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210 Vascular Surgery
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penetration, hidden to the eye, into deep tissues. Vigorous debridement must be
carried out to establish the degree of penetration and to remove all necrotic tissue
[3]. Fulminant infection may necessitate guillotine amputation. The bypass can
often be performed 3–5 days after debridement. If ischaemia plays a major role and
the infection is quiescent, then revascularisation can, in selected cases, be performed first. Vascular reconstruction can be performed in as many as 90 per cent of
diabetic patients with atherothrombotic disease [10]. The best outflow vessel in continuity with the foot should be selected [11]. Diabetes is not considered to affect the
outcome of graft patency, although female diabetic patients are reported to have
worse outcome regarding patency and leg salvage [12]. In limbs with large tissue
defects, a microvascular free muscle flap transfer can be used for defect coverage in
conjunction with long bypass [13]. [Q8: D]
Short bypasses do well if the inflow artery is not compromised, as in our patient.
Although the above-knee popliteal artery gave better results as the inflow vessel
than the below-knee popliteal artery in our own series [14], the question is not
settled. [Q9: C]
Angiography is the gold standard for intraoperative monitoring. The accuracy of
flowmetry is affected strongly by the reproducibility of the method. In contrast to
older methods, transit-time flowmetry, which does not require information on the
diameter of the vessels, has proven to be very accurate [15]. Despite this, it gives
only flow values and does not inform about the morphology. The present case
clearly shows how the typically narrow segment of the great saphenous vein below
the knee was missed despite good flow during the initial hyperaemia. In this area,
there was an intimal tear caused by the valvulectomy catheter. Unfortunately, an
angioscope was not used in the first operation. An angioscope visualises the inner
surface of the vessel, whereas intravascular ultrasound is better for detecting
changes within the vessel wall. Doppler and duplex may be used for intraoperative
monitoring as well. Doppler gives only haemodynamic information, whereas duplex
gives a combination of anatomical and haemodynamic information. There is no
best method for intraoperative monitoring, but the optimal method would be to
have both haemodynamic and morphological information. [Q10: A, D, E]
As there is a 30 per cent risk of developing neointimal hyperplasia and graft stenosis within the first postoperative year, duplex surveillance is considered an essential
part of postoperative care. All the suggested duplex criteria are indicative of vein
graft stenosis, but none of them can be 100 per cent sensitive in detecting stenosis
[16]. Our case demonstrates that using liberal duplex criteria, false positive findings
are easily encountered as the angiography was deemed normal. [Q11: A, B, C, D]
References
1. LoGerfo FW, Coffman JD. Vascular and microvascular disease in the diabetic foot: implications for
foot care. N Engl J Med 1984;311:1615–19.
2. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system.
Diabetes Care 1998;21:855–9.
3. Levin ME, O’Neal LW. The diabetic foot. St Louis: Mosby, 1983.
4. Lundin M, Wiksten JP, Peräkylä T, Lindfors O, Savolainen H, Skyttä J, Lepäntalo M. Distal pulse
palpation: is it reliable? World J Surg 1999;23:252–5.
5. Lehto S, Niskanen L, Suhonen M, Rönnemaa T, Laakso M. Medial artery calcification. A neglected
harbinger of cardiovascular complications in non-insulin-dependent diabetes mellitus. Arterioscler
Thromb Vasc Biol 1996;16:978–83.
Diabetic Foot 211
6. Takolander R, Rauwerda JA. The use of non-invasive vascular assessment in diabetic patients with
foot lesions. Diabet Med 1996;13:S39–42.
7. Veves A, Sarnow MR. Diagnosis, classification and treatment of diabetic peripheral neuropathy. Clin
Pod Med Surg 1995;12:19–30.
8. International Working Group on the Diabetic Foot. International consensus on the diabetic foot.
Netherlands: International Working Group on the Diabetic Foot, 1999.
9. Smith FCT, Shearman CP, Simms MH, Gwynn BR. Falsely elevated ankle pressures in severe leg
ischaemia: the pole test – an alternative approach. Eur J Vasc Surg 1994;8:408–12.
10. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg 1998;176 (Suppl
2A):5S–10S.
11. LoGerfo FW, Gibbons GW, Pomposelli FB, Campbell DR, Miller A, Freeman D, Quist WC. Trends in
the care of the diabetic foot. expanded role of arterial reconstruction. Arch Surg 1992;127:617–21.
