Chronic mesenteric ischemia (CMI) is an uncommon condition secondary to atherosclerotic disease of the mesenteric arteries. Symptomatic CMI must be revascularized without delay. Surgery and endovascular approaches are the ways through which this could be accomplished. 

51-year-old gentleman, a known hypertensive and a chronic smoker presented with abdominal angina, food fear, and weight loss for 1 month. He had a past history of coronary angioplasty for coronary artery disease and right femoro-popliteal bypass along with a right renal artery stenting for peripheral vascular disease. On examination, abdomen was scaphoid. He was evaluated with contrast enhanced computed tomography (CECT) of the abdomen (Figure 1). Arterial phase imaging showed complete occlusion of origins of celiac axis, Superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) and an unusual collateral pathway with a large meandering mesenteric artery collateralized through median sacral, superior hemorrhoidal, inferior mesenteric and inferior pancreatico duodenal arteries. The patient was planned for an endovascular procedure. An angiogram done confirmed the above findings with retrograde filling of the SMA through the median sacral, superior hemorrhoidal, meandering mesenteric artery, inferior pancreatico-duodenal route. However, an attempt at SMA stenting failed as SMA cannulation could not be achieved (Figure 2). The patient underwent a retrograde open re-vascularisation of the SMA with a 7 mm polytetrafluoroethylene (PTFE) graft.

Under general anesthesia, after sterile preparation and draping, the abdomen was opened through a long midline incision and retractors were positioned. A Mattox maneuver (a left medial visceral rotation) was performed. The aorta was exposed from the origin of the celiac artery to its bifurcation, Aorta was diseased with plaque throughout (Figure 3a). There was a plaque at the origin of the coeliac axis. SMA pulsations were absent at the root. Aorta was side clamped and an inflow anastomosis was done (continuous 4-0 polypropylene suture) on the infra renal aorta which was free from the disease using a 7mm PTFE graft. The graft length was cut to 5 cm and edge beveled to fashion and complete the distal landing on the proximal SMA which was free from the disease (Figure 3b). The patient had an uneventful post-operative course. Follow up aortogram showed excellent flow through the graft and reversal of flow through the meandering mesenteric artery (Figure 4). On follow up at 1 year, the patient is pain free and has gained weight. 

Chronic mesenteric ischemia is an uncommon condition¹. There is rich collateralization between the mesenteric vessels. CMI is seen due to mesenteric insufficiency in the post prandial period. In cases where one of the three mesenteric arteries are involved with an atherosclerotic process the blood supply is maintained by the other two. With the involvement of at least two arteries in the atherosclerotic process, mesenteric ischemia ensues. In our case where all three mesenteric arteries were involved in the disease process and the basal need was maintained from the median sacral artery². The classical symptoms include post prandial abdominal pain, food fear, and unintentional weight loss. In patients who are symptomatic for mesenteric ischemia, restoration of blood supply must be done without delay as more than 40% of symptomatic patients end up with acute mesenteric ischemia³. Patients are often elderly with multiple comorbidities like coronary artery disease, hypertension, renal insufficiency and diabetes like in our patient. Contrast enhanced computed tomography (CECT) is the investigation of choice. It provides three dimensional reconstruction which can assist in surgical planning. Although CT visceral angiogram gives adequate information, a flush aortogram provides more dynamic information regarding collateral flow and is the gold standard. Management options include endovascular procedures and surgery. Stenting is the preferred endovascular procedure as angioplasty is fraught with recurrence of symptoms. With the advent of advanced endovascular techniques and less physiological stress on already compromised patients, endovascular interventions have become the first line of management. Surgery is considered in patients with extensive occlusive disease and where endovascular intervention is not feasible either due to contrast allergy or endovascular failures like in our patient. However the freedom from recurrence of symptoms is higher with surgery and the requirement of re-intervention is more in the endovascular group. The recurrence free survival at 5 years of patients undergoing endovacular interventions is reported to be around 56%.² The need for reintervention is seen in around one third to half the patients with 3-year stent latency of only 40%.^2,4 These have to be clearly conveyed to the patient for him to take an informed decision. Surgical options include re-vascularisation using a graft between the aorta and mesenteric or celiac arteries, endarterectomy and rarely, retrograde SMA stenting and re-vascularisation from thoracic aorta, subclavian, or axillary vessels^5-7. Re-vascularisation is the preferred modality, however endarterectomy may be useful when there is contamination (bowel gangrene, perforation) precluding the use of a synthetic graft or extensive disease of the aorta where placement of inflow anastomosis is not possible in a safe manner.