Supraceliac Aorta-to-SMA Bypass with Ileocecectomy for Acute-on-Chronic Mesenteric Ischemia Complicated by Bowel Necrosis and Perforation
Benjamin J. Pearce, MD
UAB Hospital
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. 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.
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.
Thoracofemoral Bypass: A Retroperitoneal Approach
J. Miller Allan, MD; Victoria Aucoin, MD; Benjamin J. Pearce, MD
UAB Hospital
Surgical intervention for aortoiliac occlusive disease (AIOD) remains a vital tool in the management of AIOD. AIOD is caused by occlusion of the infrarenal and/or iliac arteries, often secondary to atherosclerosis. This article presents a case of a young, male patient with a history of familial hyperlipidemia and chronic tobacco use who underwent a thoracofemoral bypass (TFB) procedure via a retroperitoneal approach.
He presented with classic symptoms of bilateral leg pain when walking, nocturnal lower extremity pain, and correlated diminished lower extremity pulses. TFB was the preferred approach due to the aggressive, soft plaque burden extending into the suprarenal aorta, which precluded endovascular repair and would have increased risk for standard infrarenal aortofemoral bypass (AFB). This video and case report present a detailed explanation of a retroperitoneal approach to a TFB procedure.
Carotid Endarterectomy (Cadaver)
Meghan Robinson1; Laura Boitano, MD2; Samuel Schwartz, MD2
1Lake Erie College of Osteopathic Medicine
2Massachusetts General Hospital
Carotid stenosis is one of the leading causes of ischemic stroke worldwide. In the United States, nearly 800,000 strokes are reported each year, with ischemia accounting for 87% of them, and 15% traced to a carotid origin. Carotid endarterectomy represents an effective surgical treatment for carotid stenosis in preventing the risk of future ischemic stroke. This video-article demonstrates the surgical technique for carotid endarterectomy on a cadaver and discusses a typical case presentation of an individual who could potentially benefit from this procedure.
Femoral Endarterectomy for Severe Peripheral Arterial Disease
Katherine L. Morrow, MD; Anahita Dua, MD, MS, MBA, FACS
Massachusetts General Hospital
This case describes an 85-year-old gentleman with significant peripheral arterial disease and lifestyle-limiting claudication who had previously undergone an unsuccessful attempt at endovascular treatment of his significant right common femoral artery stenosis.
A right common femoral endarterectomy was performed to remove this patient’s significant plaque burden. Postoperatively, the patient noted significant improvement in his right lower extremity claudication, and his postoperative pulse volume recordings showed improved arterial inflow.
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