12. Lepäntalo M, Tukiainen E. Combined vascular reconstruction and microvascular muscle flap transfer for salvage of ischaemic legs with major tissue loss and wound complications. Eur J Vasc
Endovasc Surg 1996;12:1–5.
13. Luther M, Lepäntalo M. Femorotibial reconstructions for chronic critical leg ischaemia: influence on
outcome by diabetes, gender and age. Eur J Vasc Endovasc Surg 1997;13:569–77.
14. Biancari F, Kantonen I, Albäck A, Ihlberg L, Lehtola A, Lepäntalo M. Popliteo-to-distal bypass grafts
for leg ischaemia. J Cardiovasc Surg 2000;41:281–6.
15. Albäck A, Mäkisalo H, Nordin A, Lepäntalo M. Validity and reproducibility of transit time
flowmetry. Ann Chir Gynaecol 1996;85:325–31.
16. Sladen JG, Reid JD, Cooperberg PL, Harrison PB, Maxwell TM, Riggs MO, Sanders LD. Color flow
duplex screening of infrainguinal grafts combining low and high velocity criteria. Am J Surg
1989;158:107–12.
24. Chronic Visceral Ischaemia
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George Geroulakos
A 68-year-old woman presented with a 19-month history of generalised abdominal pain. Initially, she experienced the pain following meals, but subsequently the
pain became persistent. Over this period of time, she lost 12 kg in weight. For the
last few months before admission, she started having diarrhoea once to twice per
day. There was no blood or mucus in the stool. Her past medical history included
partial gastrectomy 17 years earlier for benign disease.
On examination, the patient looked cachectic. Her abdomen was slightly distended, and the bowel sounds were increased. There was a high-pitched epigastric bruit. Routine blood tests were normal.
Question 1
Which is the likely diagnosis for our patient on the basis of the available information so far?
A. Cancer of the pancreas.
B. Peptic ulcer.
C. Subacute intestinal obstruction secondary to adhesions.
D. Mesenteric angina.
E. Cancer of the large bowel.
Faecal fat measurement was 17.6 g/day (normal value <6 g/day). Gastroscopy was
performed, which showed features compatible with atrophic gastritis. This was followed by computed tomography (CT) scanning of the abdomen, which reported
that the pancreas could not be defined well as a result of paucity of retroperitoneal
fat. In addition, CT showed non-specific thickening of the small-bowel loops.
Endoscopic retrograde cholecystopangreatography (ERCP) was performed, which
ruled out pancreatic pathology. A small-bowel enema did not demonstrate any
significant findings. A colonoscopy was performed, which showed two isolated
215
216 Vascular Surgery
Fig. 24.1.
ischaemia.
Colonoscopic view of an isolated ulcer in the ascending colon in a patient with chronic visceral
ulcers in the ascending colon (Fig. 24.1) and raised the possibility of ischaemic
colitis. Fig. 24.2 shows the lateral aortogram of our patient, which showed occlusion
of the coeliac artery and 95 per cent stenosis of the superior mesenteric artery. A
diagnosis of chronic visceral ischaemia was made.
Fig. 24.2. Lateral aortogram demonstrating occlusion of the coeliac artery and a 95 per cent stenosis of the
superior mesenteric artery.
Chronic Visceral Ischaemia 217
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Question 2
Which of the following statements regarding chronic visceral ischaemia is correct?
A. It has a marked male preponderance.
B. As described in our patient, it usually takes more than 1 year from the first pre-
sentation of the symptoms until the final diagnosis is made.
C. It presents clinically as an undiagnosed malignancy.
D. Symptoms occur when at least one of the three visceral arteries has significant
disease.
E. It may cause malabsorption.
The patient underwent antegrade revascularisation via a ninth rib extraperitoneal
thoracoabdominal approach of the coeliac artery and the superior mesenteric
artery. An 8-mm Dacron graft was used as a conduit.
Question 3
Which of the following statements regarding the management of this patient are
false?
A. The best patency can be achieved using a venous conduit.
B. Revascularisation of the coeliac artery was unnecessary, and equally good
results could have been achieved with revascularisation of only the superior
mesenteric artery.
