There is no uniform agreement about the graft material of choice. In early reports, vein grafts had patency rates inferior to synthetic grafts.9,10 More recent reports described the use of either autogenous veins or prosthetic grafts with excellent long-term function and no difference in patency rates.11,12 In our case, we used synthetic Dacron bypass because it is always available, spares the patient from the morbidity of one or more incisions for the harvesting of the vein, and provides good early and long-term results. Aorto-superior mesenteric artery bypass alone is usually sufficient to provide good symptomatic relief as a result of the extensive collateral circulation, even when all three visceral arteries are occluded.Hollieretal.13 haveshownthatcompleterevascularisationinmultivesseldisease resulted in a late recurrence of 11%, while when one of three stenotic vessels was revascularised the recurrence rate was 50%. They concluded that it is preferable to revascularise as many vessels as possible to provide the best chance of long-term relief. Most recent series report an acceptable operative mortality rate ranging from 3% to 8%. Our patient could have been considered for angioplasty of the superior mesenteric artery. In a recent large series of patients (n = 51) who had angioplasty and stenting as first choice treatment for the management of chronic visceral ischaemia the initial technical success rate was 93%. No 30-day mortality was observed. During a median follow up of 25 months, two patients died of mesenteric ischemia and the 2 year primary patency rate dropped to 60%.14 A recent review comparing surgical and endovascular revascularization for chronic mesenteric ischaemia concluded that surgical treatment has superior long-term patency and requires fewer reinterventions. However it is more invasive with greater morbidity and mortality compared to endovascular treatment. Endovascular techniques may be preferable in patients with significant co-morbidities, concomitant aortic disease or indeterminate problems.15 [Q3: False A, B, C, D]

Recurrent visceral ischaemia is not uncommon after primary visceral revascularisation for chronic visceral ischaemia. In a large series of 109 patients who underwent primary visceral revascularisation at the University of California, San Francisco over a period of 38 years, 19 patients had recurrent visceral ischemia, 12 (11%) patients had recurrent chronic visceral ischemia, and seven (6.4%) had acute visceral ischemia.16 The minimally invasive nature of the endovascular techniques and the increased complication rate of reoperations renders the endovascular approach a reasonable first option in properly selected patients with recurrent symptoms.17 [Q4: B]

References

 1. Babu SC, Shah PM. Celiac territory ischemic syndrome in visceral artery occlusion. Am J Surg. 1993;166:227-230.

 2. Geroulakos G, Tober JC, Anderson L, Smead WL. Antegrade visceral revascularisation via a thoracoabdominal approach for chronic visceral ischaemia. Eur J Vasc Endovasc Surg. 1999;17:56-59.

 3. Zelenock G, Graham LM, Whitehouse WM, et al. Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg. 1990;115:497-501.

 4. Geelkerken RH, van Bockel JH, De Ross WK, Hermans J, Terpstra JL. Chronic mesenteric vascular syndrome. Results of reconstructive surgery. Arch Surg. 1991;126:1101-1106.

 5. Lande A. Abdominal Takayasu’s aortitis, the middle aortic syndrome and atherosclerosis. Int Angiol. 1998;17:1-9.

 6. SchneiderPA,EhrenfeldWK,CunninghamCG,ReillyLM,GoldstoneJ,StoneyRJ.Recurrent chronic visceral ischaemia. J Vasc Surg. 1992;15:237.

 7. Rheudasil JM, Stewart MT, Schellack JV, Smith RB, Salam AA, Perdue GD. Surgical treatment of chronic mesenteric arterial insufficiency. J Vasc Surg. 1988;8:495-500.

 8. Kazmers A. Operative management of chronic mesenteric ischaemia. Ann Vasc Surg. 1998;12:299-308.

 9. Rob C. Surgical diseases of the celiac and mesenteric arteries. Arch Surg. 1966;93:21-30. 10. StoneyRJ, Ehrenfeld WK, Wylie EJ.Revascularizationmethodsin chronicvisceralischaemia

caused by atherosclerosis. Ann Surg. 1977;186:468-476.

