**5.4 Chronic mesenteric ischemia**

#### **5.4.1 Transaortic endarterectomy**

Advantages of this operation include removal of atheroma from the aorta and both visceral arteries simultaneously. Limitations include the need for extended exposure of the upper abdominal aorta via medial visceral rotation and incomplete plaque removal if the atheroma extends to the distal artery or if transmural calcification is present. It is suitable for selected patients with CMI undergoing elective revascularizaion (17).

#### **5.5 Antegrade mesenteric bypass**

Reconstruction of the celiac artery and the SMA with a bifurcated prosthetic graft originating from the supraceliac aorta. The operation is done through an upper midline or

appreciated. Systemic heparinization is established. If the artery feels relatively soft and free of atherosclerotic disease, a transverse arteriotomy is performed distal to the area of obstruction, and the arterial lumen is assessed for thrombus. Balloon-tipped embolectomy catheters are gently passed proximally and distally until no more clot can be removed. Care must be taken not to overinflate the balloons and dissect the arterial intima. Distally, mesenteric vessels are very thin, and overinflation can result in rupture and intramesenteric extravasation. The transverse arteriotomy is then closed primarily with simple interrupted Prolene sutures if no endarterectomy is necessary. In cases in which a flow-limiting plaque is present, the arteriotomy is converted to a longitudinal one, and a local thromboendarterectomy is performed. Patch angioplasty with autogenous vein is the preferred method of revascularization owing to potential contamination from concomitant bowel resection. The arteriotomy site can also be used for distal anastomosis of an antegrade

Advantages of this operation include removal of atheroma from the aorta and both visceral arteries simultaneously. Limitations include the need for extended exposure of the upper abdominal aorta via medial visceral rotation and incomplete plaque removal if the atheroma extends to the distal artery or if transmural calcification is present. It is suitable for selected

Reconstruction of the celiac artery and the SMA with a bifurcated prosthetic graft originating from the supraceliac aorta. The operation is done through an upper midline or

or retrograde bypass if necessary.

**5.4 Chronic mesenteric ischemia 5.4.1 Transaortic endarterectomy** 

Fig. 4. Endarteriektomie of the SMA

**5.5 Antegrade mesenteric bypass** 

patients with CMI undergoing elective revascularizaion (17).

bilateral subcostal incision, depending on the patient's body habitus and costal cartilage flare. Supraceliac-origin grafts are a poor choice in patients with compromised cardiac or pulmonary function or those with extensive atherosclerosis or circumferential calcification of the supraceliac aorta. In these cases, infrarenal sources of inflow are preferred (18, 19, 21).

Fig. 5. Antegrade aortoceliac–superior mesenteric artery bypass
