Mesenteric and Renal Revascularization
What is Revascularization?
Atherosclerosis, or the hardening of your vessels, can also occur in the arteries supplying your bowel and kidneys. This usually takes many years to become symptomatic in the cases of mesenteric (bowel) or renal (kidney) ischemia. The mechanism is simple: the narrowing of blood vessels inhibits adequate blood supply to the bowel or the kidneys to meet the organs demands.
For your GI tract, this produces intense pain especially after eating when the demand for blood by your intestines increases dramatically. It can also result in diarrhea, food avoidance, and severe weight loss. Unfortunately, many other disease processes can also cause this constellation of symptoms, and the diagnosis for mesenteric ischemia is often delayed and difficult.
Frequently, only after an extensive search for cancer is negative will the diagnosis of intestinal arterial insufficiency be suspected. In the case of renal ischemia, the end results, renal function deterioration and hypertension, are also caused by many other, more common, causes. Vascular cause of hypertension and renal insufficiency are difficult to diagnose and difficult to prove.
Who Needs Revascularization?
As stated above, the diagnosis of mesenteric and renal ischemia are both difficult, and often involve multiple trips to different specialists, and multiple different tests performed. If you think you may have either one of these disease processes, the best way to start is to engage your primary physician in a thorough discussion of the symptoms you are experiencing.
What is Involved before the Operation?
Mesenteric ischemia: frequently the weight loss and abdominal pain prompt a thorough search for a hidden cancer. Pancreatic cancer and pancreatitis, ulcer disease, stomach/colon/gallbladder cancer, hepatitis, liver cancer, as well as inflammatory bowel disease are all in the differential diagnosis. Extensive testing may be necessary, and may include CT scans and/or endoscopies. Once mesenteric ischemia is suspected, duplex ultrasound, MR angiography, or CT angiography, may be used to further strengthen the diagnosis and provide the pattern of vascular pathology.
Renal artery stenosis: Duplex ultrasound and MR angiography are most frequently used to support the diagnostic suspicion. CT angiogram involves the use of IV contrast which is toxic to the kidney. It is therefore not used as often in this setting. Nuclear medicine scans to assess your kidneys’ uptake and excretion functions before and after certain drug challenges may also be useful to establish a diagnosis.
Choices of Operation and Details of the Operation
Operations can be broadly broken down to two categories – endovascular or open surgery. Some cardiologists or radiologists may also offer to treat the disease with endovascular approach, but they are not able to perform open surgeries if the disease requires it, and will need to refer the patient out to a vascular surgeon to perform the surgery. At CVTSA, all of our vascular surgeons possess the skills to treat these lesions by both endovascular and open means.
This is done by accessing your arterial system via a needle through either the groin (femoral artery) or the elbow (brachial artery) areas, and using balloons and/or stents to dilate the area of arterial narrowing to restore blood flow. Usually this is done with only mild degrees of sedation and local injection of a numbing medication such as lidocaine.
All images are captured by an x-ray machine and displayed on a monitor. Having an implanted device such as a pacemaker, defibrillator, or joint replacement hardware may affect the quality of the picture captured, but is not a contraindication to the procedure.
Because the procedure does not involve the opening of a large body cavity and does not involve the use of general anesthesia, it poses relatively little challenge to your body and is well tolerated by most patients. However, the endovascular repair may not be as durable as open repair.
Occasionally the wire and balloon used may cause more damage to the artery being treated, and cause the patient to require an urgent open operative repair. Thus in a younger patient with a long life expectancy, and who is a low operative risk, open surgical revascularization may be the better choice.
On the other hand, if a patient has many other medical issues such as heart or lung diseases and is ill-suited for a large operation, we can also achieve satisfactory results with endovascular procedures.
Again, we will tailor our recommendations according to your particular medical history and your particular needs.
In the mesentery and renal arterial territory, an open surgical procedure may involve bypassing an area of stenosis/occlusion of the artery, using either a synthetic graft or a segment of your vein. In certain cases, your surgeon may elect to instead open up your artery, clean out the debris and plaque inside, and close the artery with a patch of synthetic material or vein. General anesthesia is used and you will be unconscious for the operation. Please ask your surgeon about the reasoning behind a particular choice/recommendation.
What can you Expect After Surgery?
Symptoms: You should notice a decrease in the abdominal pain associated with eating. This may not be initially noticeable because you will be focused on the pain from your incision, but should be evident by the time you see your surgeon at the 2-week post-operative follow-up. Initially you should take in frequent small meals, then slowly increase the amount of intake for each meal. You should expect to re-gain some of the weight you’ve lost. If diarrhea is a symptom before the operation, this should decrease as well.
Care for your incision: You can take off the bandages 2 days after the operation. You can go ahead and shower and get the wound wet after 48 hours, and pat the area dry afterwards. Do not soak the wound in a bath or in the swimming pool. Keep the wound out of sunlight to prevent darkening of the scar. You should avoid applying creams such as vitamin E creams or others, because they may cause some skin maceration. If you have skin staples after open revascularization, do not get the area wet until after the staples are removed.
Things to watch for and call your doctor about:
On the incision:
Call your doctor if you notice redness and swelling around the incision, or observe drainage from the incision. These are the basic signs of wound infection, but your doctor usually needs to look at the wound to make the determination. If you have a fever of greater than 100.5 degrees you should call your doctor.
Pain from your incision is to be expected. Incision pain generally is mild when you are resting, and increase in severity and sharpness with movement or activity. However, if your pain is dull, constant, severe, and unrelenting, you should present to your medical care provider as soon as possible.
In the immediate (1-2 weeks) period after your procedure, you may not have the best appetite. This is to be expected. If you are taking narcotic pain relievers, you may also experience nausea and/or vomiting, and very frequently, constipation that may be severe. However, if you vomit constantly and excessively and cannot keep down any fluids, or have unrelenting diarrhea, you should seek immediate medical attention.