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Kakavand B, Burns RC, Centner A, Casas-Melley A. Median Arcuate Ligament Syndrome in Children: A Single-Center Experience. Cureus 2024; 16:e57184. [PMID: 38681309 PMCID: PMC11056100 DOI: 10.7759/cureus.57184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Data on median arcuate ligament syndrome (MALS) in children are scant. It is postulated that MALS can cause chronic abdominal pain. It is unclear what percentage of children with this condition are symptomatic and what comorbidities are associated with this syndrome. METHODS In this retrospective study, data on consecutive patients in a single center diagnosed coincidentally with MALS during routine echocardiogram were reviewed. Symptom burden, comorbidities, and the effect of anthropometric indices on MALS were investigated. Descriptive statistics and nonparametric tests were used to describe the findings and to compare variables with normal distribution. RESULTS Between 2013 and 2020, there were 82 children, 55 females (67%), mean age 13.9 ± 3.2 years, with MALS and complete record. Mean velocity across the stenotic area was 2.6 ± 0.4 m/s. Forty-six patients (57%) had abdominal pain. Age, gender, weight, body mass index (BMI), and Doppler velocity had no statistically significant influence on symptom occurrence. Conversely, patients with joint hypermobility and symptoms of orthostatic intolerance were more likely to have abdominal pain from MALS. Of 24 patients with joint hypermobility, 18 patients had abdominal pain (p=0.027). Thirty-eight patients with orthostatic intolerance (OI) with MALS complained of abdominal pain vs 13 patients with OI and no abdominal pain (p=<0.0001). CONCLUSION Nearly half of patients with MALS had abdominal pain. Age, gender, weight, and the degree of stenosis had no statistically significant influence on symptom occurrence. OI, specifically postural orthostatic tachycardia syndrome (POTS), and joint hypermobility on exam predicted a higher propensity for abdominal pain in patients with MALS.
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Affiliation(s)
| | | | - Aliya Centner
- Medicine, University of Central Florida College of Medicine, Orlando, USA
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2
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Sulzer TAL, Macedo TA, Strissel N, Hesley GK, Lekah A, Tallarita T, Dias-Neto M, Huang Y, Tenorio ER, Vacirca A, Mesnard T, Baghbani-Oskouei A, Savadi S, de Bruin JL, Verhagen HJM, Mendes B, Oderich GS. Changes in renal-mesenteric duplex ultrasound velocities after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2023; 78:1162-1169.e2. [PMID: 37453587 DOI: 10.1016/j.jvs.2023.06.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Stenting of renal and mesenteric vessels may result in changes in velocity measurements due to arterial compliance, potentially giving rise to confusion about the presence of stenosis during follow-up. The aim of our study was to compare preoperative and postoperative changes in peak systolic velocity (PSV, cm/s) after placement of the celiac axis (CA), superior mesenteric artery (SMA) and renal artery (RAs) bridging stent grafts during fenestrated-branched endovascular aortic repair (FB-EVAR) for treatment of complex abdominal aortic aneurysms (AAA) and thoracoabdominal aortic aneurysms. METHODS Patients were enrolled in a prospective, nonrandomized single-center study to evaluate FB-EVAR for treatment of complex AAA and thoracoabdominal aortic aneurysms between 2013 and 2020. Duplex ultrasound examination of renal-mesenteric vessels were obtained prospectively preoperatively and at 6 to 8 weeks after the procedure. Duplex ultrasound examination was performed by a single vascular laboratory team using a predefined protocol including PSV measurements obtained with <60° angles. All renal-mesenteric vessels incorporated by bridging stent grafts using fenestrations or directional branches were analyzed. Target vessels with significant stenosis in the preoperative exam were excluded from the analysis. The end point was variations in PSV poststent placement at the origin, proximal, and mid segments of the target vessels for fenestrations and branches. RESULTS There were 419 patients (292 male; mean age, 74 ± 8 years) treated by FB-EVAR with 1411 renal-mesenteric targeted vessels, including 260 CAs, 409 SMAs, and 742 RAs. No significant variances in the mean PSVs of all segments of the CA, SMA, and RAs at 6 to 8 weeks after surgery were found as compared with the preoperative values (CA, 135 cm/s vs 141 cm/s [P = .06]; SMA, 128 cm/s vs 125 cm/s [P = .62]; RAs, 90 cm/s vs 83 cm/s [P = .65]). Compared with baseline preoperative values, the PSV of the targeted vessels showed no significant differences in the origin and proximal segment of all vessels. However, the PSV increased significantly in the mid segment of all target vessels after stent placement. CONCLUSIONS Stent placement in nonstenotic renal and mesenteric vessels during FB-EVAR is not associated with a significant increase in PSVs at the origin and proximal segments of the target vessels. Although there is a modest but significant increase in velocity measurements in the mid segment of the stented vessel, this difference is not clinically significant. Furthermore, PSVs in stented renal and mesenteric arteries were well below the threshold for significant stenosis in native vessels. These values provide a baseline or benchmark for expected PSVs after renal-mesenteric stenting during FB-EVAR.
