# Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

## TL;DR

This paper presents a surgical technique and algorithm for treating chronic mesenteric ischemia using open revascularization, based on a quaternary-center experience with four patients.

## Contribution

The study introduces a novel open revascularization technique using a C-loop configuration and proposes a management algorithm for chronic mesenteric ischemia.

## Key findings

- All four patients experienced symptom resolution and weight recovery after open revascularization.
- All grafts remained patent after a mean follow-up of two years.
- The proposed algorithm may guide treatment decisions in other quaternary centers.

## Abstract

Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan’s arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution’s experience and a review of recent literature.

All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.