lower rates of re-interventions and better freedom from
recurrent symptoms.9,19,41,73-83
In most centers, including the author’s, mesenteric angio-
plasty with stenting is currently the first choice of treatment
in patients with chronic mesenteric ischemia who have suit-
able lesions, independent of their clinical risk (see Fig. 152-
4). A careful review of preprocedure CTA with attention to
anatomic factors determines selection of the open or endo-
vascular approach. The SMA is the primary target for revas-
cularization, and as such the anatomy of the SMA is the most
important determinant of choice of therapy. The ideal lesion
for angioplasty and stenting is a short, focal stenosis or occlu-
sion with minimal to moderate calcification or thrombus (see
Fig. 152-4). For celiac axis lesions, angioplasty with stenting
carries a higher rate of restenosis,84 and it should not be per-
formed if there is active compression by the median arcuate

ligament unless this has been surgically released. We found
no benefit with two-vessel stenting.84 The technical difficulty
of endovascular procedures is increased by the presence
of severe eccentric calcification, flush occlusion, longer
lesions, small vessels, and tandem lesions affecting branches.
Although these anatomic features do not contraindicate the
use of stents, the technical result is often not optimal, with
higher rates of arterial complications (e.g., distal emboliza-
tion, dissection) and restenosis.85,86 Our preference in lower
risk patients has been to offer open revascularization if the
anatomy is unfavorable for angioplasty and stenting.87,88 Mes-
enteric bypass has also been increasingly performed in patients
for whom percutaneous intervention has failed because of
flush occlusion or stent occlusion and in patients with recur-
rent in-stent stenosis for whom multiple re-interventions
have failed. Open reconstruction has been preferred as the
first option to treat most patients with nonatherosclerotic
lesions, such as vasculitis, neurofibromatosis, and midaortic
syndrome.28,29 Finally, for patients who are not good candi-
dates for open repair because of severe comorbidities or
cachexia, stenting can be used as a “bridge” to open surgical
bypass in those with complex lesions prone to restenosis.
REVASCULARIZATION TECHNIQUES AND
PERIPROCEDURAL MANAGEMENT
Endovascular Revascularization
Endovascular mesenteric revascularization carries definitive
risk. The average 30-day mortality in a recent systematic
review was 6% (0% to 21%), surpassing the mortality reported
for other types of endovascular interventions, including
aortic, renal, and carotid procedures.73 Even though most
interventions are done with local anesthesia, these patients
typically undergo a comprehensive medical evaluation to
identify and to optimize cardiovascular risk factors and their
nutritional status.
Preprocedure Evaluation
Many of the comorbidities may require medical therapy to be
started before or after the intervention, depending on their
severity. Revascularization should not be excessively delayed.
Patients who present with deterioration of symptoms should
be admitted, prescribed intravenous heparin, and treated
urgently within 24 to 48 hours. Patients with allergy to iodin-
ated contrast agents should be premedicated with a steroid
and antihistamine preparation. Those with chronic kidney
disease who have a serum creatinine level above 1.5 to
2.0 mg/dL (133 to 177 mmol/L) undergo intravenous hydra-
tion with sodium bicarbonate and oral acetylcysteine, starting
the day before intervention. Review of preprocedure imaging
(CTA, MRA, or conventional angiography) is key to selec-
tion of the ideal approach based on the angle of origin of the
mesenteric vessels in relation to the aorta, the amount of
calcium and thrombus load, and the presence of important
collaterals or unusual anatomy (e.g., replaced hepatic) in
proximity to the target lesion.
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2381
Diagnostic Mesenteric Angiography.  Diagnostic angiogra-
SECTION 25 MESENTERIC VASCULAR DISEASE
phy is most often done immediately before a planned inter-
vention, through either the femoral or brachial approach.
Access is established with ultrasound guidance and a 0.035-
inch guide wire system. A 5F sheath is positioned in the
external iliac artery and a 5F diagnostic flush catheter is
advanced to T12 level over a 0.035-inch guide wire. Modest
intravenous heparinization (40 units/kg) is recommended
before selective catheterization of the mesenteric arteries.
The use of a low-osmolarity contrast agent (e.g., Visipaque)
minimizes abdominal discomfort during selective injections.
Choice of catheter shape depends on access site, angle of
origin, and individual preference. A multipurpose catheter is
ideal for selective catheterization through a brachial approach,
whereas a secondary curve catheter (e.g., SOS or Simmons)
or a catheter with a more acute curve (e.g., Cobra 2) can be
used for interventions done through a femoral approach. A
complete study includes abdominal aortography with anterior-
posterior and lateral views to define the location, severity,
and extent of visceral artery involvement and to identify
concomitant lesions in the aorta and renal or iliac arteries.
The optimal projection to display the proximal celiac axis
and SMA is a lateral view; for the origin of the IMA, it is a
15-degree right lateral oblique view. Selective angiography is
necessary to confirm the severity of disease and to identify
tandem lesions and collateral patterns. In patients with ques-
tionable lesions, pressure gradients can be measured by pres-
sure wire, pullback, or simultaneous pressure measurement
techniques.89
Principles
The primary goal of percutaneous treatment is to restore
antegrade flow into at least one of the three mesenteric arter-
ies, preferentially the SMA. First reports described successful
results with balloon angioplasty alone, but elastic recoil and
restenosis limited its utility for ostial lesions.81,90-99 Although
there are no prospective comparisons between angioplasty
alone and primary stenting, most agree that routine stenting
is indicated, given that mesenteric lesions resemble renal
artery stenoses.84,100-114 Although there are no randomized
comparisons between SMA and celiac stent placement, ret-
rospective studies suggest that celiac stenting is associated
with more recurrences in the first year after treatment.84 In
patients with compression of the celiac axis by the median
arcuate ligament, there is risk of stent fracture and compres-
sion. The role of two-vessel stenting remains controversial.
Two retrospective studies by the Massachusetts General
Hospital group109 and by Silva et al106 have shown a nonsig-
nificant trend toward less recurrence with two-vessel stent-
ing. Malgor et al84 from the Mayo Clinic reported nearly
identical recurrence rates at 2 years in patients treated by
SMA stents (78%) compared with two-vessel stenting of the
SMA and celiac axis (60%). Two-vessel mesenteric interven-
tions may have a role in select patients with severe gastric
ischemia who do not have a good collateral network between
the celiac axis and SMA. However, there is no proven benefit
that routine two-vessel stenting provides more durable relief,
2382 SECTION 25  Mesenteric Vascular Disease

and a second intervention adds cost and potential risk of
complications.
Celiac axis intervention may be considered in higher risk
patients for whom attempted recanalization of the SMA has
failed or in those in whom an SMA intervention is thought
to have a low yield for success because of excessive calcifica-
tion or long-segment occlusion. In these patients, celiac
stenting may be considered a bridge to open bypass or retro-
grade SMA stenting.115 Angioplasty of the IMA in our
experience carries a higher risk of rupture, dissection, or
embolization and is not advised, with rare exceptions.
A brachial artery approach is preferred for patients with a
very angulated origin of the SMA off the aorta and in those
with occlusions or longer lesions. The author’s preference is
to use the brachial artery approach whenever possible (Fig.
152-6). This offers excellent support with small-profile
systems and precise stent deployment in patients with an
acute SMA angle. Because the risk of puncture-related com-
plications is higher with a total percutaneous technique,
another option is to use a small 1- to 2-cm incision under
local anesthesia to expose and to repair the brachial artery.
Less frequently, a radial approach has been used.
Technique
Percutaneous access is established by a 0.018-inch micro-
puncture set with ultrasound guidance, after which the
system is exchanged for a 0.035-inch guide wire system. Full
systemic heparinization (80  mg/kg) is administered before
catheter manipulations to achieve an activated clotting time
above 250 seconds. A 6F or 7F 90-cm hydrophilic sheath
is positioned in the descending thoracic aorta above the
celiac axis origin. A 5F multipurpose catheter is ideal for
selective catheterization of the mesenteric arteries through
the brachial approach, whereas an SOS or VS1 catheter
can be used from the femoral approach. The initial selective
angiography should demonstrate the origin of the vessel
from the aortic wall and the severity of the stenosis, and
it should document the distal branches for comparison with
postintervention views.
The target lesion is initially crossed with a 0.035-inch
soft angled glide wire, which is exchanged for the interven-
tional wire of choice after confirmation of true lumen access.
The author’s preference is to use a small-profile (0.014- or
0.018-inch) stiff guide wire for most interventions. Most
recently, our practice has changed to covered stents on the
basis of a recent report that indicates superior patency rates
compared with bare metal stents.116 The tip of the guide
wire should be visualized and positioned within the main
trunk of the SMA rather than within small jejunal branches,
which are prone to perforation or dissection (Fig. 152-7).
Embolic protection may be useful in select patients with
occlusions, long lesions (>30-mm length), severe calcifica-
tion, thrombus, and acute or subacute symptoms; the author’s
preference is to use a 320-cm working length 0.014-inch
filter wire (SpiderRX, Covidien, Plymouth, Minn). Alterna-
tively, Brown et  al101 described the use of temporary balloon

