Interventions for mesenteric vasculitis

Article Outline

• Abstract
• Methods
• Results
  • Patient population
  • Clinical presentation and diagnosis
  • Distribution of vascular lesions
  • Pathology
  • Medical treatment
  • Mesenteric revascularization
  • Early outcomes
  • Late outcomes
  • Comparisons with atherosclerotic disease
• Discussion
• Conclusions
• Author contributions
• Acknowledgment
• Appendix (online only). 
• References
• Copyright

Objective

This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV).

Methods

We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease.

Results

There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9).

Conclusion

Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.

Primary vasculitis is a rare disease characterized by inflammation of the vessel wall.¹ Chronic inflammation can weaken the media and thin the arterial wall causing an aneurysm, or it can cause arterial wall thickening leading to stenoses and occlusions.² The spectrum of vasculitis is broad and may affect small-, medium-, or large-sized vessels in different territories. Patients are often asymptomatic, and mesenteric arteritis is found incidentally as part of an evaluation for other systemic, renal, and cerebrovascular symptoms.³

Most patients with chronic mesenteric ischemia have ostial atherosclerotic lesions affecting at least two of the three mesenteric arteries. Mesenteric vasculitis accounts for <5% of all cases of mesenteric ischemia, but the diagnosis should be entertained in young patients without other stigmata (eg, calcifications, atherosclerotic debris) of atherosclerotic disease. Medical therapy is the first-line treatment for vasculitis, but there is no consensus on the indications, timing, and outcomes of revascularization.

The purpose of this study was to review the clinical presentation, indications, and results of open and endovascular revascularization for occlusive mesenteric vasculitis. In addition, the late outcomes of open revascularizations performed for mesenteric vasculitis were compared with the results of open mesenteric reconstructions performed for chronic atherosclerotic mesenteric ischemia.

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Methods 

In this study, which was approved by the Mayo Foundation Institutional Review Board, we used the Mayo Clinic database and vascular surgery registry to identify all consecutive patients diagnosed with vasculitis who underwent mesenteric revascularization between January 1, 1984, and June 31, 2008. Patients who underwent revascularization for mesenteric arterial stenoses or occlusions caused by vasculitis were included in the study. Patients had symptoms of mesenteric ischemia or were asymptomatic but had mesenteric revascularization as part of other aortic-based procedures performed for renovascular hypertension or midaortic syndrome. All patients treated for asymptomatic lesions had vasculitis involving the paravisceral aorta, mesenteric, and renal arteries. We excluded patients treated for aneurysms, mucosal lesions, and those with gastrointestinal bleeding without evidence of mesenteric ischemia or mesenteric occlusive lesions.

The diagnosis of vasculitis was established by the clinical or pathologic criteria recommended by the American Rheumatology Association and Chapel Hill Consensus Conference in 1994.⁴ Vasculitides were distinguished according to the size of the vessel involved and then subclassified according to the particular features of the specific vasculitis; for example, Takayasu vasculitis affects large vessels in patients aged <50 years. Specific features may include site involvement, patient age, type of inflammation, pathologic features of the inflammation or specific deposits, and markers that are available on staining or serology.

In addition, all cases were reviewed individually to establish the diagnosis of occlusive mesenteric vasculitis, defined by the presence of one or more high-grade (>70%) mesenteric artery stenoses or occlusions, typically long, smooth tapered lesions with arterial wall thickening in the absence of stigmata of atherosclerosis (calcification or atherosclerotic debris), and pathologic or operative inflammatory changes consistent with vasculitis.

Active disease was defined by two or more of the following: pathologic, operative, laboratory, or clinical criteria. These included systemic symptoms such as fevers (>38°C), myalgias, arthralgias; active inflammation on a pathologic specimen taken from the diseased artery; elevated erythrocyte sedimentation rate (normal range, 0-29 mm/h) or C-reactive protein (normal CRP ≤0.8 mg/dl); or acute inflammation of the artery and surrounding soft tissue at the time of the operation.

Medical management was the initial therapy except if acute symptoms mandated operative intervention. Daily prednisone was given at a dose of 40 to 60 mg for 4 to 6 weeks and tapered by 10% per week thereafter according to clinical response. Other medications, such as cyclophosphamide or methotrexate, were added in such patients who clinically did not respond to prednisone. Interventions were reserved for patients with persistent symptoms when medical therapy failed.