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Affiliation(s)
- Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thanila A Macedo
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
| | | | | | | | | | - Marina Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bernardo Mendes
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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3
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Kupinski AM. Mesenteric and renal arterial duplex ultrasound: A review. Vasc Med 2023; 28:463-475. [PMID: 37259501 DOI: 10.1177/1358863x231172247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Duplex ultrasound examinations of the mesenteric and renal circulations are commonly used to detect disease as well as to follow up patients after open surgery or endovascular intervention. The aims of this review were to present essential elements of these duplex ultrasound examinations as well as conduct a literature review of diagnostic criteria. Documentation of appropriate images and data will aid in an accurate interpretation. Spectral Doppler waveforms from various segments of these arterial systems can contribute both direct and indirect evidence of the presence of disease. Various studies have validated the duplex ultrasound diagnostic criteria which more recently have expanded to include specific criteria for stented vessels. This review presents a summary of the fundamental exam components and diagnostic criteria utilized for mesenteric and renal duplex ultrasound.
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Affiliation(s)
- Ann Marie Kupinski
- North Country Vascular Diagnostics, Inc., Altamont, NY, USA
- Albany Medical College, Albany, NY, USA
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4
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Molyneux K, Beck-Esmay J, Koyfman A, Long B. High risk and low prevalence diseases: Mesenteric ischemia. Am J Emerg Med 2023; 65:154-161. [PMID: 36638612 DOI: 10.1016/j.ajem.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment. CONCLUSIONS An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Kevin Molyneux
- Department of Emergency Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Jennifer Beck-Esmay
- Department of Emergency Medicine, Mount Sinai Morningside - Mount Sinai West, 1111 Amsterdam Ave, New York, NY 10025, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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5
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Aly A, Burt R, Violari E, Peña C, Bryce Y. Abdominal Vascular Evaluation. Tech Vasc Interv Radiol 2022; 25:100863. [PMID: 36404064 DOI: 10.1016/j.tvir.2022.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The vascular lab (VL) is instrumental in diagnosing vascular diseases such as renal artery stenosis and mesenteric ischemia or following a patient after transjugular intrahepatic portal systemic shunt (TIPS) creation. This article discusses indications, protocol, and diagnostic criteria for abdominal vascular ultrasound. The vascular lab can be used to investigate pathology in the abdomen either as a preliminary screening tool to evaluate for a pathology such as mesenteric artery stenosis in a patient with food fear and weight loss, renal artery stenosis in a patient with refractory hypertension or renal failure, or as a diagnostic tool in follow up after a patient has undergone a transjugular intrahepatic portal systemic shunt (TIPS) for portal hypertension. The technical success of duplex ultrasonography of the abdomen can be compromised by respiratory motion, obesity, and intestinal gas. Therefore, duplex scanning is performed in the fasting state particularly in elective outpatient cases. In emergent cases when pathology such as acute mesenteric ischemia is suspected evaluation with CT angiography may be best.
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Affiliation(s)
- Ahmed Aly
- University of Nebraska Medical Center, Omaha, NE
| | | | | | | | - Yolanda Bryce
- Memorial Sloan Kettering Cancer Center, New York, NY.