A B C D E
Figure 152-6  Angioplasty and stenting of a focal stenosis of the superior mesenteric artery (SMA) by a brachial approach. After selective angi-
ography (A), the lesion is crossed and a 0.014-inch SpiderRX filter wire is deployed in the main trunk of the SMA (B), avoiding jejunal branches.
The entire lesion is treated by a balloon-expandable stent (C), which is extended 1 to 2 mm into the aorta and flared proximally (D). Completion
angiography demonstrates patency of the stent without embolization or dissection (E).
 CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2383

SECTION 25 MESENTERIC VASCULAR DISEASE

Figure 152-7  An important technical point is to visu-
alize the tip of the guide wire during the intervention
and to position the guide wire in the main trunk of the
superior mesenteric artery (curved black arrow) as
opposed to distal jejunal branches (curved black arrow),
which are prone to perforation resulting in mesenteric
hematoma (straight white arrow).

occlusion and aspiration with the GuardWire (Medtronic,
Minneapolis, Minn). If a 0.035-inch stent is selected, a two-
wire technique can be used by combining a 0.014-inch filter
wire with a 0.018-inch “buddy wire”; the stent is introduced
via both wires for better support and to facilitate subsequent
retrieval of the embolic protection device (Fig. 152-8). Pre-
dilatation is recommended for tight stenoses, occlusions, and
severe calcification and to size stents. A balloon-expandable
stent with diameters ranging from 5 to 8  mm is used in
more than 95% of cases, allowing precise deployment and
greater radial force. The stent is positioned under protection
of the sheath, covering slightly more than the entire length
of the lesion. Positioning the stent so that it extends 1 to
2  mm into the aortic lumen is critical to avoid missing the
proximal portion of the lesion (see Fig. 152-6). Ideally, the
stent should be flared gently into the aorta, which minimizes

A B

Figure 152-8  Technique of recanalization and primary

stenting of a total superior mesenteric artery (SMA)
occlusion. In these cases, a stiff support system is built C D
with combination of a 7F 90-cm hydrophilic sheath, 7F
100-cm multipurpose guide catheter, and 5F 125-cm
multipurpose catheter. The stump of the occluded SMA
is engaged by the sheath-catheter combination (A); the
lesion is crossed with a straight glide wire. After true
lumen access is confirmed, a 0.014-inch filter wire and a
0.018-inch buddy wire are deployed into the SMA via
0.035-inch catheter (B); the lesion is predilated (C) and
stented with a balloon-expandable stent (D).
2384 SECTION 25  Mesenteric Vascular Disease
the potential to miss disease at the ostia and facilitates
repeated catheterization if needed. On occasion, a self-
expandable stent is needed to treat a nonostial lesion or
segments with excessive tortuosity extending beyond the
angulated portion of the SMA.
Recanalization of Mesenteric Occlusions.  The technique is
slightly modified in patients with difficult occlusions. In these
cases, it is of paramount importance to use the brachial
approach and a stiff support system, which is accomplished
by combining a 7F sheath, 7F multipurpose guide catheter,
and 5F multipurpose catheter (see Fig. 152-8). In the author’s
opinion, attempting a difficult recanalization from the femoral
approach adds time, contrast material, and catheter manipu-
lations and is fraught with exceedingly high failure rates.
Ideally, the tip of the multipurpose catheter is used to engage
the stump of the occluded SMA (Fig. 152-9), and sufficient
support is provided by the combination of the sheath and
guide catheter. The lesion is crossed with a straight-tip,
hydrophilic, soft 0.035-inch glide wire but also with 0.018-
inch and 0.014-inch guide wires if needed. It is ideal to avoid
the subintimal plane, which is best achieved by use of straight-
tip guide wires. A Quick-Cross (Spectranetics, Colorado
Springs, Colo) or an alternative support catheter or even a
small coronary balloon may be needed to cross a tight lesion.
Once the lesion is crossed, access into the true lumen should
be confirmed. Our preference has been to use an embolic
protection device (e.g., SpiderRX) with a two-wire technique
routinely in cases of total occlusion.
A B
Figure 152-9  Recanalization of superior mesenteric artery (SMA) occlusion by the technique described in Figure 152-8. After the stump is
engaged by the catheter, guide catheter, and sheath (A, arrow), the lesion is crossed (B) and stented with use of embolic protection (C). Note
that the balloon is used to flare the proximal part of the stent (C, arrow). Completion angiography shows a flared, widely patent SMA stent (D).
After deployment and flaring of the stent, the embolic
protection device is retrieved with careful attention to avoid
entrapment into the stent. The basket is examined for debris.
Formal completion angiography should be performed, includ-
ing a focal magnified view of the stent with the sheath into
the aorta to demonstrate the vessel origin and a panoramic
view of the entire SMA and its branches to rule out emboliza-
tion or perforation. The stiff guide wire should be retracted,
and nitroglycerin may be administered through the sheath to
minimize spasm or kinks caused by the guide wire tip. It is
particularly important to note the presence of distal emboliza-
tion, dissection, thrombus, or branch perforation. These com-
plications occur in 5% to 10% of patients and remain a major
source of morbidity and mortality if they are not immediately
recognized.85
Adjunctive Techniques.  A number of adjunctive techniques
can be used to optimize results of mesenteric stents in patients
with complex lesions, but the author acknowledges that these
techniques are anecdotal or supported by a limited number
of case reports. An acute or subacute symptom presentation
suggests fresh thrombus or complicated plaque. In these cases,
local administration of tissue plasminogen activator into the
diseased segment 20 to 30 minutes before stent placement
may improve technical success. For eccentric, calcified
lesions, percutaneous atherectomy has been carefully used in
very select cases.117 It is critical to have an appreciation of
the limitations of this technique when it is applied as an off-
label use in the mesenteric arteries.
C D