Demographics, cardiovascular risk factors, clinical presentation, operative data, and details of complications were collected from patient records. Pathology specimens were reviewed whenever possible. End points were early mortality and morbidity, patient survival, freedom from mesenteric symptoms, and vessel or graft patency. Perioperative was defined as occurring in the hospital or ≤30 days after the operation. Late follow-up data were obtained from medical records, office visits, correspondence with referring physicians, and telephone interviews.

Late outcome data for survival, freedom from mesenteric symptoms, and patency in patients who underwent open revascularization for mesenteric vasculitis were compared with the results of a cohort of 163 patients who had had similar operations for chronic atherosclerotic mesenteric ischemia since 1990. Late survival of vasculitis patients was also compared with age- and gender-matched controls from the State of Minnesota. Patient survival, freedom from mesenteric symptoms, and graft patency were analyzed using the Kaplan-Meier method. Data were presented as median values or mean ± standard deviation, as appropriate. A value of P < .05 was significant.

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Results 

Patient population 

Of 7514 patients evaluated for vasculitis during the 24 years of the study, 120 had symptoms of mesenteric ischemia. During the same time, 323 patients required open or endovascular mesenteric revascularization for mesenteric ischemia and only 15 (4%) had open or endovascular treatment for occlusive mesenteric vasculitis. There were 13 female and 2 male patients with mean age of 38 ± 17 years.

Clinical presentation and diagnosis 

Arteritis was categorized as Takayasu arteritis in 7 patients, polyarteritis nodosa in 4, indeterminate arteritis in 3, and giant cell arteritis in 1. Nine patients (60%) presented with chronic (n = 8) or acute (n = 1) symptoms of mesenteric ischemia. Seven of these 9 patients (80%) had abdominal pain, which was postprandial in four. Nausea and vomiting or weight loss was present in five patients each. The average duration of symptoms before revascularization was 22 months (range, 2-36 months). In six patients (40%) with asymptomatic high-grade mesenteric artery stenoses or occlusions, revascularization was part of combined aortic reconstructions for vasculitic involvement of the paravisceral aorta and renal arteries (Table I).

Table I. A, Demographics, cardiovascular risk factors, and extent of disease in patients treated with open revascularization for occlusive mesenteric vasculitis and atherosclerosis

GCA, Giant cell arteritis; HA, headache; HTN, hypertension; IMA, inferior mesenteric artery; IN, indeterminate; Minimal, <50%; Moderate, 50%-75%; PAN, polyarteritis nodosa; Severe, >75; SMA, superior mesenteric artery; TA, Takayasu's arteritis.

Vasculitis was active in eight patients and in remission in seven. The patients with active disease had arthralgias, headaches, night sweats and fevers, or peripheral weakness. Erythrocyte sedimentation rate was elevated in 8 patients (mean, 30 mm/h; range 3-110 mm/h) and C reactive protein in 1 (mean, 4 mg/L; range, 0.3-23 mg/L). Cardiovascular risk factors included hypertension in 9, cigarette smoking in 7, hyperlipidemia in 3, peripheral arterial disease in 3, and diabetes in 1.

Distribution of vascular lesions 

Fifteen patients had 29 diagnostic imaging studies, including computed tomography (CT) in 11, biplane aortography with or without selective mesenteric angiography in 9, magnetic resonance imaging (MRI) in 6, and duplex ultrasound imaging in 3. The lesions were long and tapered (Fig 1). A total of 70 vascular lesions were identified: 28 mesenteric and 42 extramesenteric. Mesenteric lesions affected the celiac axis in 13 patients, the superior mesenteric artery (SMA) in 13, and the inferior mesenteric artery (IMA) in two. Of the 42 extramesenteric lesions, 19 involved the axillary-subclavian arteries, 16 the renal arteries, 5 the aorta, and 2 the vertebral arteries (Fig 2, online only).

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• Fig 1. 

