Ying Geoffrey, Hill Andrew, Taylor Sam, Dean Anastasia
University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand.
Auckland Regional Vascular Service, Auckland City Hospital, Auckland, New Zealand.
EJVES Vasc Forum. 2024 Oct 5;62:83-86. doi: 10.1016/j.ejvsvf.2024.10.002. eCollection 2024.
Endovascular revascularisation (ER) is often used as first line treatment for chronic mesenteric ischaemia, with high technical success and a lower rate of peri-operative adverse events than open surgical repair. Distal embolisation following ER is a potentially life threatening complication with a high mortality rate.
A 66 year old patient with a two year history of postprandial abdominal pain presented with two weeks of constant abdominal pain. Computed tomography angiography (CTA) demonstrated extensive atherosclerotic disease within the coeliac artery (CA), superior mesenteric artery (SMA), inferior mesenteric artery (IMA), aorta, and iliac arteries. Stenting of the CA was successful. Four hours post-intervention, the patient became unstable with worsening abdominal pain. Repeat CTA showed signs of acute bowel ischaemia (pneumatosis, mural hypo-enhancement, and intravascular gas) despite a patent CA stent. Microemboli trashing secondary to ER was suspected.The patient was taken for an emergency laparotomy. The SMA was an unsuitable bypass target due to extensive atherosclerosis, and bypass to the CA was unlikely to improve perfusion, given the patent stent. A large, disease free collateral artery was identified as a potential bypass target, and a six mm Dacron graft was successfully anastomosed from the right external iliac artery to the Arc of Riolan. At the relook laparotomy, the iliac-mesenteric bypass graft was covered and the abdomen was closed. The patient has since had complete resolution of symptoms and 12 kg of weight gain at six months.
This is a unique case in which the Arc of Riolan was used as a bypass target in the context of acute on chronic mesenteric ischaemia. It highlights the possibility of collateral mesenteric vessels as potential bypass targets when the mesenteric trunks are unsuitable. Good knowledge of collateral vessel anatomy and careful pre-operative planning is critical in patients with extensive disease that is not amenable to traditional treatment.
血管内血运重建术（ER）常被用作慢性肠系膜缺血的一线治疗方法，其技术成功率高，围手术期不良事件发生率低于开放手术修复。ER术后远端栓塞是一种潜在的危及生命的并发症，死亡率很高。
一名有两年餐后腹痛病史的66岁患者，出现持续两周的腹痛。计算机断层血管造影（CTA）显示腹腔干（CA）、肠系膜上动脉（SMA）、肠系膜下动脉（IMA）、主动脉和髂动脉内有广泛的动脉粥样硬化病变。CA支架置入成功。干预后4小时，患者病情不稳定，腹痛加重。尽管CA支架通畅，但重复CTA显示有急性肠缺血迹象（肠壁积气、壁层强化减弱和血管内气体）。怀疑是ER继发的微栓子冲刷。患者接受了急诊剖腹手术。由于广泛的动脉粥样硬化，SMA不适合作为旁路目标，而且鉴于支架通畅，旁路至CA不太可能改善灌注。一条粗大、无病变的侧支动脉被确定为潜在的旁路目标，成功地将一段6毫米的涤纶移植物从右髂外动脉吻合至Riolan弓。在再次剖腹手术中，髂 - 肠系膜旁路移植物被覆盖，腹部关闭。此后患者症状完全缓解，6个月体重增加12千克。
这是一例独特的病例，在慢性肠系膜缺血急性发作的情况下，将Riolan弓用作旁路目标。它凸显了在肠系膜主干不适合时，肠系膜侧支血管作为潜在旁路目标的可能性。对于患有广泛疾病且不适合传统治疗的患者，熟悉侧支血管解剖结构并进行仔细的术前规划至关重要。