Complications
The most common causes of death after mesenteric stenting
are cardiac events, gastrointestinal bleeding, and bowel isch-
emia. Bowel ischemia is typically associated with intraproce-
dural complications, such as distal embolization, thrombosis,
or dissection. Distal embolization occurs in 8% of patients
treated by SMA stents without embolic protection, with
higher rates among patients with subacute symptoms, occlu-
sion, long lesions (>30 mm), and severe calcification.87
Therefore, there may be a role for selective use of embolic
protection in these patients. The most commonly reported
complications are access-related problems in 2% to 15%,
renal insufficiency in 5% to 12%, acute bowel ischemia in
1% to 5%, gastrointestinal bleeding in 1% to 4%, cardiac
events in 1% to 3%, and respiratory complications in 3%.
Postprocedure Management
The postprocedure care after mesenteric interventions is
comparable to that of other peripheral endovascular proce-
dures. All patients are admitted for observation overnight.
Worsening abdominal pain after the procedure is unusual and
warrants evaluation to rule out thrombosis, embolization, or
a mesenteric hematoma from jejunal branch perforation (see
Fig. 152-7). Patients are allowed to resume a regular diet
within 6 to 8 hours. Antiplatelet therapy is typically started
before the intervention with acetylsalicylic acid and contin-
ued indefinitely thereafter. Clopidogrel is started the day of
the intervention with a loading dose of 300 mg and contin-
ued for 6 to 8 weeks as a dual antiplatelet agent, after which
patients continue with acetylsalicylic acid alone. The author’s
preference is to obtain a duplex ultrasound scan before dis-
charge or within the first few days after the procedure to serve
as a baseline for future comparison. The presence of an ele-
vated velocity on duplex ultrasound may be due to inadequate
stenting with incomplete treatment of the lesion proximal or
distal to the stent. Follow-up includes clinical examination
and duplex ultrasound every 6 months during the first year
and annually thereafter.
Open Revascularization
Principles
A variety of open surgical techniques have been described to
reconstruct the mesenteric arteries. Selection involves the
type of incision (transperitoneal vs retroperitoneal), conduit
(vein vs prosthetic), graft configuration (antegrade vs retro-
grade), source of inflow (aortic vs iliac), and number of vessels
to be reconstructed (single vs multiple). The type of open
reconstruction is selected on the basis of the anatomy and
the patient’s clinical risk assessment. Elderly patients and
those with cachexia or severe cardiac, pulmonary, and renal
dysfunction are frequently not good candidates for an aortic-
based procedure. We have found that the iliac artery is a good
source of inflow in high-risk patients or those who have dis-
eased or calcified aortas. Alternatively, a stent can be placed
with surgical exposure of the SMA and introduction of the
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2385
stent retrograde by direct puncture. This option may be used
SECTION 25 MESENTERIC VASCULAR DISEASE
if there is no good source of inflow or if there is peritoneal
contamination.
Contemporary reports from large-volume centers have
shown that mesenteric bypass can be performed with mor-
tality rates of less than 3%. Improvements in the outcomes
of mesenteric reconstructions can be attributed to several
factors, including technical refinements, better patient selec-
tion, and advances in medical, anesthetic, and critical care
management. In the first two Mayo Clinic reports from
1981 and 1992, more than 50% of the patients had three-
vessel revascularization, and concomitant aortic reconstruc-
tion was performed in 20% to 30% of patients. The operative
mortality was 10% in both reports. Since then, our practice
has evolved from complete retrograde revascularization and
a low threshold for concomitant aortic reconstruction to
a preference for antegrade mesenteric reconstructions based
on the supraceliac aorta whenever possible. Aortic recon-
struction is reserved for the rare patient who needs it for
an inflow source or in whom aortic disease necessitates
repair.
Reconstruction of the celiac axis and the SMA with a
bifurcated polyester graft originating from the supraceliac
aorta compromises more than 80% of open mesenteric recon-
structions. This approach is preferentially selected in lower
risk patients who are not ideal candidates for endovascular
treatment and have multivessel disease, with no evidence of
significant supraceliac aortic calcification or debris. Other
sources of inflow, such as the infrarenal aorta or the iliac
arteries, are preferred in higher risk patients. In these cases,
we reconstruct only one artery (SMA) by a retrograde
C-shaped graft configuration. A hybrid approach of a midline
laparotomy to expose the SMA combined with retrograde
placement of an SMA stent has been proposed by the Uni-
versity of Pennsylvania and Dartmouth groups. This option
avoids the need for extensive dissection, vein harvesting, and
use of a prosthetic graft; it may be selected for patients with
extensive aortoiliac disease and no adequate source of inflow
or for those with acute mesenteric ischemia, bowel gangrene,
and contamination. Hybrid, retrograde stenting provides one
of the most expeditious methods of revascularization in
patients with difficult occlusions. Transaortic endarterectomy
is rarely indicated, but it may be considered in patients for
whom endovascular therapy has failed or in patients who are
not candidates for endovascular therapy and have bacterial
contamination or perforated bowel, previous abdominal irra-
diation, extensive abdominal wall hernias, or other hostile
conditions.
Preoperative Evaluation
Preoperative evaluation should focus on a critical review of
surgical risk, nutritional status, and anatomic factors that
affect the choice of reconstruction. A comprehensive evalu-
ation of cardiac, pulmonary, and renal performance is crucial
to optimize patient selection. These operations are often
indicated in patients with multiple comorbidities who are
not candidates for endovascular therapy or for whom
2386 SECTION 25  Mesenteric Vascular Disease
angioplasty and stenting have failed. The evaluation should
include noninvasive cardiac stress testing (dobutamine stress
echocardiography or sestamibi study), pulmonary function
tests, carotid ultrasound, and noninvasive lower extremity
arterial studies. These patients have a high incidence of
coronary artery disease as demonstrated by the landmark
report of Hertzer et  al.118 Routine cardiac catheterization is
unnecessary, and cardiac evaluation and perioperative man-
agement are guided by the recommendations of the American
College of Cardiology for patients undergoing major non-
cardiac surgery.119 The Society for Vascular Surgery clinical
comorbidity score system can be used to stratify operative
risk, but the criteria have not been validated prospectively
in patients undergoing mesenteric reconstruction. The risk
of major noncardiac surgery is increased in patients with
unstable angina, symptomatic or poorly controlled ectopy,
recurrent congestive heart failure, ejection fraction below
25%, recent myocardial infarction (<6 months), vital capac-
ity of less than 1.8  L, forced expiratory volume in 1 second
below 800  mL, diffusing capacity of lung for carbon mon-
oxide below 30%, resting PO2 of less than 60  mm Hg, PCO2
of less than 50  mm Hg, serum creatinine concentration
above 2.5  mg/dL, or ongoing renal replacement therapy.
Optimal medical therapy in these patients ideally should
include cessation of cigarette smoking and initiation of ace-
tylsalicylic acid, beta blockade, and a cholesterol-lowering
medication, preferentially a statin.
Equally important is an evaluation of the nutritional
status. In patients with severe cachexia who have stable
symptoms and cannot tolerate an enteral diet, a period of
total parenteral nutrition may be beneficial. However, it
is critical to avoid excessive delays, particularly in patients
with symptom deterioration. Those with chronic kidney
disease and serum creatinine level above 1.5 to 2.0  mg/
dL (133 to 177  mmol/L) are admitted to the hospital the
day before for intravenous hydration. Gentle bowel prepara-
tion may be used in the patient with stable symptoms but
should be avoided in those with severe or subacute
ischemia.
A
B
D
Techniques
Antegrade Supraceliac Aorta to Celiac and SMA Bypass.  The
distal thoracic or supraceliac aorta is often spared from severe
atherosclerotic disease. Bypass with an antegrade graft con-
figuration based in the supraceliac or lower thoracic aorta120
offers a potential hemodynamic advantage while avoiding
kinks that can occur with grafts placed in a retrograde fashion.
Reconstruction of the celiac axis and the SMA with a bifur-
cated polyester graft originating from the supraceliac aorta
compromises more than 80% of open mesenteric reconstruc-
tions.19,121 This approach is preferentially selected in lower
risk patients who have multivessel disease and no evidence
of significant supraceliac aortic calcification or atheromatous
debris.
The operation is performed through a transperitoneal
upper midline or bilateral subcostal incision, depending on
the patient’s body habitus and costal cartilage flare. Abdomi-
nal exploration includes an evaluation for other intra-
abdominal disease and careful inspection of the small bowel
for unsuspected ischemic perforations. A third-arm retractor
assists with exposure of the upper abdomen. Alternatively,
an Omni self-retaining retractor can be used. The lesser
omentum is opened, and the left lobe of the liver is retracted
after division of the left triangular ligament. The esophagus
is retracted toward the patient’s left side with a nasogastric
tube in place, and the stomach is gently retracted caudally.
The diaphragmatic crura are divided longitudinally, exposing
the supraceliac aorta (Fig. 152-10). Approximately 5 to
10  cm of supraceliac aorta is dissected free in preparation
for clamping. While doing so, care should be taken not to
enter the pleural cavity on either side of the aorta. Usually
only the celiac trunk and the proximal hepatic and splenic
arteries need isolation; but with more extensive disease,
the common hepatic artery may be a better target for the
anastomosis. The left gastric artery is often small and may
be divided without sequelae, which facilitates celiac anas-
tomosis and makes tunneling of the SMA graft behind the
pancreas easier.
Figure 152-10  The supraceliac aorta is exposed after
division of the diaphragmatic crura (A). After suprace-
liac aortic cross-clamping (B), an oblique aortotomy is
made for the proximal anastomosis of the bifurcated
graft. Note that the graft is gently beveled and that the
left limb is tunneled in a retropancreatic position for
anastomosis to the superior mesenteric artery (C). The
right graft limb, which is positioned more anterior (D),
is anastomosed to the celiac axis or hepatic artery.

