Acute mesenteric occlusion is a life-threatening condition with a significant mortality rate of approximately 40%. The causes of acute ischemia include arterial embolism, arterial thrombosis, and venous occlusion, as a nonocclusive form.¹ Acute-on-chronic mesenteric ischemia mainly occurs when there is acute thrombosis over a partially occluding atherosclerotic lesion. The perioperative mortality rate of thrombosis is high due to delay in the diagnosis, the extent of bowel infarction, and the complexity of surgical procedures for revascularization.¹

Although mesenteric ischemia has a low incidence, due clinical consideration based on the symptomatology and history aids in charting the appropriate investigations and thus excluding other possibilities in the differential diagnosis. Imaging studies, such as computed tomography (CT) mesenteric angiography and conventional angiography, are the cornerstones of establishing a definitive diagnosis. Rapid detection and early treatment are the principal drivers in preventing intestinal infarction and systemic complications arising therefrom.² Treatment options include open repair, hybrid procedure, or endovascular interventions (pharmacologic or mechanical thrombectomy and balloon angioplasty with arterial stent placement). Angioplasty and stenting can be performed via antegrade arterial access, from the brachial or femoral approach, or through a hybrid, retrograde open mesenteric stent (ROMS) technique.³ The treatment of mesenteric thrombosis includes 1) conservative management with anticoagulation; 2) surgical treatment, including endarterectomy and embolectomy, surgical bypass, segmental arterial resection, and anastomosis and intraoperative intra-arterial catheter-directed thrombolysis (bowel infarction requires immediate resection, while anastomosis is done in follow-up); and 3) a hybrid surgical technique, wherein the mesenteric artery in the peritoneum is dissected, arteriotomy is conducted, and ROMS is performed, followed by arteriotomy repair.³

Here we describe a novel hybrid technique for patients with flush occlusion of the superior mesenteric artery (SMA) with failed percutaneous mesenteric artery stenting. A vessel can be called flush-occluded when it is completely occluded within the first 5 mm of its origin.⁴ In our case series, all three patients required abdominal laparotomy. A retrograde mesenteric arterial intervention was done with mesenteric arterial access using ultrasonography (USG)-guided needle puncture instead of the open mesenteric arteriotomy approach; hence, we called it the modified ROMS technique. All three patients had flush occlusion of two mesenteric vessels on CT angiography, causing acute-on-chronic mesenteric ischemia, and were treated with a novel hybrid technique not described before in the literature. Percutaneous mesenteric artery angioplasty and stenting had failed in all cases, as the wire could not be negotiated across the flush mesenteric arterial occlusion. Following a laparotomy, a microcatheter was passed via USG-guided mesenteric arterial access, and the wire in the aorta was then snared from the transfemoral approach. Mesenteric angioplasty and stenting were performed from the femoral arterial approach. This procedure obviated the need for mesenteric arteriotomy and repair, unlike the conventional method.

Written informed consent for the publication of this report was obtained from the patients, and the report was approved by the institutional ethics committee. Cases with co-existing abdominal intractable pain, distention, guarding and rigidity, CT angiography suggestive of flush occlusion of the SMA and celiac trunk, and failed percutaneous approach in negotiating flush occlusion were selected. Our approach involved circumventing the mesenteric arteriotomy and repair.

Acute-on-chronic mesenteric ischemia due to arterial occlusion requires a thorough preoperative diagnosis, revascularization using open repair, hybrid procedure, or endovascular intervention, and surgical resection in case of bowel gangrene. In this case series, we present three cases of acute-on-chronic mesenteric ischemia; two patients were men and one was a woman, with an average age of 46.33 years. In all cases, due to flush occlusion of the mesenteric vessels, percutaneous angioplasty stenting had failed. Table 1 depicts the demographic data, pre-existing comorbidities, symptomatology, preoperative CT mesenteric angiography, and bowel infarction status of the three patients. Since the procedure performed was similar in all three patients, abdominal digital subtraction angiography (DSA) and bowel images of only the second patient were included as representative figures.

Table 1 . Demographic Data, Pre-Existing Comorbidities, Symptomatology, Preoperative CT Mesenteric Angiography, and Bowel Infarction Status of the Three Patients.

Demographic data/medical history	Patient 1	Patient 2	Patient 3
Sex	Female	Male	Male
Age (yr)	46	45	48
Postprandial pain (mo)	3	2	3
Acute intractable pain in the abdomen (day)	2	3	3
Vomiting	No	Yes	Yes
Guarding and rigidity	No	Yes	Yes
Paralytic ileus	No	Yes	Yes
CT angiography status of the celiac artery and SMA	Flush occlusion	Flush occlusion	Flush occlusion
CT angiography status of the celiac artery and IMA	90% osteal stenosis	90% osteal stenosis	Normal
Bowel infarction with resection anastomosis	No	Yes	Yes
GB necrosis	No	Yes	Yes
Systemic HT	Yes	No	No
Type 2 DM	No	No	No
Coronary artery disease	No	No	No
Smoking	No	Yes	No
Tobacco chewing	No	Yes	Yes

CT, computed tomography; SMA, superior mesenteric artery; IMA, inferior mesenteric artery; GB, gall bladder; HT, hormone therapy; DM, diabetes mellitus..

