Current Concepts in the Management of Chronic Mesenteric Ischemia

Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass

BACKGROUND

Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity.

METHODS

Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB.

RESULTS

377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB.

DISCUSSION

Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.

Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists

Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.

Renovascular Disease and Mesenteric Vascular Disease

Renal artery stenosis is caused by atherosclerosis and fibromuscular dysplasia and is associated with ischemic nephropathy, renovascular hypertension, and accelerated cardiovascular disease. Routine screening for renal artery stenosis is not recommended but is reasonable in patients who have rapid onset of hypertension, resistant hypertension, progressive renal insufficiency, recurrent pulmonary edema, or repeat admissions for heart failure. Acute mesenteric ischemia is caused by arterial embolism or thrombosis, mesenteric venous thrombosis, or nonocclusive mesenteric ischemia, whereas chronic mesenteric ischemia is most often caused by arterial obstruction. This article reviews the epidemiology, pathophysiology, diagnosis, and management of these two conditions.

Superior mesenteric artery endarterectomy for chronic mesenteric ischemia: A viable alternative in poor candidates for endovascular interventions

Background

Chronic mesenteric ischemia can be treated with either endovascular approaches or surgical revascularization. Recent data suggest that surgery leads to more durable symptom relief with similar long-term survival compared to transcatheter angioplasty. Splanchnic vessel endarterectomy has been shown to lead to longer freedom from recurrence compared to the more commonly used surgical bypass procedure.

Methods

We retrospectively reviewed the medical records of patients with chronic mesenteric ischemia who were considered poor candidates for endovascular repair and therefore underwent superior mesenteric artery endarterectomy in our institution. Study period was April 2016 to April 2018.

Results

A 73-year-old female and a 69-year-old male patient fulfilled our inclusion criteria. Extensive stenosis of the celiac axis and the superior mesenteric artery was found in both patients. superior mesenteric artery endarterectomy was performed in both cases. Endarterectomy was closed using a polytetrafluoroethylene patch. Both patients are alive and symptom-free at one year postoperatively with no signs of restenosis.

Conclusions

Our institutional outcomes are in line with recent literature supporting superior mesenteric artery endarterectomy as a viable alternative to surgical bypass in patients with chronic mesenteric ischemia who are suboptimal candidates for endovascular angioplasty and stenting.

The Superior Mesenteric Artery: From Syndrome in the Young to Vascular Atherosclerosis in the Old

This review is directed at increasing awareness of two diverse rare upper gastrointestinal problems that occur at opposite ends of the age spectrum and are difficult to diagnose and treat. The Superior Mesenteric Artery Syndrome (SMAS) likely involves a young patient, especially female, and is especially associated with rapid weight loss, resulting in relative strangulation of the duodenum by a narrowing of the angle between the Superior Mesenteric Artery (SMA) and the aorta. On the other hand, atherosclerosis of the SMA is associated most likely with postprandial upper intestinal ischemia and abdominal pain occurs in the elderly at high risk for cardiovascular (CV) disease. Medical management of the SMAS in the young involves good alimentation and weight gain to overall increase the intestinal fat pad. Medical management of SMA atherosclerotic ischemia in the elderly is directed at marked lipid lowering with atherosclerotic plaque stabilization or even regression. If needed, surgery for SMAS can be attempted laparoscopically with duodenojejunoscopy which is the most popular procedure but there are also more conservative possibilities that avoid division of the duodenum. In addition, sometimes direct vision is needed to successfully operate on SMAS. If surgery is needed for SMA atherosclerotic ischemia, it is usually attempted endoscopically with angioplasty and stent placement. Most important, in the case of these two rare clinical entities, is that the clinician have a suspicion of their presence when indicated so that the young or old patient can be spared unnecessary suffering and return to good health in a timely fashion.

A case of pancreatic cancer invading the superior mesenteric artery causing extensive intestinal necrosis that was successfully treated by surgery

Introduction

Pancreatic cancer often invades major arteries. However, there are few reports about extensive bowl necrosis caused by superior mesenteric artery (SMA) occlusion associated with pancreatic cancer invasion.

Case report

A 73-year-old woman who was receiving chemotherapy for locally advanced pancreatic cancer (LAPC) was referred to our hospital for abdominal swelling and vomiting that had persisted for 2 days. Contrast-enhanced computed tomography revealed occlusion of the SMA by pancreatic cancer, which had invaded the whole circumference of the SMA. On emergency laparotomy, a large amount of necrotic and ischemic intestine was resected, preserving approximately 100 cm of the ileum. Gastroileostomy was also performed. She had an uneventful postoperative course.

Conclusions

Surgical treatment is a good option for acute SMA occlusion due to invasion by LAPC.

Fractured Superior Mesenteric Artery Stent With Stent Displacement Leading to Recurrent Symptoms of Superior Mesenteric Ischemia

We report a case of a patient with recurrent symptoms of superior mesenteric ischemia 7 months after successful percutaneous angioplasty and implantation of a stent in the superior mesenteric artery (SMA). Stent fracture and stent displacement were observed. To the best of our knowledge, this is the first report of SMA stent fracture with stent displacement.

Influence of splanchnic artery stenosis on the in-hospital clinical course of elderly patients

BACKGROUND

Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition.

AIMS

The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery.

METHODS

For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission.

RESULTS

Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46).

CONCLUSIONS

In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.