The transverse mesocolon is retracted cephalad and the
root of the mesentery is incised longitudinally over the SMA
just below the pancreas. Several lymphatic and small venous
tributaries require meticulous ligation. The SMA and several
jejunal branches are dissected free and carefully controlled
with Silastic vessel loops. Excessive traction on these vessel
loops can easily result in avulsion of small branches and
should be avoided. In most cases, 4 to 5 cm of the SMA is
dissected distal to the lower border of the pancreas, but addi-
tional dissection may be required in patients with extensive
disease. In these cases, one or more crossing venous tributar-
ies from the superior mesenteric vein may need to be ligated
and divided to allow exposure of the SMA.
Patients are given systemic heparin (60 to 80  mg/kg),
and diuresis is induced with mannitol before placement of
the supraceliac clamp. Partial aortic cross-clamping can be
performed with a Satinsky or a multipurpose clamp; alter-
natively, total aortic occlusion with two cross-clamps affords
better exposure for the proximal aortic graft anastomosis.
A straight or angled aortic clamp (Cherry supraceliac clamp)
and a Wylie hypogastric clamp work well. Placed appropri-
ately, occlusion of the lumbar vessels is achieved as well.
A slightly oblique or vertical aortotomy is made. A 12 ×
7-mm knitted polyester graft is beveled in an oblique fashion
with a short main body and is anastomosed to the supra-
celiac aorta in an end-to-side fashion with running 4-0
Prolene suture. Aortic cross-clamp time rarely exceeds 20
minutes and most often ranges from 12 to 15 minutes. The
risk of renal ischemia or embolization is low when patients
are properly selected and have a relatively disease free supra-
celiac aorta.
The left limb of the bifurcated graft is positioned slightly
posterior and is tunneled in a retropancreatic position and
anterior to the left renal vein toward the SMA (see Fig. 152-
10). The anastomosis to the SMA is performed in an end-to-
side fashion when the anastomosis is performed at the base
of the mesentery below the pancreas. If the SMA is exten-
sively diseased or the patient has had prior stents, the lumen
may require modest endarterectomy or removal of stent
struts. Any endarterectomy should be done carefully to avoid
tearing of an excessively thin arterial wall remnant that
cannot be reconstructed. In a few cases with extensive plaque,
the distal graft can be beveled into a long patch or anasto-
mosed end to side into a bovine pericardium patch. It is
important to relax retraction when cutting the graft limbs to
length to avoid angulation or kinking, whether antegrade or
retrograde bypass is done. Next, the celiac axis anastomosis
is performed in an end-to-end fashion, or more frequently the
anastomosis may be performed end to side to the common
hepatic artery (Fig. 152-11).
Retrograde Iliac Artery or Infrarenal Aorta to SMA
Bypass.  Supraceliac origin grafts are not ideal in patients
with compromised cardiac or pulmonary function or those
with extensive atherosclerosis or circumferential calcification
of the supraceliac aorta. In these cases, other sources of inflow,
such as the infrarenal aorta, a prior infrarenal aortic graft, or
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2387
the iliac arteries, are preferred (Fig. 152-12). In general, we
SECTION 25 MESENTERIC VASCULAR DISEASE
reconstruct only one artery (SMA) if a retrograde graft is
used. The infrarenal aorta may be replaced, if it is diseased,
with retrograde reconstruction of the SMA based on the
aortic graft. Nonetheless, concomitant aortic reconstruction
increases operative mortality and should be avoided unless it
is absolutely necessary.19 The proximal anastomosis is per-
formed to the anterolateral wall of the aorta and can be done
with either two cross-clamps or a partial-occlusion clamp,
depending on the aortic size and the presence of atheroscle-
rosis or calcification within that segment. A 6-mm coronary
punch can be used to remove a portion of the aortic wall.
The Oregon group has reported on the use of the distal infra-
renal aorta or the infrarenal aorta–right common iliac artery
junction as the preferred site for the proximal anastomosis.122
Our preference in the higher risk patient is to select the
common iliac artery as a source of inflow whenever possible,
avoiding aortic cross-clamping.
The key to avoidance of graft elongation, angulation, or
kinking is to cut it to length with the SMA in a nearly ana-
tomic position. This is done by relaxing the retractors before
cutting the graft and after the proximal or distal anastomosis
is done. A large 8- or 10-mm graft should be used for a ret-
rograde aortomesenteric graft, and it is imperative to perform
the distal anastomosis first and then push the mesentery close
to the aorta and select the appropriate aortic site for the
anastomosis. The Oregon group has favored a C-shaped graft
configuration.122 We have also preferred a C-shaped graft
when the iliac artery is the source of inflow. In these cases,
the proximal anastomosis may be done first to the iliac artery
or distal aorta, followed by the distal anastomosis to the
SMA. In our most recent analysis, retrograde grafts worked
as well as antegrade grafts, although the patients with retro-
grade grafts were older and had reduced lifespans.19,121 There
are some patients who have extensive circumferential aortic
calcification but soft common or external iliac arteries that
can serve as good donor vessels. Either the right or left
common iliac artery can be chosen for inflow, depending on
the orientation of that artery to the normal anatomic position
of the SMA. In general, the right iliac artery lays better if
both vessels are suitable. Two-vessel reconstructions can also
be accomplished with retrograde grafts by performing a side-
to-side anastomosis to the SMA and an end-to-side anasto-
mosis to the common hepatic artery. These grafts may be
passed on top of or beneath the pancreas and curved in a
C-shaped fashion toward the hepatic artery.
Retrograde Hybrid Revascularization.  A hybrid approach of
a midline laparotomy to expose the SMA and retrograde
placement of an SMA stent has been reported by Milner
et al123 from the University of Pennsylvania and Wyers et al124
from Dartmouth. This option avoids the need for extensive
dissection, vein harvesting, and use of a prosthetic graft. It
may be selected in patients with extensive aortoiliac disease
and no adequate source of inflow or in those with acute mes-
enteric ischemia with bowel gangrene and contamination
(Fig. 152-13).
2388 SECTION 25  Mesenteric Vascular Disease
B C
Figure 152-11  Bifurcated supraceliac aorta to common hepatic artery (A) and superior mesenteric artery bypass (B). Computed tomography
angiogram (C) demonstrates a widely patent bypass graft.
The SMA is dissected below the pancreas as previously
described. Several jejunal branches are controlled with Silas-
tic vessel loops and occluded before manipulation to avoid
distal embolization. Retrograde SMA access is established by
use of a micropuncture set with a 0.018-inch guide wire. This
is exchanged for a 0.035-inch guide wire system, and a 6F to
7F sheath is advanced into the SMA. Retrograde angiography
is obtained, and the SMA occlusion or stenosis is crossed,
predilated, and stented with a balloon-expandable stent.
Before antegrade flow is restored to the SMA, the sheath is
flushed to prevent distal embolization. The puncture site may
be closed with interrupted sutures or opened longitudinally
and closed with a patch if it is severely diseased.
Transaortic Mesenteric Endarterectomy.  Transaortic endar-
terectomy is rarely indicated but may be considered in patients
for whom endovascular therapy has failed and in patients who
have bacterial contamination, perforated bowel, previous
abdominal irradiation, extensive abdominal wall hernias, or
other hostile conditions. The most recent experience by
the University of Wisconsin group reported an operative
mortality of 3.8% among 80 patients treated by transaortic
endarterectomy.125
Our preference has been to approach the paravisceral
aorta through a full-length midline abdominal or subcostal
incision or a thoracoabdominal incision for patients who
have narrow costal flares or are truly obese. Exposure by an
abdominal incision alone in the latter patients is suboptimal
because access to the origins of the visceral arteries is
restricted, orientation from which to perform the endarterec-
tomy is poor, and adequate retraction of the costal margins is
difficult.
The aorta is exposed by medial visceral rotation with the
left kidney left in its bed, and dissection is carried anterior to
the renal vein. The diaphragmatic crus is transected longitu-
dinally, allowing exposure of the left anterior lateral wall of
the aorta and origins of the SMA and celiac axis (Fig. 152-
14). The SMA is dissected free for several centimeters. After
systemic heparinization and induced diuresis, the supraceliac
aorta and infrarenal aorta are clamped. A longitudinal or
trap-door aortotomy is performed, starting at the level of the
renal arteries and extending up to just above the celiac axis
 CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2389

SECTION 25 MESENTERIC VASCULAR DISEASE

A

B C
Figure 152-12  Retrograde C-shaped iliac artery to superior mesenteric artery bypass in a patient with severe aortic atherosclerotic disease
affecting the supraceliac (A) and infrarenal aorta (B). The bypass was based in the distal left common iliac artery (C), which was relatively free of
disease.