  Imaging findings consistent with the diagnosis of mesenteric vasculitis. Computed tomography angiography shows (A) significant arterial wall thickening (arrowheads) and (B) a long, smooth tapered lesion (arrow). C, A lateral aortogram shows long smooth tapered lesions of the proximal celiac axis and superior mesenteric artery (arrows).

Pathology 

One renal arterial wall, four mesenteric, and seven aortic specimens from 10 patients were reviewed. Eight were obtained from the anastomotic sites rather than the diseased artery and showed no abnormalities. Ten samples were full-thickness, and two contained only intima and media. Four samples (3 aorta and 1 SMA) had chronic lymphoplasmacytic granulomatous patterns with giant cells (Fig 3, online only).

Medical treatment 

Twelve patients were treated medically, 10 at an average of 20 months preoperatively (range, 2-120 months) and the other two after the procedure. Eleven of the 12 received corticosteroids, 3 had multiple immunosuppressive medications, including azathioprine in 2, and cyclophosphamide in 1; and 1 patient each received cyclosporine or methotrexate (Table I). The three remaining patients had chronic disease and were not treated with an immunosuppressant.

Table I. B, Treatment and outcomes in patients treated with open revascularization for occlusive mesenteric vasculitis and atherosclerosis

AA, Abdominal aorta; Ao-CA-SMA, aortoceliac-SMA bypass; Ao-SMA, aorto-SMA bypass; Ao-SMA/Renals, aorto-SMA and b/l renals bypass; AZA, azathioprine; DC, discharge; IL-SMA, ileo-SMA bypass; GI, gastrointestinal PTA, percutaneous balloon angioplasty; SMA, superior mesenteric artery; SMV, superior mesenteric vein.

Mesenteric revascularization 

Procedures included open revascularization in 14 patients and percutaneous transluminal angioplasty (PTA) of the SMA in one. Overall, 22 mesenteric arteries were treated. The PTA was done as a therapeutic trial because of atypical symptoms and to assess symptom response because the patient had a short (<2-cm) focal stenosis of the SMA. The procedure was performed from the femoral approach with 6 mm × 2 cm angioplasty balloon using 0.035-inch system, with 40% residual stenosis. The mesenteric symptoms improved, so open revascularization was not needed.

Operations included reconstruction of the celiac and SMA in 5 patients, SMA only in 5, aortoplasty with concomitant SMA patch angioplasty in 3, and median arcuate ligament release with bovine pericardial patch angioplasty of the celiac axis in 1. Nine bypasses included four supraceliac single grafts, three supraceliac bifurcated grafts, and two grafts originated from the common iliac artery (Fig 4). The conduit was polyester in eight patients and reversed saphenous vein in one. One patient underwent thoracoabdominal repair with four-vessel reimplantation. Combined aortic reconstruction was required in four patients (3 aortoplasties and 1 graft) for three symptomatic stenoses and one paravisceral aneurysm. Seven patients needed 12 renal artery reconstructions (10 bypasses and 2 patch angioplasties) because of medically refractory renovascular hypertension caused by renal artery vasculitis. All patients underwent intraoperative ultrasound imaging at the end of the procedure or at dismissal.

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• Fig 4. 

  A, Open mesenteric revascularization for mesenteric vasculitis was with an iliac artery to superior mesenteric artery bypass or (B) a supraceliac aorta to superior mesenteric and bilateral renal artery bypass in a patient with concomitant bilateral renal artery stenoses and renovascular hypertension.

Early outcomes 

There were no early deaths, and no renal, cardiac, or pulmonary complications were documented. The average hospital length of stay was 13 days (range, 1-45 days). Gastrointestinal bleeding, ileus requiring re-exploration, and superior mesenteric vein (SMV) thrombosis occurred in one patient each. The patient with SMV thrombosis did not have thrombophilia but was treated with anticoagulation. In the subset of patients who had concomitant renal reconstructions, mean preoperative and postoperative creatinine levels were 0.9 ± 0.4 and 0.8 ± 0.4 mg/dL, respectively. The nine symptomatic patients improved immediately after treatment, and patent mesenteric arteries at dismissal were verified in all patients by ultrasound imaging or CT.