C. Surgical revascularisation should not have been considered in this elderly, frail
patient because it has an excessive mortality rate of about 30 per cent in most
series.
D. Percutaneous transluminal angioplasty (PTA) should have been the method of
choice.
The postoperative recovery of the patient was uneventful. She was discharged
home on the eighth postoperative day. Six months later, she was asymptomatic and
had gained 5 kg in weight. However, at 12 months the patient presented to the outpatient clinic with recurrent postprandial abdominal pain. A duplex examination
showed that the graft to superior mesenteric artery anastomosis had more than
60 per cent stenosis and the graft to coeliac artery anastomosis was occluded.
Question 4
What would you advise your patient?
A. Reoperation aiming to revascularise the coeliac artery and place a patch on the
graft to superior mesenteric artery anastomosis.
218 Vascular Surgery
B. Angioplasty and stenting of the graft to superior mesenteric artery anastomosis.
C. Conservative management advising the patient to take small and frequent
meals.
The patient underwent angioplasty and stenting of the graft to superior mesenteric artery anastomosis with an excellent technical and clinical result. Twenty-four
months following this procedure the patient remains asymptomatic.
Commentary
As described in our patient, the clinical picture of chronic visceral ischaemia
includes abdominal pain with or without diarrhoea and weight loss. The diagnosis
of chronic visceral ischaemia is in doubt if the patient has no significant decrease in
total body mass. The abdominal pain occasionally radiates to the back. The pain of
visceral ischaemia has similarities to that of carcinoma of the stomach, pancreatic
carcinoma and peptic ulceration. Diarrhoea may be explained by the increased
motility of the bowel induced by the ischaemia; it may also be secondary to malabsorption. [Q1: A, B, D, E]
Other symptoms that may be seen include nausea and vomiting, which have been
associated with gastric motility disorders caused by ischaemia [1]. An epigastric
bruit may or may not be present. Our group and others have reported a marked
female patient distribution of this condition [2–4]. The reason for this peculiar sex
distribution remains undetermined. However, it has been suggested that it could be
the result of the inclusion of cases of Takayasu’s aortitis in reports of atherosclerotic
chronic visceral ischaemia [5]. Takayasu’s aortitis closely mimics atherosclerosis of
the abdominal aorta and has a marked female predominance.
The time from the onset of symptoms to diagnosis is usually more than 12
months [6]. The diagnosis of chronic visceral ischaemia is a clinical one. As shown
clearly in our case, contrast studies, abdominal ultrasound, endoscopy and CT are
not essential to the diagnosis but will prove important in eliminating other sources
of abdominal discomfort. In all instances, lateral views of biplane aortography
demonstrate visceral occlusive lesions compatible with the diagnosis. As a result of
an abundant network of collateral vessels, clinical symptoms are present when at
least two of the three visceral arteries have significant disease. There are known
asymptomatic cases with all three visceral arteries thrombosed, thus emphasising
the fact that chronic visceral ischaemia cannot be diagnosed exclusively on the basis
of X-rays. [Q2: B, C, E]
Techniques of revascularisation include transection and reimplantation, bypass
grafting, endarterectomy and balloon angioplasty with or without stent placement.
There is no consensus regarding the best surgical approach for the treatment of
chronic visceral ischaemia. This condition is encountered infrequently, and it is
unlikely that a single centre can treat enough patients and accumulate sufficient
experience to develop principles of treatment by demonstrating significant differences between the various mesenteric revascularisation strategies. Bypass grafting is
the most common type of visceral revascularisation performed; it may originate
from several different locations, including the supracoeliac aorta, the infrarenal
Chronic Visceral Ischaemia 219
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aorta and the common iliac arteries. Regardless of the bypass technique used, the
status of the donor artery is critical to success [7]. The distal thoracic aorta is
usually free of atherosclerotic disease and is an excellent origin of a short antegrade
bypass to the superior mesenteric artery. The bypass is placed in the direction of
normal blood flow, thus reducing anastomotic turbulence. In addition, this design
eliminates the possibility of kinking and thrombosis by compression or traction
from the overlying intestinal mesentery, which may be observed with retrograde
grafts originating from the infrarenal aorta or the iliac arteries. The distal portion of
the thoracic aorta may be approached from the abdomen through division of the
crura.