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6
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Kazmi SSH, Safi N, Berge ST, Kazmi M, Sundhagen JO, Julien K, Thorsby PM, Ånonsen KV, Medhus AW, Hisdal J. Plasma α-Glutathione S-Transferase in Patients with Chronic Mesenteric Ischemia and Median Arcuate Ligament Syndrome. Vasc Health Risk Manag 2022; 18:567-574. [PMID: 35903288 PMCID: PMC9315055 DOI: 10.2147/vhrm.s365625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Chronic mesenteric ischemia (CMI) due to either atherosclerosis of the mesenteric arteries or median arcuate ligament syndrome (MALS) is an underdiagnosed entity. The etiology of MALS and its existence have been debated and questioned. We aimed to identify plasma biomarkers indicating mesenteric ischemia in patients with CMI and MALS. Methods Plasma α-glutathione S-transferase (α-GST), intestinal fatty acid-binding protein (I-FABP), citrulline, and ischemia modified albumin (IMA) were analyzed in fifty-eight patients with CMI (Group A, n=44) and MALS (Group B, n=14) before and after revascularization. The plasma levels of these potential biomarkers were compared with those of healthy individuals (Group C, n=16). Group comparison was performed with the Mann–Whitney U-test. Cross-tabulation and its derivatives were obtained. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were calculated. Results Plasma levels of α-GST were significantly raised in the patients with CMI (7.8 ng/mL, p<0.001) and MALS (8.4 ng/mL, p<0.001), as compared with the control Group C (3.3 ng/mL). The threshold for normal median plasma α-GST levels of 4 ng/mL yielded a sensitivity of 93% and 86%, specificity of 86% and 88%, respectively, for the diagnosis of CMI due to atherosclerosis and MALS. AUC of ROC curves was 0.96 (p<0.0001) for CMI and 0.85 (p<0.002) for MALS. The patient groups did not differ from the healthy controls in any other biomarkers. Conclusion Plasma α-GST levels are elevated in CMI and MALS patients. Elevated plasma levels of α-GST suggest ischemia as the etiology of MALS.
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Affiliation(s)
- Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Simen Tveten Berge
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marryam Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Faculty 2, Poznan University of Medical Sciences, Poznan, Poland
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Kari Julien
- The Hormone Laboratory, Department of Medical Biochemistry, Oslo University Hospital, Aker, Oslo, Norway
| | - Per Medbøe Thorsby
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,The Hormone Laboratory, Department of Medical Biochemistry, Oslo University Hospital, Aker, Oslo, Norway
| | - Kim Vidar Ånonsen
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Asle Wilhelm Medhus
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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7
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Almeida I, Amorim J, Vasconcelos C. Ultrasound evaluation of bowel vasculopathy in systemic sclerosis but…. Eur J Intern Med 2022; 100:31-32. [PMID: 35422373 DOI: 10.1016/j.ejim.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/30/2022] [Indexed: 12/18/2022]
Affiliation(s)
- Isabel Almeida
- Internal Medicine, UIC-Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Member of European Reference Network RITA and ReCONNECT, Responsible of the UIC Systemic Sclerosis Cohort, UMIB, ICBAS, Universidade do Porto, Portugal
| | - João Amorim
- Radiology, Radiology depatment, Centro Hospitalar Universitário do Porto, Portugal
| | - Carlos Vasconcelos
- Internal Medicine, UIC-Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Member of European Reference Network RITA and ReCONNECT, UMIB, ICBAS, Universidade do Porto, Portugal.
