div epub:type=”chapter” role=”doc-chapter”>
17. Inferior Mesenteric Artery Reimplantation
Management of the Inferior Mesenteric Artery During Aortic Aneurysm Replacement
When the aortic aneurysm sac is opened, the orifice of the inferior mesenteric artery should be inspected. If pulsatile backbleeding is noted, it is usually safe to oversew the origin of the inferior mesenteric artery. The orifice is suture ligated from within the aneurysmal lumen to avoid injury to its branches, especially at the junction of the left colic to the sigmoidal and superior rectal branches.
If the backbleeding from the inferior mesenteric artery is poor, the orifice is occluded by a Fogarty catheter . Alternatively, the inferior mesenteric artery may be carefully dissected and controlled close to its origin by a vessel loop. After completing the distal part of the aortic reconstruction and reestablishing distal flow, the backbleeding from the inferior mesenteric artery (IMA) is reassessed. If the backbleeding is brisk and pulsatile, the IMA is ligated from within. Occasionally, the backbleeding may not be impressive due to the presence of an orificial atherosclerotic plaque and will improve following endarterectomy of the origin of the IMA. If the backbleeding from a patent IMA is still weak even after completing the aortic reconstruction, reimplantation of the IMA may be necessary. If the backbleeding from the IMA is questionable, back pressure measurements can help determine the need for IMA reimplantation. IMA back pressure can be measured by inserting a blunt tip needle through the IMA orifice; a vessel loop is pulled around the needle to prevent bleeding around the needle. Reimplantation of the IMA is considered if the back pressure is less than 35 mmHg.
Other reasons for reimplanting the IMA include inability to perfuse at least one internal iliac artery, previous colonic resection that may have interrupted the collaterals between the left colic artery and the middle colic artery, and a widely patent IMA as seen by angiogram, with stenotic pathology in the superior mesenteric artery.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