Late outcomes 

There were no late deaths after a mean follow-up of 41 months (median, 22 months; range, 7-120 months). All patients reported symptom improvement at their last follow-up. In the seven patients who had renal revascularization, the average of three outpatient blood pressure measurements decreased from 162 ± 42/87 ± 10 mm Hg preoperatively to 119 ± 19/67 ± 7 mm Hg postoperatively (P < .01).

Fourteen patients (93%) remained asymptomatic. Thrombosis of the celiac limb and high-grade stenosis of the SMA limb at 74 months caused subacute symptoms in the other patient with an aorta-celiac and SMA bypass. This was treated with patch angioplasty of the SMA graft, which was patent 9 months later. There were no additional restenoses or occlusions in patients with arterial imaging. Duplex ultrasound imaging at 40 months showed a patent artery in the patient treated with SMA angioplasty.

Comparisons with atherosclerotic disease 

The clinical data and late results of the 14 patients with mesenteric vasculitis who underwent operations were compared with the outcomes of 163 patients with 287 arteries reconstructed for chronic atherosclerotic mesenteric ischemia. These reconstructions included the celiac and SMA in 109 patients (76%) and a single SMA reconstruction in 53 (24%).

Patients with vasculitis were 3 decades younger (mean, 38 vs 65 years old; P < .01) and had significantly fewer cardiovascular risk factors (P < .05), including less hypertension (53% vs 77%), hyperlipidemia (20% vs 51%), and tobacco use (37% vs 76%).

Primary graft patency at 5- and 10-years was 83% in the vasculitis group and 92% and 84% in the atherosclerotic group (P = .68; Fig 5). Freedom from mesenteric symptoms at 10 years was 83% for patients with vasculitis and 75% for those with atherosclerotic disease (P = .68; Fig 6).

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• Fig 5. 

  Primary graft patency is shown in patients treated with open revascularization for mesenteric vasculitis (MV)) and for atherosclerotic (ASO) disease.

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• Fig 6. 

  Freedom from mesenteric symptoms in the patients treated for mesenteric vasculitis (MV) vs atherosclerosis (ASO).

Cumulative survival estimate at 10 years was 100% in the vasculitis group (SE > 0, Fig 7, online only), similar to the 98% expected survival of age- and gender-matched controls from the State of Minnesota (P = .69). However, 10-year survival in patients with atherosclerosis was markedly decreased at 45% (P < .0001, Fig 7, online only).

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Discussion 

The incidence of vasculitis is low, affecting 20 individuals per million each year.¹ Involvement of the mesenteric arteries is noted in up to 50% of patients diagnosed with vasculitis, but only 16% have isolated mesenteric arterial involvement.⁵ The disorders most commonly implicated are Takayasu arteritis due to aortic involvement proximal to or at the ostia of the mesenteric arteries, giant cell arteritis, and polyarteritis nodosa, which typically presents with multiple aneurysms. However, Wegener granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and other small-vessel arteriopathies also may affect the mesenteric circulation.⁶ Most patients are asymptomatic, and mesenteric involvement is discovered because of systemic, cerebrovascular, or renal manifestations of the disease, as occurred in one-third of our patients. Symptoms of acute or chronic mesenteric ischemia are rare. Most symptomatic patients present with bleeding from gastrointestinal mucosal erosions or from small aneurysms of the distal mesenteric or hepatic artery branches.²

Because vasculitis is primarily an inflammatory process, corticosteroids alone or combined with other immunosuppressants are the basis of medical therapy. Our medical regimen is based on previous work published from our institution,⁷, ⁸ which includes a daily dose of 40 to 60 mg of prednisone, which we prefer over a lower dose or alternate day corticosteroid therapy, and aspirin.⁸ Prednisone is maintained at this dosage for approximately 4 to 6 weeks, after which it is tapered by 10% every 2 to 4 weeks, depending on absence of symptoms and levels of inflammatory markers. The addition of an antimetabolitic or steroid-sparing agent may allow reduction of the prednisone dose, although these medications are reserved for patients without an initial response to prednisone.⁷, ⁸ Although medical treatment effectively resolved mesenteric symptoms in >87% of our patients, the indications, timing, approach and outcomes of mesenteric revascularization, when needed, have been poorly described. We reserve operation for failure of medical therapy in the acute or chronic setting, or because of severe side effects from the immunosuppressive medications.

