Endovascular Therapy for Chronic Mesenteric Ischemia

An unusual case of stent migration after celiac trunk endovascular revascularization

A 61-year-old woman underwent celiac trunk stenting to treat abdominal angina. Three months later, she was readmitted for recurrent symptoms. Computed tomography control revealed the migration of the stent into the splenic artery. No sign of vessel injury or end-organ ischemia was detected. Repeat stenting of the celiac trunk was performed; the postoperative course was uneventful. 12 months later, the patient was asymptomatic with the second stent in its correct position, and she was asymptomatic for mesenteric ischemia.

Intestinal ischemia

Ischemic changes of the abdominal organs are crucial since they develop slowly and are therefore often diagnosed at a late stage. Due to this general aspect, mortality from this disease could not be significantly reduced over the last decade. One of the main causes of these high mortality rates is the insufficient integration of the overall clinical picture into the diagnostic work-up. Acute mesenteric ischemia should be differentiated from chronic visceral ischemia. Acute intestinal ischemia is a vascular emergency with a mortality rate of 60-80%. The incidence of chronic visceral vascular disorders accounts for approximately 1-2% of all abdominal conditions and has to be differentiated from the acute form, since intestinal ischemia has a progressive nature and usually is related to general atherosclerotic disease. Therefore, this condition is associated with an increase of arteriosclerotic-related multimorbidity in an increasingly elderly population. Due to excellent collateralization, extensive chronic occlusion processes affecting the visceral arteries can be asymptomatically treated on a long-term basis.

Outcomes of endovascular and open treatment for chronic mesenteric ischemia

PURPOSE

To measure contemporary practice patterns and compare outcomes of open and endovascular repair for chronic mesenteric ischemia (CMI).

METHODS

The New York State Health Department Statewide Planning and Research Cooperative System database was queried for the ICD-9-CM codes for CMI for the years 2000 to 2006. In this time period, 6549 patients were evaluated for CMI in New York State. Of these patients, 666 received an intervention and underwent either open (n = 280) or endovascular (n = 347) repair; 39 patients underwent both treatments and were excluded. Trends in operative management and short-term outcomes were analyzed.

RESULTS

Over the 7-year study period, there was a steady increase in the number of endovascular procedures from 28% in 2000 to 75% in 2006. The overall mortality rate for the 7-year period was significantly lower for endovascular versus open repair (11.0% versus 20.4%, respectively; p = 0.0011). Endovascular repair was associated with a significantly lower rate of mesenteric ischemic complications compared to open repair (6.92% versus 17.1%, respectively; p<0.0001). Moreover, compared with open surgery, endovascular repair resulted in significantly lower rates of cardiac, pulmonary, and infectious complications (p<0.05). Only 37% of patients having open repair were discharged home compared to 55% of patients treated with endovascular procedures (p<0.0001).

CONCLUSION

The number of patients treated for CMI continues to increase and correlates with the increasing utilization of endovascular procedures. The patients undergoing endovascular treatment had fewer complications, lower in-hospital mortality, and a greater likelihood of being discharged home.

[Chronic intestinal ischemia]

Ischemic lesions of the splanchnic organs are characterized by an insidious course and therefore are often underestimated. They can result in dramatic courses of disease which even in the last decade still results in a mortality of up to 90%. The reasons for this depressing situation are various but mainly due to insufficient consideration of the symptoms and late therapy due to delayed diagnosis.The incidence of chronic splanchnic ischemia is approximately 1-2% of all abdominal diseases. In contrast to acute intestinal ischemia the course is progressive, caused by progression of the underlying atherosclerosis and polymorbidity in this aging society. On the one hand occlusions of splanchnic arteries are diagnosed more often and on the other hand the incidence has increased due to the rising number of therapy-linked vascular catheter maneuvers. Due to excellent collateralization, diffuse stenotic processes can maintain asymptomatic for a long time. Duplex sonography should be performed as this technique reveals relevant insights into the hemodynamic severity of lesions.

Open and endovascular revascularization for chronic mesenteric ischemia: tabular review of the literature

Chronic mesenteric ischemia is an uncommon disease in vascular surgery practice worldwide. Open revascularization remains the best treatment for low-risk patients due to durability and efficacy. Endovascular revascularization for chronic mesenteric ischemia was primarily indicated for elderly and higher-risk patients, but this has changed over the past 10 years due to development of more precise devices and lower morbidity and mortality rates despite the higher recurrence and restenosis rates. Our purpose was to summarize the data on endovascular and open revascularization for chronic mesenteric ischemia in a schematic tabular presentation.

Imaging in intestinal ischemic disorders

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel or colon. The incidence of bowel ischemia and infarction is on the rise for several reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have greatly contributed to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this article, role of radiology in the detection, differential diagnosis, and management of patients who have intestinal ischemia and infarction is discussed.

Acute abdominal vascular emergencies

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.