A case of a common iliac-mesenteric bypass for chronic mesenteric ischemia with coral reef aorta after common iliac endarterectomy.

Chronic mesenteric ischemia is a clinical diagnosis characterized by weight loss, food fear, and postprandial pain. Although retrograde mesenteric bypass is a commonly described technique in the literature, an end-to-end anastomosis directly from the common iliac artery (CIA) concurrent with iliac endarterectomy has not been frequently performed. Combined endarterectomy and bypass approaches have been proved to be durable in regard to patency rates and freedom from restenosis. We have described the case of a 75-year-old woman who had presented with a 15-lb weight loss, postprandial abdominal pain, and food fear. Additionally, she complained of claudication in her right lower extremity, with an ankle brachial index of 0.50. Multiphase computed tomography angiography demonstrated chronic occlusion of the origins of all three mesenteric arteries, confirming the diagnosis (A). Imaging also revealed a coral reef aorta and right common, external, and internal iliac artery occlusion. Her mesenteric symptoms were addressed first. We proceeded with open repair using a transverse abdominal incision. No options for aortic clamping were available owing to significant calcific disease. The distal aorta was exposed, and the left CIA was clamped. The right CIA was transected, and circumferential endarterectomy was performed to address inflow. An end-to-end anastomosis was created between the right CIA and a bifurcated Hemashield Gold knitted Microvel double velour 12 × 6-mm graft (Gentinge, Göteborg, Sweden). The distal anastomosis was performed in an end-to-end fashion to the superior mesenteric artery and the celiac artery (B/Cover). The celiac limb was tunneled in retropancreatic fashion. The postoperative course was uneventful. Multiphase computed tomography angiography obtained at 3 months demonstrated good patency of the bypass (C). The patient experienced resolution of her mesenteric symptoms and gained 15 lb. To address her initial claudication, she underwent femorofemoral bypass with a polytetrafluoroethylene graft 3 months later. Her ankle brachial index had improved to 0.86. The patient provided written informed consent for the report of her case details and imaging studies.