Similar to our experience with the management of occlusive lesions from Takayasu arteritis, we prefer open arterial reconstruction in most patients with vasculitis, independent of vascular territory.⁹ We have learned that the best surgical results are seen in patients who are operated on when the arteritis is quiescent, and preferably when they are no longer taking steroids.

Our operative approach to patients with mesenteric vasculitis has evolved over the years. Before 1990, we prophylactically reconstructed a mesenteric artery if it was severely stenotic, even when the primary indication for operation was abdominal aortic coarctation, aneurysm, or renovascular hypertension. This was most often done because reoperation to revascularize a visceral artery would have been difficult, a view shared by Stanley et al.¹⁰ Currently, mesenteric revascularization is done for symptomatic patients and selectively for those who effectively have three-vessel involvements, either with mesenteric trunk disease or aortic coarctation involving the origins of all three arteries.

There are no guidelines for how to approach open mesenteric reconstruction in patients with vasculitis. The general principal is for the inflow and outflow anastomoses to be done to noninflamed arteries. Similar to the patients with atherosclerotic mesenteric disease, we favor an antegrade bypass from the supraceliac aorta, whenever possible. Both the celiac and SMA are reconstructed with a bifurcated graft, because we believe that late failure of one graft doesn't necessarily result in recurrent symptoms.¹¹, ¹² If the patient is older and has cardiac disease or a calcified non-stenotic aorta, we prefer a retrograde iliomesenteric bypass with a straight or C-shaped configuration, as was needed in two of our patients.¹¹, ¹² Finally, although concomitant aortic and renal reconstructions are avoided in most patients treated for atherosclerotic chronic mesenteric ischemia because of the high mortality and morbidity, these vasculitic patients may need them. Seven of the 15 patients (47%) with mesenteric vasculitis also had refractory hypertension and required bypass of the renal arteries, and four (27%) had asymptomatic but preocclusive mesenteric lesions, which were bypassed in conjunction with aortic and renal reconstructions.

Aortic reconstruction may be required for aneurysm (rare) or suprarenal coarctation. Although we use aortoplasty for patients with developmental coarctation when the lumen permits, as Stanley espouses, aortoaortic bypass is required as an inflow source for those with periaortic inflammation and small lumens.¹⁰ These latter patients often have symptomatic renal artery stenosis.

A literature search using the Medline database from 1965 to 2008 found 16 reports of open or endovascular revascularizations for mesenteric vasculitis in 32 patients.⁹, ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷ Table II summarizes the demographics, diagnoses, and outcomes these patients, who were treated with 20 open surgical and 12 endovascular procedures. Most patients were young women. Similar to our findings, the three most common diagnoses were Takayasu arteritis, giant cell arteritis, and polyarteritis nodosa. Most patients had mesenteric ischemia, which improved after reconstruction. Follow-up was <1 year in all but one report or was not reported beyond the hospital dismissal. No patients died, although two of the 20 patients treated with open revascularization required reoperation for early graft thrombosis or late restenosis. Among the 12 patients treated with PTA, one patient with recurrent mesenteric ischemia at 3 months was retreated with another angioplasty. However, no conclusions can be reached about the role of endovascular therapy because of the short follow-up in the 12 patients.

Table II. Summary of clinical reports dealing with open and endovascular revascularization for mesenteric vasculitis

