Clinical Guidelines for Right Iliac Artery to Right Mesenteric Artery Bypass with PTFE Graft
For right iliac artery to right mesenteric artery bypass, PTFE graft is an acceptable conduit when autogenous vein is unavailable, though autogenous vein remains the preferred conduit for mesenteric revascularization. 1
Indications
- Mesenteric ischemia requiring revascularization when other options are not feasible 1
- Patients with extensive aortoiliac disease who are not candidates for aortobifemoral bypass 1
- Acute or chronic mesenteric ischemia with hemodynamically significant stenosis or occlusion of the superior mesenteric artery 1
Preoperative Assessment
- Confirm hemodynamic significance of mesenteric artery stenosis with imaging and/or pressure gradient measurements 1, 2
- Assess outflow vessels as poor tibial runoff can decrease durability of intervention 2
- Evaluate bilateral arm blood pressures, duplex ultrasound flow assessments, and/or imaging of the aortic arch and great vessels if considering alternative bypass options 1
Graft Selection
- Autogenous vein is the preferred conduit for mesenteric revascularization when available 1
- PTFE is an acceptable alternative when autogenous vein is unavailable 1
- For PTFE grafts, allow 3-6 weeks for healing and incorporation into local tissues before cannulation (if needed) 1
Technical Considerations
- The most distal artery with continuous flow from above and without significant stenosis (>20%) should be used as the point of origin for bypass 1
- The iliac artery can serve as an appropriate inflow source when the aorta is not suitable 1
- Direct tunneling of the graft under the mesentery helps avoid kinking concerns 3
- For retrograde bypass from iliac artery to SMA, the graft should be tunneled through the base of small bowel mesentery to create a direct course 3
Postoperative Management
- Allow 14 days minimum before cannulation of PTFE grafts, though 3-6 weeks is ideal 1
- Monitor for potential complications including mesenteric ischemia, graft thrombosis, and infection 1
- Appropriate antiplatelet therapy should be administered post-procedure 2
Expected Outcomes
- Five-year patency rates for iliac-based bypass grafts range from 79-92% depending on technique and target vessel 1, 4
- Single-vessel bypass to the superior mesenteric artery alone can be effective and durable for treatment of intestinal ischemia 4
- Retrograde bypass from iliac artery may have shorter operative time compared to antegrade bypass techniques 3
Potential Complications
- Graft thrombosis (higher risk with retrograde versus prograde bypass) 5
- Mesenteric ischemia or bowel infarction if graft fails 5
- Mortality rates of approximately 3% for chronic ischemia and 12-22% for acute ischemia 4, 5
Special Considerations
- Female gender and hormone replacement therapy have been reported to decrease patency of iliac-based stents and may potentially affect graft patency 1
- Consider complete revascularization of both SMA and celiac artery when feasible to reduce risk of late bowel ischemia 5
- For patients with both inflow and outflow disease, inflow problems must be corrected first 1