title: Emergency revascularisation in a patient with acute mesenteric ischaemia: the role of open revascularisation and compensatory blood flow.
abstract: OBJECTIVE
  This case highlights the importance of timely diagnosis and management of acute mesenteric ischaemia and illustrates the compensatory mechanisms of the mesenteric vasculature.
  
  
  METHODS
  A 53-year-old female presented with fever, abdominal pain, and vomiting. The patient had no risk factors for atherosclerosis and was a non-smoker in sinus rhythm with no history of coagulopathy. She was initially treated for viral gastroenteritis. Due to lack of clinical improvement and a rising C-Reactive Protein (416), a CT scan was performed. This demonstrated small bowel ischaemia, chronic occlusion of the coeliac axis, and a long acute-on-chronic occlusion of the superior mesenteric artery (SMA). The length and morphology of the SMA occlusion precluded endovascular treatment. Emergency laparotomy demonstrated 1 m of necrotic small bowel and a pulseless mesentery. An aorto-SMA bypass, using good-quality long saphenous vein was performed, with segmental small bowel resection. Postoperative nutritional support was required with discharge on the 23rd post-operative day. Interval surveillance confirmed graft patency. One year post-discharge, she presented to routine clinic with paroxysmal right iliac fossa pain and decreased appetite. CT angiography showed a long tight 75% stenosis of the graft and she was admitted for mesenteric angioplasty. Angiography confirmed a significantly hypertrophied inferior mesenteric artery, which was now the dominant mesenteric supply.
  
  
  CONCLUSIONS
  This case demonstrates the importance of emergency mesenteric revascularisation and how it acts as a bridge to anatomical compensation, allowing the collateral circulation to develop and the IMA to hypertrophy, becoming the dominant mesenteric supply.
authors.affiliation: a Department of Vascular Surgery , University Hospital Southampton NHS Foundation Trust , Southampton , UK.
authors.forename: Abigail H M
authors.initials: AH
authors.lastname: Morbi
authors.affiliation: a Department of Vascular Surgery , University Hospital Southampton NHS Foundation Trust , Southampton , UK.
authors.forename: Ian M
authors.initials: IM
authors.lastname: Nordon
mesh_terms: D000006:Abdomen, Acute / Q000175:diagnosis / Q000209:etiology; D000792:Angiography / Q000379:methods; D017130:Angioplasty / Q000379:methods; D003097:Collateral Circulation / Q000502:physiology; D003131:Combined Modality Therapy; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D065666:Mesenteric Ischemia / Q000175:diagnosis* / Q000601:surgery*; D008875:Middle Aged; D018570:Risk Assessment; D012720:Severity of Illness Index; D013152:Splanchnic Circulation / Q000502:physiology*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*
keywords: Collateral circulation; mesenteric arteries; mesenteric circulation; mesenteric ischemia