A 45-year-old smoker with chronic mesenteric ischaemia secondary to occlusion of both the superior mesenteric artery (SMA) and coeliac axis presented with severe postprandial abdominal pain, weight loss, and progressive constant abdominal pain. Previous endovascular attempts to recanalise the native mesenteric vessels had failed, and the patient subsequently underwent a left common iliac artery to SMA bypass using a reinforced Dacron graft.
Two years later, following cessation of antiplatelet therapy, he re-presented with recurrent postprandial pain. MDT consensus was to attempt endovascular revascularisation before considering redo surgery.
Initial attempts to recanalise the native SMA were unsuccessful despite wire passage across the heavily calcified SMA origin (Figure 1). Attention was then turned to the occluded iliac-SMA bypass graft. The occluded proximal anastomosis was engaged (Figure 2), and the graft was traversed using catheter-wire dissection techniques with successful re-entry into the distal SMA.
Following aggressive angioplasty, the graft was relined using a 7 mm Viabahn stent graft to exclude debris and treat the proximal anastomosis. A 6 mm Formula balloon-expandable stent was deployed across the acutely angulated distal anastomosis to optimise outflow. Completion angiography demonstrated brisk flow through the graft and SMA (Figure 3).
At 6-month ultrasound follow-up the graft remained patent, and the patient was completely symptom-free.

Learning point: Endovascular recanalisation and relining of an occluded mesenteric bypass graft can provide an effective minimally invasive alternative to complex redo mesenteric bypass surgery.