Moquin KJ, Division of Plastic and Reconstructive Surgery, Duke University, DUMC, Box 3974, Durham, NC, USA, Darian VB, Division of Plastic Surgery, K-13, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, USA, Grzybowski M, Department of Emergency Medicine, Wayne State University, University Health Center - 6G, 4201 St. Antoine, Detroit, MI, USA, and Levin LS, Division of Plastic and Reconstructive Surgery, Duke University Medical Center, DUMC, Box 3974, Durham, NC, USA.
We confirmed the anatomic feasibility of using a pedicled deep inferior epigastric artery, with its attached rectus abdominis muscle, to revascularize the mesenteric circulation by studying three human cadavers (fresh and formalin-preserved) and two dog cadavers (fresh). We then evaluated the physiologic efficacy of the mesenteric revascularization in dogs. Using three large (>50lbs) female dogs as an animal model for acute mesenteric ischemia, we performed laparotomies and divided the deep inferior epigastric artery and rectus abdominis muscle caudally in each dog. The muscle was then transposed into the peritoneal cavity on its superiorly-based vascular pedicle. Under loupe magnification (4.5x), the deep inferior epigastric artery was then anastomosed to the middle colic artery in an end-to-side fashion. Intraoperative ultrasonic bloodflow measurements demonstrated flows of 365-370 mL/min in the superior mesenteric artery (SMA), 65-70 mL/min in the ileocolic artery, 25-30 mL/min in the middle colic artery, and 5-10 mL/min in the deep inferior epigastric artery bypass. Approximately two weeks later, a repeat laparotomy was performed and the SMA was ligated at its origin. Acute SMA ligation in dogs produces acute mesenteric ischemia and is normally lethal within 24 hours. However, the dogs survived between three days and five months. Angiography confirmed complete ligation of the SMA but did not demonstrate the epigastric artery bypass. This was likely due to equipment and technique limitations. No abdominal wall hernia or intestinal volvulus was present at autopsy. This pilot study demonstrates the anatomic feasibility in humans and physiologic efficacy in dogs, of a superiorly-based transperitoneal deep inferior epigastric artery bypass for mesenteric revascularization. Our results suggest that this bypass may prove to be a viable less invasive treatment option for chronic mesenteric ischemia, where minor supplemental blood flow may alleviate the clinical symptoms associated with enteral nutrition and prevent the need for extensive aorto-visceral bypass procedures.