Chronic Mesenteric Ischemia with Aortorenal Occlusive Disease: Repair with Trifurcated Aorto/Mesenteric/Renal Bypass and Bifurcated Aortoiliac Bypass

Abstract

This case report describes the management of chronic mesenteric ischemia in a patient with a single kidney and severe mesenteric, renal, and aortic atherosclerosis. This complex vascular problem became more taxing with the unexpected intraoperative finding of a large supraceliac aortic bleb that was threatening imminent rupture. Mesenteric and renal artery disease were reconstructed by a combination of superior mesenteric artery (SMA) endarterectomy and creation of aortic to inferior mesenteric, left renal, and superior mesenteric artery bypass. A trifurcated 12 x 6 mm polytetrafluoroethylene (PTFE) graft that originated from the side of the distal descending thoracic aorta was used for this reconstruction. Aortobiiliac reconstruction with an in-line 18 x 9 mm PTFE graft excluded the remaining diseased abdominal aorta below the trifurcated graft. This case demonstrates the value of maintaining visceral and renal perfusion through (1) tangential thoracic aortic clamping, (2) individual aortic branch vessel reconstruction, and (3) separate distal revascularization.