CONTROVERSIES

30. What is celiac compression syndrome (Dunbar’s syndrome)?

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Celiac compression is a rare and controversial disorder most commonly described in women (female-to-male ratio = 4:1) between the ages of 20 and 50 years. Patients appear to suffer from chronic mesenteric ischemia without angiographic evidence of atherosclerotic disease. The mechanical compression is believed to be caused by the left crus of the diaphragm (i.e., marginal arcuate ligament), and diagnosis occasionally is confirmed by demonstrating transient celiac compression during expiration. The associated pain is the result of a complicated and still heavily debated redirection of flow (foregut steal) away from the SMA. Effective treatment has required not only release of the compression but also bypass to improve the likelihood of pain resolution.

31. Which is the preferred treatment for chronic mesenteric ischemia, antegrade or retrograde visceral artery bypass? Is it necessary to reconstruct more than one mesenteric vessel?

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As they apply to intestinal bypass, the terms antegrade and retrograde refer to the origin of the graft from the aorta as either proximal to the celiac axis or distal to the SMA, respectively. The stated advantages of antegrade bypass are less kinking of the graft and possibly better blood flow characteristics. The disadvantages are that supraceliac exposure is technically more difficult and clamping may result in renal or spinal cord ischemia. Retrograde bypass grafts are more difficult to position to avoid kinking.
Recent series suggest that the results for single- or multiple-vessel reconstruction in either antegrade or retrograde fashion are excellent, with symptom-free survival rates > 90% at 5 years.

32. What is the role of percutaneous transluminal angioplasty (PTA) in chronic mesenteric ischemia?

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The endovascular treatment of chronic mesenteric ischemia is a relatively new technique. The obvious avoidance of surgery is an important advantage, but the rare complications of dissection and embolus can be devastating in arterial beds without adequate collaterals. Success rates approximate 70%; restenosis and recurrent symptoms are reported in 50% of patients. No prospective trials have compared PTA with arterial bypass; however, retrospective reviews suggest that initial results with either technique are similar with regard to morbidity, death, and recurrent stenosis. However, symptom recurrence rates are higher with PTA.

References
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BIBLIOGRAPHY
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