Background and Aims: For patients with superior mesenteric artery (SMA) occlusion, especially those with no obvious stump due to atherosclerotic occlusion of the orifice, retrograde open mesenteric stenting (ROMS) is an effective treatment method. However, the surgical trauma of this procedure is relatively large, so it may not be feasible in some patients with poor physical status. Here, the authors present a surgical technique of modified minimally invasive ROMS through reporting the treatment process for a case with total SMA occlusion, so as to provide a treatment option for some clinical situations.
Methods: The clinical data of a patient with total SMA occlusion treated in October 2019 in the Department of Vascular Surgery of Xiamen Branch, Zhongshan Hospital, Fudan University were reviewed. The patient was a 64-year-old woman, was diagnosed as chronic mesenteric ischemia caused by SMA occlusion, and then underwent hybrid procedures for SMA recanalization.
Results: The patient had a flush ostial SMA occlusion without stump, and also no collateral vessels connecting the celiac artery and splenic artery were observed, so either antegrade or retrograde total endovascular revascularization attempt failed. In addition, the patient was unlikely to tolerate an open revascularization procedure or the traditional ROMS due to poor general condition. Then, a mini-laparotomy was made and a pathway to the distal portion of the SMA was created by transmesenteric puncture under ultrasound guidance. A retrograde guidewire successfully passed the occlusion of the SMA and was advanced into the descending aorta. An antegrade catheter from the right brachial artery access was successfully passed the occlusion of the SMA after engaging with the retrograde guidewire. After that, balloon predilation and stenting were performed. The patient recovered uneventfully after operation, with total alleviation of symptoms. The follow-up CTA on 3 months after operation demonstrated undeformed shape and accurate position of the stent as well as excellent patency of the vessel. 
Conclusion: For patients with the SMA total occlusion and poor general condition following failed endovascular intervention, mini-laparotomy retrograde recanalization by transmesenteric puncture under ultrasound guidance is a feasible strategy.