Retrograde approaches are most often used. For retrograde bypasses, the proximal anastomosis can be placed on the right common iliac artery (most common), infrarenal aorta, or left common iliac artery and is performed in an end-to-side fashion. The distal anastomosis on the SMA can be performed in an end-to-side or end-to-end fashion. The graft is typically tunneled so that it forms a curve or “C loop” between the proximal and distal anastomosis as it traverses caudal to cephalad (Fig. 49.8).

may be required to achieve successful thrombolysis. Given these limitations, purely endovascular approaches may be used in select groups of patients. Percutaneous mechanical thrombectomy, aspiration thrombectomy, and intra-arterial thrombol­ysis, with or without adjuvant angioplasty and stenting, have been increasingly described in recent literature. To perform an endovascular revascularization, vas­cular access can be gained through a retrograde femoral approach or antegrade brachial approach. Once an introducer sheath is placed, a lateral and anteroposterior aortogram is performed to identify the origin of the CA and SMA. Next, systemic heparin is given and guidewire placed across the lesion. Once wire placement has crossed the lesion, the catheter is advanced and its position confirmed by angio­gram. Thrombectomy, aspiration, or balloon angioplasty can then be completed and a postangioplasty angiogram performed. If the completion angiogram demonstrates incomplete angioplasty, placement of mesenteric stent is warranted. Involvement of the orifice or proximal vessel should be treated with balloon-expandable stent (Fig. 49.10a–d). To reduce vasospasm, an intra-arterial infusion of nitroglycerine or papaverine can be used. Intra-arterial delivery of thrombolytic agents into the thrombus is another potentially useful treatment modality in acute thrombotic mesenteric ischemia.