Figure 152-13  Hybrid revascularization with retrograde stenting of the superior mesenteric artery through midline laparotomy.
2390 SECTION 25  Mesenteric Vascular Disease
A C
origin. Endarterectomy of the paravisceral aorta, the celiac
artery, and the SMA is performed, ending at the renal artery
orifices, except in rare patients in whom there is symptomatic
renal artery stenosis; in these cases, the specimen can include
the renal artery plaque as well. The aortotomy is closed lon-
gitudinally and rarely requires a patch. Endarterectomy of the
celiac artery usually has an endpoint at its bifurcation,
whereas SMA disease may extend beyond the limits that
ostial endarterectomy allows, requiring a separate transverse
or longitudinal SMA arteriotomy after flow is restored
through the distal aorta and celiac artery. If a longitudinal
arteriotomy is performed, this can be closed with a patch. The
IMA may be reimplanted onto an infrarenal aortic graft after
transaortic endarterectomy.
Intraoperative Duplex Ultrasound Monitoring
Technical imperfections may be a cause of early graft failure
after mesenteric revascularization. We have routinely per-
formed intraoperative duplex ultrasound on all patients who
undergo open mesenteric or renal reconstructions. We have
found technical defects in 15% of the reconstructions.126
Minor defects (7%) are typically left untreated; these include
arterial abnormalities with normal velocities such as small
kinks, mild residual stenosis, and small intimal flaps. Major
defects (9%) consist of hemodynamically significant arterial
abnormalities, including significant stenosis, kinks, throm-
bus, and large intimal flaps. We reviewed our experience with
68 patients who had intraoperative duplex ultrasound and
found that patients who left the operating room with a
normal study had remarkably low rates of early thrombosis
(<1%) and late re-intervention (3%).126
Complications
Complication rates after open mesenteric revascularization
average 20% to 40%.9,27,60,122,127-130 In the last report of the
Mayo Clinic group, the incidence of complications was 36%.
The most common complications were pulmonary (15%),
gastrointestinal (14%), cardiac (10%), and renal (4%).
Patients with severe malnutrition require perioperative nutri-
tional support; prolonged ileus occurs in 8% of patients,
often requiring parenteral nutrition.19 Meticulous wound
Figure 152-14  Technique of transaortic mesenteric
endarterectomy with medial visceral rotation and a
trap-door aortotomy (A). The endarterectomy is carried
into the origins of the celiac axis and superior mesen-
teric artery (B and C). The aortotomy is closed with
running Prolene sutures (D).
closure is important, particularly in those with malnutrition,
because of the risk of wound-related complications (4% to
8%).25,120,126-129,131 Severe ascites can occur, highlighting the
importance of meticulous abdominal wall closure. In a few
patients, compartment syndrome requires abdominal decom-
pression.19,132 Early graft thrombosis is uncommon (<2%)
and indicates technical problems (e.g., kink, intimal flap,
dissection, thrombus), poor runoff, or a hypercoagulable
state.19 If it is not recognized, early graft thrombosis is a
deadly complication.
Postoperative Management
Patients undergoing open mesenteric reconstruction are
admitted to the intensive care unit for monitoring for 1 to 3
days. The average length of stay in the hospital is 12 days.19
Patients with severe ischemia typically undergo major fluid
shifts and have a high volume requirement during the first 48
hours because of the loss of autoregulation of the mesenteric
arterioles and the systemic inflammatory response. These
patients can develop significant ascites and rarely abdominal
compartment syndrome.19,132 Persistent hypotension, tachy-
cardia, leukocytosis, reduction in urinary output with elevated
bladder pressures, or increase in abdominal pain may indicate
graft occlusion, ischemic bowel, or abdominal compartment
syndrome. Computed tomography, abdominal re-exploration,
or both are needed to exclude these problems.
Return of oral intake varies, but many patients develop
prolonged postoperative ileus and may need enteral or par-
enteral nutritional support. Total parenteral nutrition is often
started early after the operation once fluid requirements
diminish if ileus is anticipated in the malnourished patient.
The food fear that many patients have preoperatively does
not resolve quickly after the operation, as it is often a “learned
behavior.” Furthermore, absorptive capacity of the gut
changes, and patients often experience diarrhea during the
first few postoperative weeks.
Postoperative medical therapy includes ongoing recom-
mendations for smoking cessation as well as antiplatelet and
cholesterol-lowering agents. Imaging surveillance is recom-
mended with duplex ultrasound, which is obtained every 6
months during the first year and annually thereafter.
 CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2391

techniques may not be comparable unless outcomes are ana-

SECTION 25 MESENTERIC VASCULAR DISEASE

RESULTS
Comparative Results of Open and
Endovascular Revascularization
Despite the lack of prospective randomized comparisons
between open surgery and endovascular treatment, mesen-
teric angioplasty with stenting has been widely adopted in
most centers, resulting in a decline in the number of open
surgical reconstructions. A systematic review of outcomes of
mesenteric revascularization should include analysis of mor-
tality, morbidity, symptom relief, and long-term goals of
freedom from restenosis, recurrence, and re-intervention.
The interpretation of published reports is difficult for several
reasons.79 There is inconsistent use of reporting standards,
including variability in the definition of technical success and
lack of analysis of time-dependent outcomes, such as patency
rates, symptom recurrence, restenosis, and re-intervention.
Most studies have limited patient follow-up or do not report
patency objectively with arterial imaging. Because the selec-
tion of type of treatment is dependent on the physician’s
preference and the patient’s comorbidities, results of the two
lyzed with clinical risk stratification. Finally, several reports
tend to collect a small number of patients treated for long
periods or include patients with acute and chronic presenta-
tions, different causes (e.g., arteritis, median arcuate ligament
syndrome), and a mixture of open surgical (e.g., antegrade,
retrograde) and endovascular (e.g., angioplasty alone vs
stenting) strategies.
Morbidity and Mortality
On the basis of review of single-center reports and a sys-
tematic review, endovascular revascularization has been
associated with decreased morbidity, length of stay, and
convalescence time (Tables 152-1 and 152-2).73 Morbidity
and length of stay average 11% and 3 days with endovas-
cular revascularization compared with 33% and 14 days
with open surgery.73 Mortality rates are similar on the basis
of a recent systematic review, which indicates average 30-day
mortality of 6% (0% to 15%) for open and 5% (0% to
21%) for endovascular revascularization.73 Open surgical
bypass can be performed with low mortality in good-risk

Table 152-1 Results of Contemporary Reports of Angioplasty and Stenting for Treatment of Chronic Mesenteric Ischemia
Technical Primary
Stented Success Mortality Morbidity Recurrence Re-intervention Patency Follow-Up
Author (Year) N Vessels Vessels (%) (%) (%) (%) (%) (%) (%) (Months)

BARE METAL STENTS

Kasirajan (2001) 28 32 82 100 11 18 34 — 73 at 3 24
years
Matsumoto 33 47 32 88 0 13 15 15 — 20
(2002)
van Wanroij 27 33 94 93 0 11 — 19 81 at 19 19
(2004) months
Landis (2005) 29 63 27 97 7 10 45 37 70 28
Silva (2006) 59 79 100 96 2 — 17 17 71 38
Biebl (2007) 23 40 96 — 0 4 26 22 — 10
Atkins (2007) 31 42 87 100 3.2 13 23 16 58 15
Sarac (2008) 65 87 100 — 8 31 — 31 65 12
Lee (2008) 31 41 — 98 14 6 44 10 69 at 7 32
years
Dias (2009) 43 49 100 98 0 23 12 33 — 43
Oderich (2009) 83 105 72 95 2.4 18 31 31 41 at 5 36
years
Fioole (2009) 51 60 100 93 0 4 25 22 86 25
Peck (2010) 49 66 89 100 2 16 29 29 64 at 3 37
years
Schoch (2011) 107 116 78 100 0 — 42 42 67 16
Turba (2012) 166 221 74 92 3 10 17 19 67 34
AbuRahma (2013) 83 105 100 97 2 2 35 30 19 31
COVERED STENTS
Schoch (2011) 14 14 100 100 0 — — 0 100 16
Oderich (2012) 42 42 100 98 0 12 10 10 92 at 3 19
years
Total 950 1242 84 97 3 13 27 22 25
2392 SECTION 25  Mesenteric Vascular Disease

Table 152-2 Results of Contemporary Reports of Open Surgical Revascularization for Treatment of Chronic
Mesenteric Ischemia
Mortality Morbidity Recurrence Re-intervention Primary Patency Follow-Up
Author (Year) N Vessels (%) (%) (%) (%) (%) (Months)

