Distal Superior Mesenteric Artery Endarterectomy Remains Excellent Option for Mesenteric Revascularization in the Endovascular Era.

Abstract: Background Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy, has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be employed. Herein we present two cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. Case Reports Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status post placement of a proximal SMA stent, and was transferred to our institution due to concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up and radiographic imaging at 2-months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with post-prandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with stent was not successful due to flush occlusion of the SMA approximately one centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The post-operative course was uneventful and at 1-month follow up, she reported continued improvement in pain and appetite. Conclusion SMA endarterectomy can be successfully performed on mid- to distal-lesions of the SMA. This operation should remain a viable option in the management of CMI.