Response to: reimplanting the superior mesenteric artery on the infra-renal aorta

We thank Manenti et al2 for their comments. Acute intestinal ischemia and intestinal resection associated with chronic, ostial stenosis/ occlusion of the superior mesenteric artery (SMA) represents a completely different clinical setting and pattern of associated problems than chronic mesenteric ischemia associated with long stenosis/occlusion of the SMA, which is the actual object of our article. We agree with Manenti and his associates that reimplantation of the SMA on the aorta, usually on its right antero-lateral aspect just below the origin of the renal arteries is an excellent method of revascularization. It is the ideal technique when the quality of the aortic wall is good or a well-patent aortic graft is in place and the lesion is confined to the first centimeter of the SMA.1 Short, ostial stenoses of the SMA associated with soft or mildly calcified plaques are well managed by endovascular treatment, whereas we think that heavily calcified stenoses or occlusions are still best treated by operative revascularization. Acute ischemia due to embolism to an undiseased SMA is treated by embolectomy via a transverse arteriotomy after dissecting the artery just out the root of the mesentery. When dealing with long SMA stenoses in contaminated fields, bypass with autogenous greater saphenous vein is a viable alternative, but can involve an excessively long course of the graft, because the greater saphenous vein is more prone to twisting and kinking than Dacron (Intervascular Datascope, La Ciotat, France) or polytetrafluoroethylene.