11. Bauer GM, Millay DJ, Taylor LM, Porter JM. Treatment of chronic visceral ischaemia. Am J Surg. 1984;148:138-144.

12. McMillan WD, McCarthy WJ, Bresticker MR, et al. Mesenteric artery bypass: objective patency determination. J Vasc Surg. 1995;21:729-741.

13. HollierLH,BernatzPE,PairoleroPC,SpencerPayneW,OsmundonPJ.Surgicalmanagement of chronic intestinal ischaemia. A reappraisal. Surgery. 1981;90:940-946.

14. Fioole B, van de Rest HJ, van Leersum M, et al. Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischaemia. J Vasc Surg. 2010;15:386-391.

15. Biebl M, Oldenburg WA, Paz-Fumagalli R, McKinney JM, Hakaim AG. Surgical and interventional visceral revascularization for the treatment of chronic mesenteric iscahemiawhen to prefer which? World J Surg. 2007;31:562-568.

16. SchneiderDB,SchneiderPA,ReillyLM,EhrenfeldWK,MessinaLM,StoneyRJ.Reoperation for recurrent chronic visceral ischaemia. J Vasc Surg. 1998;27:276-286.

17. Robless P, Belli AM, Geroulakos G. Endovascular versus surgical reconstruction for the management of chronic visceral ischaemia: a comparative analysis. In: Geroulakos G, Cherry K, eds. Diseases of the Visceral Circulation. London: Arnold; 2002:108-118.

A 78-year-old woman presented to the emergency department with a 12-h history of sudden-onset abdominal pain. She had vomited after the pain started, and she had also had two episodes of diarrhoea. Until this time, she had been well, although she was known to be in atrial fibrillation and took digoxin 125 mg daily.

On examination, she was distressed and obviously in pain. Baseline observations revealed a pulse of 110 bpm, irregularly irregular, blood pressure of 95/60 mm Hg, respiratory rate of 28 breaths/min, and temperature of 37.3°C. Her chest was clear, heart sounds were normal (irregular rhythm), and the jugular venous pressure was not elevated. Abdominal examination was unremarkable, with a soft abdomen and minimal tenderness despite severe pain, and normal bowel sounds.

The investigations shown in Table 28.1 were performed by the admitting surgeon. Electrocardiogram (ECG) revealed atrial fibrillation with no other acute changes.

Erect chest X-ray revealed normal lung fields and no free gas under the diaphragm. Abdominal radiography was unremarkable except for minimal small-bowel distension.

Question 1

Which of the following is the most unlikely diagnosis?

A.  Acute ulcerative colitis

B.  Pancreatitis

C.  Mesenteric venous thrombosis (MVT)

D.  Acute mesenteric ischaemia (AMI)

E.  Diabetic ketoacidosis

J.S. Refson ( )

Department of Vascular Surgery, Princess Alexandra Hospital, Harlow, UK

HC03- 17 mmol/1

Base excess -8

Question 2

What are the most common causes of AMI?

A.  Renal failure

B.  Atrial fibrillation

C.  Multi-organ failure

D.  Anti-phospholipid syndrome

E.  Atherosclerotic disease

Question 3

Which of the following tests are of use in the acute management of a patient with AMI?

A.  Echocardiography

B.  Lateral-view mesenteric angiography C.  Thyroid function tests (TFTs)

D.  Non-contrast computed tomography (CT) scanning E.  Mesenteric vessel duplex Doppler

At this point, the patient was taken to the high-dependency unit, where the following measures were undertaken: high-flow oxygen therapy by mask (15 L/min), continuous ECG monitoring, central venous pressure (CVP) monitoring, urinary catheter inserted to monitor urinary flow hourly, and infusion of 4 L of fluid resuscitation. Intravenous broad-spec- trum antibiotics and an anticoagulant dose of intravenous heparin were also given. After 2 h of resuscitation, the patient’s blood pressure was 130/85 mm Hg, pulse 100 bpm and CVP +8 cm water. She was still in a lot of pain despite 10 mg of diamorphine, and she was still tachypnoeic. Repeat blood gas and blood count investigations were as in Table 28.2.

Because the patient was persistently acidotic with an elevated white count and in severe pain, she was taken to the operating theatre for an emergency laparotomy. Almost the