Supraceliac Aorta-to-SMA Bypass with Ileocecectomy for Acute-on-Chronic Mesenteric Ischemia Complicated by Bowel Necrosis and Perforation

Case Overview

Chronic mesenteric ischemia (CMI) is a complex vascular pathology with reported incidence rates of up to 10 per 100,000 individuals, predominantly affecting female patients over 60 years of age.^1,2 Traditional risk factors include smoking, hypertension, and hyperlipidemia, all of which were present in this case.^3,4

Treatment options for CMI include endovascular stenting, hybrid procedures, and open surgical bypass.^5,6 While endovascular approaches offer lower perioperative morbidity and shorter hospitalization, the durability of open revascularization remains superior. The decision to proceed with open surgical revascularization was influenced by the extent of disease, anatomical alterations, and extensive adhesions from previous aorto-bifemoral bypass, and the necessity for complete revascularization given the compromised collateral circulation.^7,8

This case involved a 63-year-old female with a history of chronic tobacco use, hypertension, and hyperlipidemia, who had undergone aortobifemoral bypass several months earlier at an outside institution. Shortly afterward, she developed progressive postprandial abdominal pain, alternating constipation and diarrhea, unintentional weight loss, and food fear. During a prolonged hospital admission, she underwent upper and lower endoscopy and autoimmune evaluation, none of which yielded a definitive diagnosis. She was dependent on total parenteral nutrition due to intolerance of enteral intake.

On transfer to our facility, she was found to have a high-grade occlusion of the superior mesenteric artery (SMA), beginning approximately 3–4 cm distal to the ostium, caused by a bulky, calcified atherosclerotic plaque. The SMA origin was patent but significantly narrowed, correlating with her chronic symptoms. Her medication regimen included aspirin 75 mg daily, atorvastatin 20 mg, enalapril 10 mg BID, and furosemide 20 mg PRN. There was no known history of atrial fibrillation, myocardial infarction, stroke, heart failure, or diabetes.

Given her worsening condition, surgical exploration was undertaken and revealed necrotic terminal ileum, a contained perforation, and localized peritonitis. A supraceliac aorta-to-SMA bypass was performed using a cryopreserved superficial femoral artery (SFA) graft routed through a retropancreatic tunnel, followed by ileocecal resection.

The operative approach required significant modification upon discovery of bowel compromise and enteric contamination. The identification of perforated ischemic bowel and an ileal-transverse colon fistula necessitated immediate adaptation of the surgical strategy. The use of cryopreserved SFA instead of prosthetic material represented a crucial intraoperative decision, balancing the risks of graft infection against the need for immediate revascularization. Prosthetic grafts were avoided due to the high infection risk, while alternative inflow sources such as the gastroepiploic artery or autologous vein grafts were deemed inadequate due to flow limitations and the need for additional dissection time in an already complex and contaminated setting. The supraceliac aorta was selected for its reliability, and the proximal anastomosis was performed first to anchor the graft and ensure accurate length and orientation through the tunnel—while also allowing the operation to proceed from a clean to a contaminated field.

This surgical video demonstrates critical aspects of complex mesenteric revascularization. The technical elements of supraceliac aortic exposure, retropancreatic tunnel creation, and management of bowel complications provide valuable insights for surgeons encountering similar challenging scenarios. This case demonstrates the continued importance of open surgical expertise alongside endovascular techniques.

This article documents the first stage of surgical intervention. A second-look laparotomy with ileostomy formation and abdominal closure was performed two days later. A third-stage reconstruction to restore bowel continuity is planned for later this year, pending the patient’s recovery, and will be presented in a follow-up publication if circumstances allow.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.