Grafto-mesenterial steal syndrome developing after aorto-bifemoral bypass causing ischaemic intestinal – and reperfusion syndrome

Introduction: abdominal discomfort caused by mesenterial steal is a long known disorder. Up until now grafto-mesenterial steal syndrome following vascular reconstructions was unknown to us in our own practice.

Case report: the admission of a 65 year old woman was commented by a 50 m claudication. Hypertension and diabetes mellitus was in her medical history, and previously she had no abdominal complaints. DSA verified bilateral iliac occlusion and a moderate aortic bifurcation stenosis. An aorto-bifemoral Gelsoft bypass was implanted, with the preservation of the inferior mesenteric artery (IMA). On the 3-rd postoperative day, nausea, vomiting, meteorism, severe diffuse abdominal pain developed. Assuming mesenterial ischemia relaparotomy was performed. During the operation we found the acute ischemia of the right large- and total small intestine, but didn't find perforation. Exploring the superior mesenteric artery (SMA) we found the subtotal occlusion of the artery, but could not find thrombosis in the vessel even after several attempts with a Fogarty catheter. We did a thrombendarteriectomy, after which a good pulse could be palpated, even above the distal part of the artery. A day later – despite intensive care – the patient developed cardiac insufficiency and died. The autopsy found suffusions on the serosal side of the small intestines, and ulcers on the proximal part of the large intestine and the stomach. The proximal part of the celiac trunk and SMA were narrowed by plaques, but the distal part of the SMA, including the part where the TEA was performed was open, without any sign of thrombosis. No sign of ischemia or perforation along the small intestine was found. The cause of death was acute cardiac insufficiency, which was contributed by the reperfusion-syndrome of the intestinal tract.

Conclusion: the improved circulation in the lower extremities due to the vascular reconstruction significantly reduced the perfusion in the proximal part of the celiac trunk and the SMA. This was associated by the distension, caused by the lack of peristalsis, which induced the microcirculation disorder in the wall of the intestines, leading to acute ischemia.