Leke (2002) 17 25 6 41 0 0 100 at 34 months 34

Cho (2002) 25 41 4 — 32 20 57 at 5 years 64
Brown (2005) 33 51 9 30 9 7 100 at 6 months 34
Sivamurthy (2006) 46 66 15 46 32 12 83 at 6 months 9
Biebl (2007) 26 48 8 42 11 8 — 25
Kruger (2007) 39 67 2.5 12 5 3 92 at 5 years 39
Atkins (2007) 49 88 2 4 22 22 90 42
Mell (2008) 80 120 3.8 26 11 11 90 46
Oderich (2009) 146 265 2.7 36 6 5 88 at 5 years 36
  Low risk 101 — 0.9 37 6 6 94 at 5 years —
  High risk 45 — 6.7 38 11 11 90 at 5 years —
  Concomitant aortic reconstruction 23 — 8.4 — — — — —
Rawat (2010) 52 75 13 32 15 13 81 41
Ryer (2012) 116 203 2.5 50 14 16 86 at 5 years 43
Total 629 1049 6.3 32 14 11 — 38

patients at institutions with a large experience in these
types of reconstructions.79 The Mayo Clinic group has ana-
lyzed outcomes of 229 patients treated for chronic mesenteric
ischemia by use of clinical risk stratification.19 The overall
mortality was similar for open (2.7%) and endovascular
(2.4%) revascularization. The Society for Vascular Surgery
comorbidity score system was used to define a high-risk
group. Mortality was 1% for low-risk and 6.7% for high-
risk patients treated by open bypass, with the highest mor-
tality rate (8.9%) in those patients who had concomitant
aortic reconstructions. Nonetheless, despite the excellent
results reported in large-volume centers, these results may
not be generalizable as these operations carry high mortality
in population-based studies, reaching 20% in the state of
New York and 13% in the United States.9,79 Low mortality
after endovascular repair, however, was reproduced nation-
ally (3.7%).
Symptom Relief
Both methods of revascularization are highly effective in
patients who have the correct diagnosis of chronic mesenteric
ischemia. In a systematic review, symptom improvement
averaged 88% with endovascular and 93% with open
revascularization.73 Single-center reports indicate symptom
improvement in more than 90% of patients treated by stents.
A pooled review of the literature suggests that angioplasty
alone may be associated with lower rates of technical success
(78%) compared with stenting (94% and 93%).79 Symptom
improvement is noted immediately after revascularization,
but it is not uncommon for patients to complain of modest
bloating and worsening diarrhea. The presence of persistent
abdominal pain may suggest another diagnosis (e.g., motility
disorder, irritable bowel syndrome) or inadequate revascular-
ization. Oral intake is resumed in most patients who are able
to maintain an enteral diet, except for those who develop
short bowel syndrome after resection of long segments of
bowel.
Restenosis, Symptom Recurrence,
and Reintervention
Most single-center reports and a systematic review indicate
that open reconstructions are more durable (see Table 152-2).
Bypass is associated with lower rates of restenosis, better
patency, and higher freedom from recurrent symptoms or
re-interventions compared with mesenteric angioplasty and
stenting. Primary patency of open bypass averaged 89% at 5
years in a recent review of the pooled literature (57% to
92%), with freedom from re-interventions of 93%.79 A recent
report by Ryer et al60 indicated that open bypass has been
increasingly performed in patients with more comorbidities
and worse anatomy. Despite these adverse characteristics,
open surgery had excellent primary patency of 76% at 5 years.
In the systematic review of van Petersen et al,73 endovascular
treatment was associated with more restenosis (37% vs 15%),
symptom recurrences (30% vs 13%), and re-interventions
(20% vs 9%). Primary patency was lower for mesenteric
stenting (51% vs 86%), with similar secondary patency rates
(83% vs 87%).
Endovascular treatment has been plagued by high rates of
restenosis affecting as many as 20% to 66% of patients, not
matching the excellent patency rates reported for open
reconstructions (see Table 152-1).* With few exceptions,
most of these reports have included a large number of patients
treated by angioplasty alone and had inconsistencies in
their reporting standards. Contemporary reports of primary
*References 19, 41, 75, 76, 82, 83, 101, 103, 106, 107, 109, 110, 133, 134.

