Retrograde superior mesenteric artery stenting via jejunal arterial access-how I do it.

Acute mesenteric ischemia exists as a vascular surgery emergency that portends a great degree of morbidity and even mortality, with a recent study suggesting a mortality of 31% for acute presentations.1Andraska E.A. Tran L.M. Haga L.M. et al.Contemporary management of acute and chronic mesenteric ischemia: 10-year experience from a multihospital healthcare system.J Vasc Surg. 2022; 75: 1624-1633.e8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Classically treated through open revascularization, there have been suggestions of fully endovascular or even hybrid approaches to restore visceral perfusion.2Lim S. Halandras P.M. Bechara C. Aulivola B. Crisostomo P. Contemporary management of acute mesenteric ischemia in the endovascular era.Vasc Endovascular Surg. 2019; 53: 42-50Crossref PubMed Scopus (41) Google Scholar Retrograde mesenteric stenting via a “mini-laparotomy” has been previously described and can reduce the morbidity for mesenteric revascularization through a midline approach.3Gilmore B.F. Fang C. Turner M.C. et al.Jejunal arterial access for retrograde mesenteric stenting.J Vasc Surg. 2018; 67: 1613-1617Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar,4Oderich G.S. Macedo R. Stone D.H. et al.Low Frequency Vascular Disease Research Consortium Investigators. Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia.J Vasc Surg. 2018; 68: 470-480.e1Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar The patient provided written informed consent for the report of any potentially identifiable images or data included in our report. The present case illustrates our hybrid approach to stenting of the superior mesenteric artery through only a small 5-cm periumbilical laparotomy incision. This treatment has been performed for ∼25 patients at our institution. The present patient, with moderate chronic obstructive pulmonary disease requiring home oxygen, presented with acute on chronic mesenteric ischemia after a failed attempt at antegrade revascularization at an outside institution. Successful mesenteric revascularization via a small jejunal branch in retrograde fashion allowed for procedural success with minimal perioperative morbidity. Jejunal branches, identified with transillumination, can be readily accessed at sites of planned bowel resection in acute mesenteric ischemia or in the mid-distal jejunum in those cases without infarcted bowel owing to less tortuosity and facile access to the proximal superior mesenteric artery in this region. By creating a small arteriotomy in the jejunal branch, the microsheath and dilator can be directly inserted intraluminally with a guided 0.18-in. wire. The Supplementary Video (online only) demonstrates the ease with which jejunal access can be obtained for subsequent mesenteric artery stenting without the morbidity from full midline laparotomy, particularly for patients with multiple medical comorbidities who might not be able to tolerate a large abdominal surgery. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI5YzczYTRkOGFhMDU2YzZmZTNhZjdlZjgzNGY5NGZjZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk2ODkxODEyfQ.KIZFVSHYwvhYbYkU1UJrGbFdnDkS8o120RWZFk8qObOK9O0flag7WbRH7Hjj4to45AOyq83CVkKGprzvMA3eTgCYz8ctcc0q40TzdGCvOFlve0Ll_PqSs9CMYBd9Dg7jxPxGgU9IlCAyNZXIsT--sRhAOMwwG2KHXttsx-QgYoFgco1S8lduwBRwqDPahAt4LaPz8lIYwAtSSneQATsBUaIwyaDG7abtz30ympb9KjL29x4AAAfCZmNlapXde5j1lpe8XeBS7dd3FvxxXy-rmONzVhkmLa9Bb7weZY7n-SxqSK15hLGtlxWGT6LL5F4VucZTjN1k2ZnpIwserRmW2Q Download .mp4 (57.8 MB) Help with .mp4 files Supplementary Video (online only)Retrograde stenting of the superior mesenteric artery via jejunal branch access.