There is no uniform agreement about the graft material of choice. In early
reports, vein grafts had patency rates inferior to synthetic grafts [9, 10]. More recent
reports described the use of either autogenous veins or prosthetic grafts with excellent long-term function and no difference in patency rates [11, 12]. In our case, we
used synthetic Dacron bypass because it is always available, spares the patient from
the morbidity of one or more incisions for the harvesting of the vein, and provides
good early and long-term results.
Aorto-superior mesenteric artery bypass alone is usually sufficient to provide
good symptomatic relief as a result of the extensive collateral circulation, even when
all three visceral arteries are occluded. Hollier et al. [13] have shown that complete
revascularisation in multivessel disease resulted in a late recurrence of 11 per cent,
while when one of three stenotic vessels was revascularised the recurrence rate was
50 per cent. They concluded that it is preferable to revascularise as many vessels as
possible to provide the best chance of long-term relief.
Most recent series report an acceptable operative mortality rate ranging from 3 to
8 per cent.
Our patient could have been considered for angioplasty of the superior mesenteric artery. There is limited information about the selection of patients for PTA and
the long-term results. A number of small series reported early technical success in
70–100 per cent of patients. Recurrence after PTA is greater than after surgery. In a
series of 18 patients with chronic visceral ischaemia who had a technically successful angioplasty, symptomatic recurrence occurred in three (20 per cent) patients at
a mean interval of 28 months, while three patients had only partial symptomatic
relief [14]. Angioplasty is safer than surgery, although fatal distal embolisation and
fatal superior mesenteric artery dissection with thrombosis and bowel infarction
have been reported. At present, it should probably be limited to high-risk patients.
PTA of the visceral arteries can be difficult when performed via the femoral artery
approach. Access through the brachial and axillary artery may be easier, but this
route does not guarantee technical success. [Q3: False A, B, C, D]
Recurrent visceral ischaemia is not uncommon after primary visceral revascularisation for chronic visceral ischaemia. In a large series of 109 patients who underwent primary visceral revascularisation at the University of California, San
Francisco over a period of 38 years, 19 patients had recurrent visceral ischaemia, 12
(11 per cent) patients had recurrent chronic visceral ischaemia, and seven (6.4 per
cent) had acute visceral ischaemia [15]. The minimally invasive nature of the
endovascular techniques and the increased complication rate of reoperations
renders the endovascular approach a reasonable first option in properly selected
patients with recurrent symptoms [16]. [Q4: B]
220 Vascular Surgery
References
1. Babu SC, Shah PM. Celiac territory ischemic syndrome in visceral artery occlusion. Am J Surg
1993;166:227–30.
2. Geroulakos G, Tober JC, Anderson L, Smead WL. Antegrade visceral revascularisation via a thoracoabdominal approach for chronic visceral ischaemia. Eur J Vasc Endovasc Surg 1999;17:56–9.
3. Zelenock G, Graham LM, Whitehouse WM, Erlandson EE, Kraft RO, Lindenauer SM, Stanley JC.
Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg 1990;115:497–501.
4. Geelkerken RH, van Bockel JH, De Ross WK, Hermans J, Terpstra JL. Chronic mesenteric vascular
syndrome. Results of reconstructive surgery. Arch Surg 1991;126:1101–6.
5. Lande A. Abdominal Takayasu’s aortitis, the middle aortic syndrome and atherosclerosis. Int Angiol
1998;17:1–9.
6. Schneider PA, Ehrenfeld WK, Cunningham CG, Reilly LM, Goldstone J, Stoney RJ. Recurrent chronic
visceral ischaemia. J Vasc Surg 1992;15:237.
7. Rheudasil JM, Stewart MT, Schellack JV, Smith RB, Salam AA, Perdue GD. Surgical treatment of
chronic mesenteric arterial insufficiency. J Vasc Surg 1988;8:495–500.
8. Kazmers A. Operative management of chronic mesenteric ischaemia. Ann Vasc Surg
1998;12:299–308.
9. Rob C. Surgical diseases of the celiac and mesenteric arteries. Arch Surg 1966;93:21–30.
10. Stoney RJ, Ehrenfeld WK, Wylie EJ. Revascularization methods in chronic visceral ischaemia caused
by atherosclerosis. Ann Surg 1977;186:468–76.