stenting indicate that restenosis occurs in 40% of patients
and that half of these require re-intervention.86 The average
3-year primary patency rate for bare metal stents is 52%
(range, 30% to 81%) calculated from pooled literature.79
Contemporary reports show modest improvement in primary
patency at 1 year ranging from 76% to 90%.19,103,106,109 The
secondary patency rate is better than 90%, as evidenced by
reports of mesenteric re-interventions.79,86 Oderich et al116
recently reported a nonrandomized comparison of covered
versus bare metal stents in 225 patients treated for chronic
mesenteric ischemia. In that study, covered stents had
92% ± 6% primary and 100% secondary patency rates at 3
years, rivaling the results of open bypass. Covered stents
outperformed bare metal stents, with lower rates of restenosis,
symptom recurrence, and re-intervention and improved
patency rates. These observations held fast both in primary
interventions for native artery lesions and in re-interventions
for in-stent or native artery restenosis after prior endovascular
procedures. Independent predictors of restenosis were use of
bare metal stents, cigarette smoking, advanced age, and
female gender.
The interest in covered stents to treat mesenteric lesions
originated from improved patency rates reported with such
stents in other vascular beds for different indications.135,136
The clinical data on covered stents for treatment of mesen-
teric artery disease are scarce. The University of Tennessee
group was the first to report favorable results in 14 patients
treated by covered stents, with no re-interventions after 2
years of follow-up.113 Tallarita et al86 described no restenosis
in four patients treated by mesenteric re-intervention with
covered stents compared with 62% restenosis and 38%
re-intervention rates for bare metal stents. These lower reste-
nosis and re-intervention rates observed with covered stents
are likely explained by the barrier to tissue ingrowth.137,138
Other potential benefits of covered stents include precise
deployment, excellent radial force, prevention of embolism
by entrapment of debris, ability to overexpand the stent to
the desired diameter with minimal stent foreshortening, and
potentially less risk of arterial disruption. However, the cost
of a covered stent is three to five times more than a bare metal
stent, and most require 7F sheaths, a major limitation com-
pared with smaller profile stents that can be introduced
through a 4F to 6F sheath over a 0.014- or 0.018-inch
guide wire.
Patient Survival
Poor prognostic indicators for long-term patient survival after
mesenteric revascularization include advanced age and pres-
ence of severe cardiac, pulmonary, or renal disease.19,139 The
type of revascularization has not been shown to affect sur-
vival, but comparative analysis is limited by selection bias
favoring open bypass for lower risk patients and endovascular
revascularization for higher risk patients. Tallarita et  al139
reported long-term survival in a cohort of 343 patients
treated for chronic mesenteric ischemia, with nearly identical
5-year survival rates using propensity matched scores for
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2393
patients treated by open (57%) or endovascular (60%) revas-
SECTION 25 MESENTERIC VASCULAR DISEASE
cularization. Five-year patient survival averaged 71% ± 4%
for low-risk patients, 49% ± 6% for intermediate-risk
patients, and 38% ± 7% for high-risk patients. Freedom
from mesenteric-related death was 91% ± 2% after open
revascularization and 93% ± 4% after endovascular revas-
cularization at 5 years. Independent predictors of any-cause
mortality were age older than 80 years (odds ratio [OR],
3.3; confidence interval [CI], 1.03-10.6; P < .001), chronic
kidney disease stage IV or stage V (OR, 5.5; CI, 1.4-16.6;
P < .01), diabetes (OR, 1.7; CI, 1.2-2.6; P < .01), and home
oxygen therapy (OR, 3.7; CI, 1.2-9.1; P < .001). Chronic
kidney disease stage IV or stage V (OR, 3.4; CI, 3.3-345;
P = .003) and diabetes (OR, 4.2; CI, 1.7-10.5; P = .005)
were independently associated with mesenteric-related
death. In that study, the most common causes of late death
were cardiac events, followed by cancer, respiratory compli-
cations, and mesenteric-related complications. The com-
bined rate of early and late mesenteric-related death was
8% for patients treated by open surgery and 6% for those
who had endovascular revascularization.
Re-Interventions for In-Stent Stenosis
Multiple approaches have been used to treat in-stent stenosis.
Innovative techniques to maintain an “endovascular first
approach” have included balloon angioplasty with cutting or
cryoplasty balloons, repeated stenting with bare metal or
drug-eluting stents, and atherectomy.117,140 Atherectomy has
been used either as primary therapy or as an adjunct to debulk
areas of neointimal hyperplasia before angioplasty or stenting.
To date, none of these approaches has shown any benefit
compared with standard angioplasty alone.
There are currently no reporting standards or consensus
on the definition of in-stent restenosis, which largely is based
on surveillance duplex ultrasound imaging. The specific
velocity criteria that define high-grade in-stent stenosis are
controversial. AbuRahma et al141 reported a retrospective
review of paired duplex ultrasound and contrast angiography
in 150 patients treated by mesenteric stents. The peak systolic
velocity that had the best overall accuracy to identify greater
than 50% SMA stenosis was 295 cm/s; a peak systolic veloc-
ity higher than 400 cm/s indicated stenosis greater than 70%.
Baker et al142 noted that the average peak systolic velocity
measured immediately after placement of mesenteric stents
was 335 cm/s, increasing to 390 cm/s by the end of the
first year.
Despite the high rates of restenosis after mesenteric stent-
ing, clinical data on outcomes of re-interventions are scarce.
Tallarita et al86 reported outcomes of 30 patients treated for
in-stent restenosis. The type and location of restenosis were
also analyzed by contrast angiography. Intimal hyperplasia
within the stented segment accounted for 43% of the 30
cases of restenosis, whereas 57% of patients had restenosis
affecting arterial segments proximal or distal to the stent
edge. Importantly, in 43% of the patients, the area of reste-
nosis coincided with technical imperfections noted on review
2394 SECTION 25  Mesenteric Vascular Disease
A B C
of the index completion angiography performed at the time
of the first intervention. This finding emphasizes how critical
it is to pay attention to detail at the time of the first mes-
enteric intervention. Therefore, some “restenosis” reported
on postintervention ultrasound imaging may actually repre-
sent incomplete or inadequate treatment rather than progres-
sion of disease or development of neointimal hyperplasia.
Technical imperfections include inadequate stent length or
positioning and poor stent expansion due to unfavorable
anatomy, such as highly calcified or eccentric lesions. Our
preference has been to treat restenosis with a covered
balloon-expandable stent (Fig. 152-15).
Remedial Procedures for Failed Open
Mesenteric Reconstructions
Remedial procedures for failed mesenteric reconstructions are
not as rare as previously described. Recurrent symptoms of
mesenteric ischemia, usually from stenosis or thrombosis of
one or more graft limbs, affect approximately 10% of patients
who undergo open mesenteric reconstruction.19,75 In these
patients, a minimally invasive approach is appealing. Angio-
plasty with stenting is preferred for focal graft limb stenosis.
For acute graft thrombosis, mechanical thrombectomy and
catheter-directed thrombolytic therapy may be attempted,
provided the patient has no evidence of acute mesenteric
ischemia and can tolerate a treatment delay of 24 to 48 hours.
Repeated open reconstruction may be needed in the patient
who presents with chronic occlusions or acute mesenteric
ischemia and in those who are not candidates for endovascu-
lar therapy. In these patients, hybrid retrograde stenting or
iliac-based reconstruction should be considered.122,124 Reop-
erations are technically more challenging because of scar,
distal involvement, and risk of damage to important collater-
als. Giswold et al143 reported operative mortality of 6% and
primary patency at 4 years of 62% among 22 patients who
underwent repeated mesenteric revascularization. In the rare
patient with hostile anatomy and inadequate source of inflow
in the abdominal aorta or iliac arteries, mesenteric bypass can
be originated from the thoracic or ascending aorta and rarely
from the axillary artery.120,144,145
Figure 152-15  Treatment of in-stent restenosis with
placement of a covered balloon-expandable stent (A).
Pre-deployment angiography demonstrates a high-
grade stenosis in the proximal aspect of the stent (B).
After placement of a covered balloon-expandable
stent (C), there is no residual stenosis.
OTHER CONSIDERATIONS
Mesenteric Infarction
Normal bowel oxygen consumption can be maintained with
20% of maximum blood flow and one fifth of mesenteric
capillaries.146 The intestinal mucosa is able to extract increas-
ing amounts of oxygen during hypotension.147 Therefore, it is
no surprise that the bowel is able to tolerate ischemia without
permanent cellular damage until collaterals are overcome or
until there is in-situ thrombosis of a critically narrowed
vessel. Acute thrombosis superimposed on preexisting severe
atherosclerotic disease accounts for 25% to 56% of cases of
acute mesenteric ischemia, surpassing emboli as the most
common cause in many reports.22,23 Bowel gangrene can be
precipitated by gastroenteritis, dehydration, bowel obstruc-
tion, or an inflammatory disorder. Symptoms are often more
insidious in onset because of the extensive collateral network
that is able to maintain bowel viability until there is acute
thrombosis or progression of a critically stenotic vessel. The
pattern of bowel ischemia is confluent, not patchy, and does
not spare the proximal jejunum beyond the ligament of Treitz
because the SMA is most often chronically diseased proximal
to the origin of the middle colic artery.
Approximately 10% to 20% of patients with chronic mes-
enteric ischemia present with symptom deterioration during
days or weeks, characterizing a subacute presentation.19 On
occasion, these patients may be found to have bowel gan-
grene or a sealed perforation at the time of open revascular-
ization. The appearance of the bowel can be deceiving, and
areas of severe ischemia may be viable after revascularization.
Management principles include rapid control of sepsis fol-
lowed by revascularization before resection of any intestine
that has questionable ischemia. Bowel resection is needed for
frank necrosis or perforation, but the bowel should not be
anastomosed and containment of the spillage should be
achieved rapidly before revascularization. Evaluation of ques-
tionable bowel after revascularization can be difficult. Several
adjuncts have been used, including simple inspection for peri-
stalsis, Doppler examination for signals in the mesentery
and on the antimesenteric border, and administration of