In the first patient, abdominal DSA revealed flush occlusion of the celiac trunk and SMA, 80% tight stenosis of the right renal artery, and 90% inferior mesenteric artery (IMA) osteal stenosis. Preoperative medications included clopidogrel and aspirin (75 + 150 mg once daily), cilostazol (100 mg twice daily), rosuvastatin (20 mg at bedtime), and intravenous antimicrobials. Preprocedural CT abdominal angiography in the second patient revealed flush occlusion of the celiac and SMA (Fig. 1, 2A), and the IMA showed 90% stenosis at its ostium. Abdominal DSA revealed flush occlusion of celiac and SMA with the failed percutaneous approach of recanalization in the third patient. This hybrid technique involved intraoperative USG-guided access to the mesenteric trunk, retrograde negotiation of the wire across the mesenteric flush occlusion, snaring of the wire from the transfemoral approach, and transfemoral mesenteric angioplasty and stenting. Conventional open laparotomy was performed, and USG-guided mesenteric arterial access was achieved (Fig. 2B) using 18G Jelco (Smiths Medical, Minneapolis, MN, USA). Through the Jelco cannula, a microcatheter (Progreat; Terumo, Tokyo, Japan) was passed and the mesenteric occlusion was negotiated. The wire in the aorta was then snared from the transfemoral approach, and mesenteric angioplasty and stenting were performed from the femoral arterial approach. This procedure obviated the need for mesenteric arteriotomy and repair. A 3 mm × 40 mm balloon was used for predilatation and then a 7 mm × 37 mm balloon-mounted stent was placed (Fig. 3). The ischemic bowel loops had good blood supply following angioplasty stenting. Post-procedural manual compression sealed the mesenteric arterial access site without any complications. Bowel areas showing necrosis (secondary to acute-on-chronic mesenteric ischemia) were resected (Fig. 4), and double-barrel ileostomy with closure of the laparotomy was performed in two patients. On follow-up at 1 year, all patients did well with no stent occlusion. This hybrid technique does not require mesenteric arteriotomy and subsequent repair, unlike retrograde open mesenteric artery stenting.

Figure 1. Computed tomography angiography of a 45-year-old male with pain in the abdomen, vomiting, constipation, and guarding and rigidity is suggestive of flush occlusion of the celiac artery (arrow, A), superior mesenteric artery (arrow, B), normal gall bladder (C), and normal bowel (D).

Figure 2. (A) Computed tomography angiography suggestive of flush occlusion of the celiac artery with no obvious distal reformation, and long-segment flush occlusion of the superior mesenteric artery. (B) Trans-mesenteric ultrasound-guided canulation of the superior mesenteric artery trunk.

Figure 3. (A) Digital subtraction angiography through the trans-mesenteric approach. (B) The wire from the superior mesenteric artery (SMA) cannulation through retrograde cannulation is snared out by the transfemoral approach. (C) Balloon angioplasty of the occluded SMA. A 7 mm × 37 mm balloon-mounted stent in situ and after deployment (D and E, respectively). (F) Contrast flowing well across the stent.

Figure 4. (A) Normal bowel after the re-establishment of superior mesenteric artery flow. (B) Gangrenous jejunal loops. (C) Resected jejunal loops.

Dual platelet inhibitors—clopidogrel (for 6 months) and acetylsalicylic acid (as maintenance treatment)—were administered once the patients’ bowel function was restored. The postoperative course of all the cases was uneventful, and the patients have been doing well at 3 years (case 1), 2 years (case 2), and 1 year (case 3) follow-ups respectively.

Advances in endovascular techniques have significantly improved the prognosis and outcomes of mesenteric ischemia. The key principle in the reduction of mortality and morbidity has been aptly summarized as “revascularize first, resect later” by Blauw et al.³ Open surgery is reserved for emergency conditions requiring exploratory laparotomy. A retrograde approach for SMA revascularization in a critically ill 85-year-old female with acute mesenteric ischemia (AMI) due to an occluded celiac axis and high-grade SMA stenosis was first reported by Milner et al⁵ in 2004. Retrograde open SMA stenting during laparotomy for AMI has a high technical success rate and serves as a substitute for the bypass procedure, especially for patients in critical condition. Combining it with an open laparotomy aids in evaluating and resecting nonviable bowel, thus abiding by the essential surgical principles.⁶

For patients with acute-on-chronic mesenteric ischemia who have peritoneal contamination and no other good source of inflow to the mesenteric arteries, retrograde hybrid SMA stenting has proven to be an efficient means of revascularization and preventing further complications.⁷ ROMS offers an alternative to bypass procedures or percutaneous stenting for AMI patients who may require abdominal exploration. It is also an alternative for patients with flush mesenteric occlusion in whom prior percutaneous stenting procedures have failed or who are deemed unfit for them.⁸ Although the hybrid technique has been proven as an effective approach for treating AMI, further studies are required comparing it to open surgery and endovascular techniques.⁹

Our case series illustrates a novel hybrid approach for endovascular recanalization of flush mesenteric occlusion without mesenteric arteriotomy or subsequent arterial repair, as is required in the conventional approach. This technique has not been reported previously in the literature to the best of our knowledge. The short- and long-term post-procedure follow-up has proven to be favorable for prognosis, and this hybrid approach is recommended in patients with flush acute and subacute occlusions in whom the percutaneous approach has failed.

The authors would like to acknowledge Hashtag Medical Writing Solutions Pvt. Ltd. for editorial assistance and proofreading.

None.

No potential conflict of interest relevant to this article was reported.