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Ann Vasc Surg. 2020 Jan 10. pii: S0890-5096(20)30039-X. doi: 10.1016/j.avsg.2020.01.019. [Epub ahead of print]

Direct retrograde bypass is preferable to antegrade bypass for open mesenteric revascularization.

Author information

1
University of Kentucky College of Medicine, Department of Surgery, Section of Vascular Surgery, Lexington, KY.
2
University of Kentucky College of Medicine, Department of Surgery, Section of Vascular Surgery, Lexington, KY. Electronic address: edende0@uky.edu.

Abstract

BACKGROUND:

Mesenteric bypass grafts can be constructed either antegrade or retrograde. There is debate regarding which is the optimal approach. We have modified the technique for retrograde mesenteric revascularization using a direct open retrograde revascularization (DORR) technique. This report is a retrospective, single institution study that describes the DORR technique and compares it to antegrade mesenteric bypass.

METHODS:

The medical records of patients undergoing open mesenteric bypass between January 2001 and December 2017 for mesenteric ischemia were reviewed. Patients who underwent mesenteric thromboembolectomy, retrograde stenting, or bypass for aneurysmal disease were excluded. Patient demographics, operative details and follow-up data were recorded. Antegrade bypasses were constructed using a Dacron bifurcated graft. The supra-celiac aorta was exposed and the Dacron graft limbs were tunneled to the celiac and/or superior mesenteric artery (SMA). The DORR was constructed by anastomosing a vein graft to an iliac artery. The vein was tunneled through the base of the small bowel mesentery to create a direct course to the SMA. When revascularization to both the SMA and celiac vessels was indicated, the vein was anastomosed to the SMA in a side-to-side fashion with the distal vein tunneled through the mesocolon and anastomosed end-to-side to the hepatic artery. Statistical analysis was done using Student's t-test, Man-Whittney U test, Fisher's exact test and log-rank test with a p ≤ 0.05 considered significant.

RESULTS:

Forty-one patients underwent open mesenteric bypass: 16 antegrade; 25 retrograde. Patient age, gender and BMI were similar. Indication for operation was acute ischemia in a greater portion of patients undergoing retrograde bypass (p=0.025). For antegrade bypasses, Dacron was used in 15 and saphenous vein in 1. The DORR bypass originated from an iliac artery (21), limb of an aorto-femoral graft (2), or infrarenal aorta (2). All DORR were constructed using vein (19 femoral vein, 6 greater saphenous vein). In DORR configurations, the bypass was created to only the SMA in 23 cases (92%). By comparison, in antegrade bypasses, the bypass was constructed to both the SMA and celiac arteries in all but one case (p<0.00001). Median operative time was significantly shorter for DORR compared to antegrade bypass (282 vs. 375 min., p<0.05). Blood loss, need for second look laparotomy, morbidity, mortality, LOS and discharge disposition were similar between groups. There was a shift in favor of the DORR technique in the second half of the study [4/15 (27%) DORR from 2001-2009 vs. 21/26 (81%) DORR from 2010-2017]. In survivors, 57% of the antegrade cohort and 74% of the DORR cohort had documented follow-up (average 47.5±59.9 months and 28.8±31.3 months, respectively). No difference was noted in survival between groups. All grafts in both cohorts were patent at follow-up CONCLUSIONS: Direct tunneling of the graft under the mesentery with the DORR technique avoids concern for kinking and has shorter operative time despite the need for vein harvest. No differences were noted in long-term survival between patient groups. The use of a venous conduit makes DORR adaptable for both chronic and acute mesenteric ischemia. These factors have resulted in the DORR technique to be our preferred method for open mesenteric revascularization.

PMID:
31931133
DOI:
10.1016/j.avsg.2020.01.019

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