Non-occlusive mesenteric ischemia after staged revascularization of visceral trunks and lower extremities in patient with leriche syndrome

Chronic mesenteric ischemia (CMI) is a pathology with high morbidity and mortality rates, as it is usually associated with severe systemic arteriosclerosis.

CMI usually produces post-prandial abdominal pain, sometimes associated with nausea, vomiting and diarrhea, leading to food aversion and weight loss.

Clinical disorders usually appear if at least two of the three aortic visceral arteries are involved, and the cause is atherosclerosis in 90% of the cases. Non-occlusive mesenteric ischemia is a type of acute mesenteric ischemia that frequently occurs in the postoperative period of major surgery or as a complication in critical patients.

We present the case of a female patient with chronic mesenteric ischemia and critical ischemia of the lower limbs due to Leriche Syndrome in which two-staged revascularization was performed.

Case report

The authors present the case of a 55-year-old woman who smoked (1.5 paq/day), with a history of HTA and severe malnutrition, who was referred to the vascular clinic of Hospital de León (León, Spain) due to intestinal angor and disabling intermittent claudication of lower limbs with resting pain and occasional paresthesias. Upon physical examination, the patient had a diffuse epigastric pain radiated to both flanks and absence of pulses at all levels in the lower limbs. The blood count showed leukocytosis with biochemistry with data of severe malnutrition.

Screening of hidden neoplasia was performed. Preoperative angioTC and aortoarteriography were performed with the finding of atheromatosis and severe calcification in the descending and abdominal aorta, in addition to critical stenosis of the celiac trunk (CT), superior mesenteric artery occlusion (SMA) of more than 5 cm in length and complete obstruction of both iliac axes.

A percutaneous revascularization of the celiac trunk was performed at a first time, with the aim of improving the general and nutritional status of the patient. Two expandable balloon stents (Biotronik 6×12 and 6×15 mm) by left humeral access were placed. The nutritional status of the patient improved and after 6 months a Body Mass Index (BMI) above 18 was reached.

In the postoperative period, she started to suffer arterial hypotension, progressive metabolic acidosis and elevation of acute phase reactants. 48 hours later, a CT scan was performed, checking the permeability of the bypass, and a new laparotomy was performed to review intestinal loops, evidencing hypotony of the bowel with small areas of patched cyanosis, without areas of necrosis.

Treatment with fluid therapy and vasodilators was established, limiting the amines. The subsequent evolution was good, with clinical and analytical improvement. The patient started a liquid diet, which did not tolerate. Nutritionist decided to establish parenteral nutrition to maintain digestive rest. 14 days later, she started to have leukocytosis and intermittent fever with metabolic acidosis.

Another AngioTC was performed, where the bypasses were seen to be permeable and there was an image compatible with digestive abscess / perforation (Fig. 3). An urgent laparotomy was performed, which showed complete necrosis of the small intestine and colon, with large perforation. The patient died few hours later.



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