11. Bauer GM, Millay DJ, Taylor LM, Porter JM. Treatment of chronic visceral ischaemia. Am J Surg
1984;148:138–44.
12. WD, McCarthy WJ, Bresticker MR, Pearce WH, Schneider JR, Golan JF, Yao JST. Mesenteric artery
bypass: objective patency determination. J Vasc Surg 1995;21:729–41.
13. Hollier LH, Bernatz PE, Pairolero PC, Spencer Payne W, Osmundon PJ. Surgical management of
chronic intestinal ischaemia. A reappraisal. Surgery 1981;90:940–6.
14. Allen RC, Martin GH, Rees CR, Rivera FJ, Talkington CM, Garrett WV, et al. Mesenteric angioplasty
in the treatment of chronic intestinal ischaemia. J Vasc Surg 1996;24:415–23.
15. Schneider DB, Schneider PA, Reilly LM, Ehrenfeld WK, Messina LM, Stoney RJ. Reoperation for
recurrent chronic visceral ischaemia. J Vasc Surg 1998;27:276–86.
16. Robless P, Belli AM, Geroulakos G. Endovascular versus surgical reconstruction for the management
of chronic visceral ischaemia: a comparative analysis. In: Geroulakos G, Cherry K, editors. Diseases
of the visceral circulation. London: Arnold, 2002;108–118.
25. Acute Mesenteric Ischaemia
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Jonathan S. Refson and John H. N. Wolfe
A 78-year-old woman presented to the emergency department with a 12-h
history of sudden-onset abdominal pain. She had vomited after the pain started,
and she had also had two episodes of diarrhoea. Until this time, she had been
well, although she was known to be in atrial fibrillation and took digoxin 125 mg
daily.
On examination, she was distressed and obviously in pain. Baseline observations revealed a pulse of 110 bpm, irregularly irregular, blood pressure of
95/60 mm Hg, respiratory rate of 28 breaths/min, and temperature of 37.3°C. Her
chest was clear, heart sounds were normal (irregular rhythm), and the jugular
venous pressure was not elevated. Abdominal examination was unremarkable,
with a soft abdomen and minimal tenderness despite severe pain, and normal
bowel sounds.
The investigations shown in Table 25.1 were performed by the admitting
surgeon.
Electrocardiogram (ECG) revealed atrial fibrillation with no other acute
changes. Erect chest X-ray revealed normal lung fields and no free gas under the
diaphragm. Abdominal radiography was unremarkable except for minimal
small-bowel distension.
Question 1
Which of the following is the most unlikely diagnosis?
A. Acute ulcerative colitis.
B. Pancreatitis.
C. Mesenteric venous thrombosis.
D. Acute mesenteric ischaemia (AMI).
E. Diabetic ketoacidosis.
221
222 Vascular Surgery
Table 25.1. Investigations performed by the admitting surgeon. Updated
Investigation Finding
Urinalysis No abnormality
Biochemistry Na
Haematology Haemoglobin 12.3 g/dl
Arterial blood gas pH 7.21
+
139 mmol/l
+
K
4.6 mmol/l
Creatinine 112 mmol/l
Glucose 6.1 mmol/l
Amylase 2000 IU/l
White cell count 27,000
Platelets 235,000
pCO
3.2 kPa
2
pO
9.4 kPa
2
–
HCO
17 mmol/l
3
Base excess –8
Question 2
What are the most common causes of AMI?
A. Renal failure.
B. Atrial fibrillation.
C. Multi-organ failure.
D. Anti-phospholipid syndrome.
E. Atherosclerotic disease
Question 3
Which of the following tests are of use in the acute management of a patient with
AMI?
A. Echocardiography.
B. Lateral-view mesenteric angiography.
C. Thyroid function tests (TFTs).
D. Non-contrast computed tomography (CT) scanning.
E. Mesenteric vessel duplex Doppler.
At this point, the patient was taken to the high-dependency unit, where the following measures were undertaken: high-flow oxygen therapy by mask (15 l/min),
continuous ECG monitoring, central venous pressure (CVP) monitoring, urinary
catheter inserted to monitor urinary flow hourly, and infusion of 4 litres of fluid
resuscitation. Intravenous broad-spectrum antibiotics and an anticoagulant dose of
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