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8
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Safi N, Ånonsen KV, Berge ST, Medhus AW, Sundhagen JO, Hisdal J, Kazmi SSH. Early Identification of Chronic Mesenteric Ischemia with Endoscopic Duplex Ultrasound. Vasc Health Risk Manag 2022; 18:233-243. [PMID: 35431549 PMCID: PMC9005355 DOI: 10.2147/vhrm.s358570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/21/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Due to diagnostic delay, chronic mesenteric ischemia (CMI) is underdiagnosed. We assumed that the patients suspected of CMI of the atherosclerotic origin or median arcuate ligament syndrome (MALS) could be identified earlier with endoscopic duplex ultrasound (E-DUS). Patients and Methods Fifty CMI patients with CTA-verified stenosis of either ≥50% and ≥70% of celiac artery (CA) and superior mesenteric artery (SMA) were examined with E-DUS and transabdominal duplex ultrasound (TA-DUS). Peak systolic velocities (PSV) of ≥200cm/s and ≥275cm/s for CA and SMA, respectively, were compared with CTA. Subgroup analysis was performed for the patients with (n=21) and without (n=29) prior revascularization treatment of CMI. The diagnostic ability of E-DUS and TA-DUS was tested with crosstabulation analysis. Receiver operating characteristics (ROC) curve analysis was performed, and the area under the curve (AUC) was calculated to investigate the test accuracy. Results In the patients with ≥70% stenosis, E-DUS had higher sensitivity than TA-DUS (91% vs 81% for CA and 100% vs 92% for SMA). AUC for SMA ≥70% in E-DUS was 0.75 and with TA-DUS 0.68. The sensitivity of E-DUS for CTA-verified stenosis ≥70% for CA was 100% in the patients without prior treatment. E-DUS demonstrated higher sensitivity than TA-DUS for both arteries with stenosis ≥50% and ≥70% in the treatment-naive patients. Conclusion E-DUS is equally valid as TA-DUS for the investigation of CMI patients and should be used as an initial diagnostic tool for patients suspected of CMI.
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Affiliation(s)
- Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kim Vidar Ånonsen
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Simen Tveten Berge
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle Wilhelm Medhus
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Correspondence: Syed Sajid Hussain Kazmi, Tel +47 92468309, Email
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9
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Mitchell EL. The Society for Vascular Surgery clinical practice guidelines define the optimal care of patients with chronic mesenteric ischemia. J Vasc Surg 2021; 73:84S-86S. [PMID: 33349350 DOI: 10.1016/j.jvs.2020.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Erica L Mitchell
- Department of Surgery, University of Tennessee, and the Division of Vascular and Endovascular Surgery, Regional One Health, Memphis, Tenn.
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10
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Abstract
In the mid-1970s, a group of clinicians and bioengineers at the University of Washington, under the direction of Dr D Eugene Strandness, Jr, built a prototype duplex scanner that combined B-mode imaging and pulsed Doppler flow detection in a single instrument. At that time, I was a general surgery resident with an interest in vascular disease, and arrangements were made for me to spend a year in the Strandness laboratory. The prototype duplex system was just being completed when I arrived in 1978, and I immediately became involved in a series of validation studies in which patients with carotid disease were scanned and spectral waveform parameters were correlated with independently read contrast arteriograms. This work resulted in the University of Washington duplex criteria for carotid artery disease, which have been widely adopted and modified. Subsequent advances in ultrasound technology expanded the applications of duplex scanning to the peripheral arteries and veins, as well as the abdominal vessels. In 1984, I joined Dr Strandness on the faculty in the Department of Surgery at the University of Washington where I have remained throughout my career. Over the years, I have had the opportunity to participate in many important developments, described in this article, that have helped to make the vascular laboratory the essential clinical resource that it is today.
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Affiliation(s)
- R Eugene Zierler
- University of Washington School of Medicine, Department of Surgery, Division of Vascular Surgery, Seattle, WA, USA.,D.E. Strandness Jr Vascular Laboratory, University of Washington Medical Center - Montlake, Seattle, WA, USA.,Vascular Laboratory, Harborview Medical Center, Seattle, WA, USA
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11
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Green J, Ryer E, Borden N, Ali B, Garvin R, Yang A, Hashmi A, Salzler G, Elmore J. Defining Duplex Ultrasound Criteria for In-Stent Restenosis of the Superior Mesenteric Artery. Ann Vasc Surg 2021; 74:294-300. [PMID: 33508454 DOI: 10.1016/j.avsg.2020.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/11/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study sought to define duplex ultrasound (DUS) velocity criteria predicting ≥70% stenosis in superior mesenteric artery (SMA) stents by correlating in-stent peak systolic velocity (PSV) with computed tomographic angiography (CTA) measurements of percent stenosis. METHODS A retrospective review of 109 patients undergoing SMA stenting between 2003 and 2018 was conducted at a single institution. Thirty-seven surveillance duplex ultrasound studies were found to have a CTA performed within 30 days of study completion. Bare metal (n = 20) and covered stents (n = 17) were included. Velocities were paired to in-stent restenosis (ISR) measured by mean vessel diameter reduction on SMA centerline reconstructions from CTA. Receiver operating characteristic (ROC) curves was generated and logistic regression models for ≥70% ISR probability were used to define velocity criteria in the stented SMA. RESULTS At a PSV of 300 cm/sec, the sensitivity is 100% and specificity 80% for a ≥70% in-stent SMA stenosis. At a PSV of 400 cm/sec, the sensitivity and positive predictive value (PPV) is 63% and the specificity and negative predictive value (NPV) is 90%. A PSV of 450 cm/sec was consistent with the highest specificity (100%) and PPV (100%) but lower sensitivity (50%) and NPV (87.9%). One patient with a PSV of 441 cm/sec on surveillance DUS died from complications of acute-on-chronic mesenteric ischemia. CONCLUSIONS A PSV of 400 cm/sec on mesenteric DUS can predict ≥70% ISR with high sensitivity and should be considered as a diagnostic threshold for SMA in-stent restenosis.