fluorescein combined with Wood’s lamp evaluation. A
“second-look” operation is scheduled at the time of the opera-
tion in most patients with extensive ischemia because assess-
ment of the full extent of visceral ischemia is often unreliable
at the initial operation. In our most recent report, 80% of the
patients treated for acute mesenteric ischemia underwent
second-look laparotomy and 28% had necrotic bowel requir-
ing resection.23 Primary anastomosis is performed only if the
bowel has unquestionable viability and the patient is stable
and not taking vasopressors. For patients with marginal-
appearing bowel, repeated laparotomy may be scheduled, or
a stoma is created, allowing daily assessment of the bowel at
the bedside.
Revascularization is performed by bypass, endarterectomy,
or hybrid revascularization. The last option is an excellent
alternative, can be performed expeditiously with minimal
arterial exposure, and avoids vein harvesting or the use of a
prosthetic graft. If a bypass is performed, autologous vein
should be used if there is frank necrosis or perforation.
Femoral vein offers better patency rates compared with
saphenous vein.148 One alternative in the absence of con-
tamination is to use a polyester rifampin-soaked graft.23 If a
prosthetic conduit is chosen, the graft should be covered by
omentum. Chapter 153 describes in detail the clinical pre-
sentation of and management strategies for acute mesenteric
ischemia.
Median Arcuate Ligament Syndrome
The median arcuate ligament is the fibrous edge of the
diaphragmatic crura that crosses anterior to the aorta and
above the origin of the celiac axis. Extrinsic compression
of the celiac axis by fibers of the median arcuate ligament
or fibrotic celiac ganglion is found in 20% to 70% of indi-
viduals during imaging studies performed for screening or
investigation of abdominal disease.149 Compression is typi-
cally augmented by full expiration. Chronic compression of
the celiac axis can cause a syndrome of postprandial abdomi-
nal pain, nausea, vomiting, and weight loss. Although the
pain is postprandial in more than 80% of the patients,
exercise-related abdominal pain is not uncommon.150,151
Other common symptoms are nausea and vomiting (56%),
weight loss (50%), and bloating (40%). There is skepticism
by many of the mere existence of the syndrome, but evidence
of symptom relief after surgical decompression is irrefutable.
Decreased gastrointestinal blood flow with steal phenome-
non, increased motility, and neuroendocrine modulation are
postulated disease mechanisms.150,151
The diagnosis can be difficult to establish because celiac
compression is frequent in the general population and there
is not a reliable confirmatory test. Duplex ultrasound with
expiratory maneuvers is an excellent screening study to
identify stenosis or occlusion of the celiac axis. MRA or
single-injection inspiratory/expiratory dual source multide-
tector CTA provides anatomic detail with expiratory maneu-
vers.152,153 Because of vague and variable presentation, the
diagnosis is often made by exclusion of other more common
CHAPTER 152  Mesenteric Vascular Disease: Chronic Ischemia 2395
conditions after an extensive investigation, which includes
SECTION 25 MESENTERIC VASCULAR DISEASE
endoscopy, computed tomography or magnetic resonance
imaging, and gastrointestinal motility studies. Predictors of
clinical improvement with surgical decompression are female
gender, age between 40 and 60 years, postprandial pain,
weight loss of more than 20 pounds, and absence of a
psychiatric disorder or drug abuse.154 Symptom improvement
after temporary celiac ganglion block may help identify
patients who would benefit from surgery, but this has not
been validated in a systematic manner.151 In select centers,
gastric tonometry has been used successfully to identify
patients with gastric ischemia. In the study of Mensink
et  al,155 if gastric ischemia was confirmed in a symptomatic
patient, decompression with revascularization resulted in
100% long-term relief of the symptoms. With negative
tonometry, only 25% of the patients improved.
Although symptoms are similar to those encountered in
patients with chronic mesenteric ischemia, the two condi-
tions are distinctly different. Chronic mesenteric ischemia
results from decreased perfusion to the intestine below critical
levels, usually from atherosclerosis of at least two of the three
mesenteric arteries, and untreated progresses to cachexia,
bowel gangrene, and death. With median arcuate ligament
syndrome, there is no convincing evidence that mesenteric
ischemia occurs, although some attribute symptoms to a steal
phenomenon.156 The celiac axis is typically the only vessel
involved; rarely the SMA is compressed as well157; and there
is a rich collateral network with not a single report of bowel
gangrene or death.
Decompression of the celiac axis can be done by an open
or laparoscopic approach, with or without reconstruction (or
stenting) of the celiac axis. Open surgical decompression by
transection of the diaphragm proximal to the celiac axis,
neurolysis, and transection of the ganglionic tissue over the
aorta is usually performed through a short upper midline lapa-
rotomy.151,158 If the artery is occluded, scarred, or chronically
narrowed by inspection, or if there is evidence of critical
stenosis by intraoperative duplex ultrasound, reconstruction
is performed with a patch or bypass based on the supraceliac
aorta. In the author’s experience, intraluminal dilatation
seldom works. Reilly et al154 reported poor long-term results
with celiac decompression alone, advocating a low threshold
to perform some form of reconstruction.
Several centers have increasingly used laparoscopy to
decompress the arcuate ligament.159-164 Laparoscopy can be
done through a transperitoneal or retroperitoneal approach.
The group from Enschede, The Netherlands, advocate the
retroperitoneal approach, which is potentially associated
with lower rates of gastroesophageal reflux.164 Conversion to
open repair because of bleeding complications or the need
to perform open reconstruction occurs in 2% to 27% of
cases.159-164 The most common strategy is to release the liga-
ment and to use angioplasty and stents or open bypass only
if the patient has persistent or recurrent symptoms with evi-
dence of stenosis. Jimenez et al165 reported a review of the
pooled literature with 400 patients treated for median arcuate
ligament syndrome. Symptom relief was obtained in 85% of
2396 SECTION 25  Mesenteric Vascular Disease
the patients, with no difference in late recurrence for the
open or laparoscopic approach. Nonetheless, these studies are
limited by a short follow-up period and the lack of predefined
treatment algorithms.
Mesenteric Reconstruction Combined
with Aortic Reconstruction
Mesenteric revascularization combined with aortic recon-
struction is avoided whenever possible and is rarely necessary
in the patient who needs it for inflow source or in whom
aortic disease necessitates repair.19,166 These operations carry
a higher mortality rate, particularly in patients who are frail,
elderly, or at higher risk from multiple comorbidities. The
Mayo Clinic group reported a mortality of 8.6% for concomi-
tant mesenteric and aortic reconstructions compared with
2.4% for isolated mesenteric reconstructions.19 In patients
who have diffuse aortoiliac disease precluding the use of
aortic or iliac inflow, hybrid retrograde mesenteric revascu-
larization has been used successfully and may be the best
alternative.124,167 Alternatively, the procedure can be staged,
with either open or endovascular mesenteric revasculariza-
tion performed first.42
Nonatherosclerotic Mesenteric Artery Disease
Mesenteric artery disease can be due to a variety of nonath-
erosclerotic causes in less than 10% of patients.28,29,168-171
Open revascularization is more often required in these
patients because of their younger age and presence of unfa-
vorable features, such as long lesions recalcitrant to angio-
plasty or stenting.
Mesenteric vasculitis is the second most common cause of
chronic mesenteric ischemia after atherosclerosis.28 Clinical
data are scarce, with only a few case reports and one case
series. Surgical principles include avoiding reconstruction
during the active phase and selecting the source of inflow and
outflow from healthy unaffected vessels. Rits et al28 reported
the Mayo Clinic experience with 15 patients treated for
mesenteric vasculitis due to Takayasu’s arteritis, polyarteritis
nodosa, giant cell arteritis, or indeterminate cause. There
were 13 female and 2 male patients, with a mean age of 38
years (range, 15 to 66 years). Most patients were treated by
open repair, with no operative deaths. All patients were alive
at 10 years with expected survival similar to that of the
general population. In comparison to patients treated for
atherosclerotic disease, open reconstructions for mesenteric
vasculitis had similar freedom from mesenteric symptoms
(83% vs 75%; P = .80) and similar primary graft patency
(83% vs 84%; P = .9).
Abdominal aortic coarctation or midaortic syndrome
involving the visceral segment can be manifested by symp-
toms of mesenteric ischemia. The most common presentation
is lower extremity claudication or difficult to control hyper-
tension. Causes include Takayasu’s arteritis, giant cell arteri-
tis, and neurofibromatosis type 1.29,168 Mesenteric artery
stenosis is found in approximately one third of the patients,
and they can present with symptoms of chronic mesenteric
ischemia; in patients with critical lesions, revascularization
combined with aortic reconstruction may be required.
Although endovascular treatment has been used in select
patients, open reconstruction remains the treatment of choice
for most. The aorta may be reconstructed with patch angio-
plasty or bypass, with or without concomitant renal or
mesenteric reconstruction, yielding a durable and effective
treatment in these younger patients with extensive disease.
Fibromuscular dysplasia can affect the mesenteric arteries and
responds well to balloon angioplasty, similar to renal artery
lesions.172
Aortic and Visceral Artery Dissections
Aortic dissection can be manifested with mesenteric isch-
emia in up to one third of the patients as a result of extension
of the dissection flap, causing either fixed or dynamic obstruc-
tion.173 Most patients present with acute ischemia from mal-
perfusion, for which endovascular treatment has gained
widespread acceptance and become the first line of therapy.
Treatment goals are expansion of the true lumen and decom-
pression or thrombosis of the false lumen, which is achieved
by coverage of the entrance site. Mesenteric stenting or fen-
estrations can be used to treat mesenteric stenosis or occlu-
sion, either as sole therapy or as an adjunct.
Isolated mesenteric artery dissection can be caused by
fibromuscular dysplasia, atherosclerosis, trauma, neurofibro-
matosis, pregnancy, and segmental arterial mediolysis.174-177
The majority of patients are male with a median age of 55
years.176 Tameo et al177 reviewed 47 patients with segmental
arterial mediolysis described in the literature. Presentation
included abdominal pain, rupture, ischemia, or asymptomatic
lesions. Among patients treated for acute presentation, the
mortality rate was 40%. CTA is the diagnostic study of choice
and provides anatomic information about extent of the
dissection, thrombus, false and true lumen perfusion, and
bowel involvement. Asymptomatic patients are treated con-
servatively with antiplatelet therapy. Open surgical or endo-
vascular treatment is indicated in patients with ischemic or
hemorrhagic complications.176,178,179 Anticoagulation has
been used selectively in patients who are minimally symp-
tomatic or have significant luminal compromise by the dis-
section flap.176,177,180 Takayama et al176 described 19 patients
with segmental arterial mediolysis, the majority (60%) of
whom had no symptoms and were incidentally diagnosed.
After a mean follow-up of 20 months, none of the patients
developed symptoms or required intervention.
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One of the largest single-center experiences of endovascular revascularization
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