Ultrasound-Guided Transmesenteric Retrograde Recanalization of Ostial Superior Mesenteric Artery Occlusion

BACKGROUND: Chronic mesenteric ischemia caused by superior mesenteric artery (SMA) occlusion is treated with endovascular or open revascularization. However, complete ostial SMA occlusion without a stump or collaterals poses significant technical challenges, particularly in high-risk patients. CASE SUMMARY: A 64-year-old woman with multiple autoimmune disorders presented with postprandial abdominal pain and occult gastrointestinal bleeding. Computed tomography angiography demonstrated complete ostial SMA occlusion without a residual stump and absence of the inferior mesenteric artery. Antegrade and collateral retrograde recanalization attempts failed. Modified retrograde open mesenteric stenting (ROMS) was performed via minilaparotomy with ultrasound-guided distal SMA puncture. The patient's symptoms resolved with weight gain and improved nutrition. Stent patency was maintained for 2 years; restenosis at 36 months was treated with drug-coated balloon angioplasty, with 4-year patency. DISCUSSION: This case highlights an invasive ROMS modification that may provide a salvage option for high-risk patients with complex SMA occlusion unsuitable for standard approaches. TAKE-HOME MESSAGE: Ultrasound-guided transmesenteric revascularization via minilaparotomy is a salvage option for patients with high-risk SMA ostial occlusion refractory to endovascular therapy and prohibitive risk profiles for conventional ROMS.