First author (Year)	Vasculitis Type	No.	Mean age	Gender (M/F)	Type of revascularization		Outcome
					Open	Endo
Tyagi (1993)23	TA	1	21	0/1		SMA PTA	6 mon, pain-free
Kempczinski (1993)14	TA	1	38	0/1	Ao-CA-SMA		6 mon, symptom-free
Hodgins (1984)15	TA,2	2	34	0/1		SMA PTA	Recurrent abdominal pain in 3 mon, redilation, symptom-free 6 mon
			34	0/1	Ao-SMA		Occlusion of bypass in 3 yrs
Tyagi (1997)13	TA	1	21	0/1		SMA PTA	6 mon, symptom-free
Zhul (2006)16	TA	1	36	1/0	Ao-SMA		6 mon, symptom-free
Ozdil (1996)17	TA	1	49	0/1		SMA-CA PTAS	8 mon, symptom-free
Arguedas (2000)18	GCA	1	72	0/1	Il-SMA		DC from the hospital, symptomatic relief
Chubachi (1993)19	Behçet	1	37	1/0	Ao-SMA		3 mon, improvement in symptoms
Sujobert (2007)20	GCA,4	4	73		PTA and bypass		No follow-up
Scola (2008)21	GCA,2	2	72	0/2	Il-SMA	SMA PTA	Clinical improvement
Lacombe (2002)22	TA,3	3	20	1/2	Ao-SMA, 3		1 acute revision
Fields (2006)9	TA,5	5	29	1/4	Ao-SMA and Ao-CA		Clinical improvement
Min (2005)24a	TA	(25)2	37	3/22		PTAS	26% restenosis at mean 17-mon follow-up
Esato (1982)25	TA	1	36	0/1	Thromboendarterectomy		4 mon symptom-free
	TA						2 and 6 yrs symptom-free
Scott (1986)26b	TA	(6)2	17	5/1	Il-splenic, Il-SMA		Occlusion of SMA bypasses at 12 and 17 yrs
Kalangos (2006)27c		(10)4	13	5/5	Ao-R, SMA, HA; Il-SMA, Renal; Ao-renal, SMA	PTA

Ao-CA, Aortoceliac bypass; Il-SMA, ilio-SMA bypass; Ao-CA-SMA, aortoceliac-SMA bypass; Ao-SMA, aorto-SMA bypass; DC, discharge; GCA, giant cell arteritis; M/F, male and female ratio; PTA, percutaneous transluminal angioplasty; PTAS, percutaneous transluminal angioplasty and stenting; SMA, superior mesenteric artery; TA, Takayasu arteritis.

Only one of our patients was treated with angioplasty of an isolated, focal SMA lesion because of atypical symptoms, and that treatment was durable. Theoretically, preferential use of endovascular intervention in such patients faces some challenges:

First, the durability of mesenteric angioplasty in patients with atherosclerotic disease has not matched the results obtained with open surgical bypasses.²⁸ This becomes a major limitation for these younger patients with normal life expectancy.

Second, long, tubular vasculitic lesions are prone to recoil, which may lead to a poor technical result or early failure without long stents.

Third, angioplasty or stent placement contradicts the basic principle of avoiding the inflammatory bed, especially in patients with active disease, acute inflammation, or those with chronic disease still on steroids. This patient subset in Takayasu arteritis causes the highest level of restenosis and occlusion.⁹

Several study limitations deserve comment. Because the disease is rare, our study spanned >2 decades to collect 15 patients treated for a variety of vasculitides with different types of procedures. Substantial advances in diagnostic imaging, medical therapy, and revascularization techniques occurred during this time. The exact circumstances involved in the clinical decision making, such as choice of the medications and the timing, method, and the extent of reconstruction, are difficult to determine because of the retrospective design. Finally, follow-up imaging of mesenteric grafts was not uniformly available, which may underestimate restenoses rates.

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Conclusions 

Occlusive mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, giant cell, or other vasculitides. Involvement of other vascular territories is common. The choice of reconstruction depends on the associated aortic inflammation, but open surgical reconstructions are durable and effective when needed.

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Author contributions 

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We acknowledge Stephen Cha for statistical analysis and David Factor for the medical illustrations.

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Appendix (online only) 

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• Fig 2. (online only) 

  Distribution of mesenteric and extramesenteric lesions in patient with occlusive mesenteric vasculitis involving the celiac axis, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA).

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• Fig 3. (online only) 

  Histologic examination arterial wall biopsy obtained from the patient described in Fig 1 confirmed the diagnosis of giant cell arteritis, showing chronic lymphoplasmacytic vasculitis with patchy transmural inflammation and periadventitial fibrosis. A, Hematoxylin and eosin (H&E) stain at original magnification ×12.5. B, The arrow designates a multinucleated giant cell (H&E; original magnification ×200).

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• Fig 7. (online only) 

  Kaplan-Meyer survival curves of the patients treated for mesenteric vasculitis (MV) compared with Minnesota (MN) age- and gender-matched controls vs patients treated for atherosclerosis (ASO).

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