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Affiliation(s)
- Jessica Green
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Evan Ryer
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA.
| | - Nicholas Borden
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Bilal Ali
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Robert Garvin
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Andrew Yang
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Ammar Hashmi
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Gregory Salzler
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - James Elmore
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
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12
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Suzuki K, Takehara Y, Sakata M, Kawate M, Ohishi N, Sugiyama K, Akai T, Suzuki Y, Sugiyama M, Kawamura T, Morita Y, Kikuchi H, Hiramatsu Y, Yamamoto M, Nasu H, Johnson K, Wieben O, Kurachi K, Takeuchi H. Daikenchuto increases blood flow in the superior mesenteric artery in humans: A comparison study between four-dimensional phase-contrast vastly undersampled isotropic projection reconstruction magnetic resonance imaging and Doppler ultrasound. PLoS One 2021; 16:e0245878. [PMID: 33503053 PMCID: PMC7840032 DOI: 10.1371/journal.pone.0245878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
Respiratory-gated four-dimensional phase-contrast vastly undersampled isotropic projection reconstruction (4D PC-VIPR) is magnetic resonance (MR) imaging technique that enables analysis of vascular morphology and hemodynamics in a single examination using cardiac phase resolved 3D phase-contrast magnetic resonance imaging. The present study aimed to assess the usefulness of 4D PC-VIPR for the superior mesenteric artery (SMA) flowmetry before and after flow increase was induced by the herbal medicine Daikenchuto (TJ-100) by comparing it with Doppler ultrasound (DUS) as a current standard. Twenty healthy volunteers were enrolled in this prospective single-arm study. The peak cross-sectionally averaged velocity was measured by 4D PC-VIPR, peak velocity was measured by DUS, and flow volume (FV) of SMA and aorta were measured by 4D PC-VIPR and DUS 25 min before and after the peroral administration of TJ-100. The peak cross-sectionally averaged velocity, peak velocity, and FV of SMA measured by 4D PC-VIPR and DUS significantly increased after administration of TJ-100 (4D PC-VIPR: the peak cross-sectionally averaged velocity; p = 0.004, FV; p = 0.035, DUS: the peak velocity; p = 0.003, FV; p = 0.010). Furthermore, 4D PC-VIPR can analyze multiple blood vessels simultaneously. The ratio of the SMA FV to the aorta, before and after oral administration on the 4D PC-VIPR test also increased (p = 0.015). The rate of change assessed by 4D PC-VIPR and DUS were significantly correlated (the peak cross-sectionally averaged velocity and peak velocity: r = 0.650; p = 0.005, FV: r = 0.659; p = 0.004). Retrospective 4D PC-VIPR was a useful modality for morphological and hemodynamic analysis of SMA.
