Author: Castigliano Bhamidipati, DO, Kwame S. Amankwah, MD, Msc, Michael Costanza, MD, Vivian Gahtan, MD Author Affiliations: From the Department of Surgery, Division of Vascular Surgery and Endovascular Services, State University of New York, Upstate Medical University, Syracuse, New York. Correspondence: Kwame Amankwah, MD, Chief, Vascular and Interventional Radiology, VA Healthcare Network Upstate New York, Syracuse, NY 13210. Email: email@example.com. Manuscript submitted November 11, 2008, provisional acceptance given November 26, 2008, accepted December 4, 2008. Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein. ________________________________ Case A 48-year-old male with an extensive history of tobacco use, peripheral vascular disease, and previous myocardial infarction requiring a two-vessel coronary bypass presented with progressive claudication, post-parandial abdominal pain, and weight loss. A computed tomography angiogram of the aorta revealed significant celiac stenosis, occlusion of the origin of the superior mesenteric artery (SMA), and infrarenal aortic occlusion (Figure 1). Preoperative evaluation determined the patient to be an open surgical candidate with an intermediate cardiopulmonary risk. Therefore, no endovascular interventions were attempted. The patient underwent an aorto-bifemoral (AFB) bypass with retrograde revascularization of the celiac axis and SMA off of the ABF graft (Figures 2 and 3). The SMA was revascularized at the root of the mesentery while the celiac artery revascularization was retropancreatic to the common hepatic artery. Postoperatively, the patient did well with complete resolution of his symptoms. Discussion Chronic mesenteric ischemia (CMI) revascularization has been described in the literature using a variety of approaches and techniques. An 87% 3-year, symptom-free durability for the open surgical approach versus a 63% 3-year, symptom-free durability for the endovascular approach has been reported.1 Endovascular therapy has been associated with more frequent restenosis, requiring multiple subsequent interventions for improved primary-assisted patency.1,2,5 Historically, restenosis has been seen in 30–50% of the earlier endovascular cases. Advances in technique and technology have allowed for comparable primary patency rates to surgical revascularization. Low morbidity endovascular procedures remain a viable choice for those without an open surgical option.5 Comparative antegrade and retrograde revascularization of the mesenteric vessels has been described in the literature showing no difference in outcomes and patency.3,4 The inflow for antegrade bypass is usually the supraceliac aorta, though distal thoracic aorta use has also been attempted. The inflow for retrograde bypass is typically the iliac artery. Although long-term outcomes are pending, complex mesenteric revascularizations with newer hybrid techniques achieving satisfactory primary patency have been described. In complicated pathology, such as in our patient with an aortic occlusion, open retrograde mesenteric revascularization, along with concurrent inflow revascularization, was a viable consideration (Figure 3).5 Procedure selection should be commensurate with premorbid functional status, and although endovascular interventions portend the ability to intervene for refractory disease, it should be used judiciously.