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Affiliation(s)
- Katsunori Suzuki
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yasuo Takehara
- Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University, Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mayu Sakata
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Masanori Kawate
- Department of Radiology, Hamamatsu University Hospital, Hamamatsu, Shizuoka, Japan
| | - Naoki Ohishi
- Department of Radiology, Hamamatsu University Hospital, Hamamatsu, Shizuoka, Japan
| | - Kosuke Sugiyama
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Toshiya Akai
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yuhi Suzuki
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Masataka Sugiyama
- Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University, Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takafumi Kawamura
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yoshifumi Morita
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hirotoshi Kikuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yoshihiro Hiramatsu
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Masayoshi Yamamoto
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Hatsuko Nasu
- Department of Diagnostic Radiology & Nuclear Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kevin Johnson
- Department of Medical Physics, University of Wisconsin, Madison, WI, United States of America
- Department of Radiology, University of Wisconsin, Madison, WI, United States of America
| | - Oliver Wieben
- Department of Medical Physics, University of Wisconsin, Madison, WI, United States of America
- Department of Radiology, University of Wisconsin, Madison, WI, United States of America
| | - Kiyotaka Kurachi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- * E-mail:
| | - Hiroya Takeuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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Usefulness of Transesophageal Echocardiography in the Evaluation of Celiac Trunk and Superior Mesenteric Artery Involvement in Acute Aortic Dissection. J Am Soc Echocardiogr 2020; 34:327-335. [PMID: 33385502 DOI: 10.1016/j.echo.2020.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/08/2020] [Accepted: 12/27/2020] [Indexed: 12/27/2022]
Abstract
Mesenteric ischemia is a serious complication of acute aortic dissection (AAD), and its early diagnosis is vital for prognosis and appropriate treatment indication. Arteries affected by this complication are the celiac trunk and superior mesenteric artery, and their evaluation is usually based on computed tomographic angiography. Transesophageal echocardiography is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when computed tomographic angiography is not available. However, the usefulness of transesophageal echocardiography for evaluating celiac trunk and superior mesenteric artery involvement and mesenteric ischemia mechanisms in AAD is not well established. Real-time information on mesenteric malperfusion is needed at the bedside, in primary care facilities, and in the operating room to achieve prompt diagnosis and better therapeutic management. The aims of this review are to assess the role of TEE to diagnose celiac trunk and superior mesenteric artery involvement in AAD, determine the mechanisms that can cause flow obstruction in patients with mesenteric ischemia, and analyze possible implications in the treatment of this complication.
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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15
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Revzin MV, Pellerito JS, Nezami N, Moshiri M. The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia. Abdom Radiol (NY) 2020; 45:2960-2979. [PMID: 31410506 DOI: 10.1007/s00261-019-02165-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications. RESULTS Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of "imaging wisely" raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia. CONCLUSION Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.
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Barnes JA, Columbo JA, Ponukumati AS, Zwolak RM, Olive FT, Goodney PP, Powell RJ, Zacharias N. Long-Term Outcomes of Mesenteric Stenting and Analysis of In-Stent Restenosis Duplex Velocity Criteria. Ann Vasc Surg 2020; 68:226-233. [DOI: 10.1016/j.avsg.2020.04.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 12/01/2022]
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17
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Kim ES, Sharma AM, Scissons R, Dawson D, Eberhardt RT, Gerhard-Herman M, Hughes JP, Knight S, Marie Kupinski A, Mahe G, Neumyer M, Poe P, Shugart R, Wennberg P, Williams DM, Zierler RE. Interpretation of peripheral arterial and venous Doppler waveforms: A consensus statement from the Society for Vascular Medicine and Society for Vascular Ultrasound. Vasc Med 2020; 25:484-506. [PMID: 32667274 DOI: 10.1177/1358863x20937665] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This expert consensus statement on the interpretation of peripheral arterial and venous spectral Doppler waveforms was jointly commissioned by the Society for Vascular Medicine (SVM) and the Society for Vascular Ultrasound (SVU). The consensus statement proposes a standardized nomenclature for arterial and venous spectral Doppler waveforms using a framework of key major descriptors and additional modifier terms. These key major descriptors and additional modifier terms are presented alongside representative Doppler waveforms, and nomenclature tables provide context by listing previous alternate terms to be replaced by the new major descriptors and modifiers. Finally, the document reviews Doppler waveform alterations with physiologic changes and disease states, provides optimization techniques for waveform acquisition and display, and provides practical guidance for incorporating the proposed nomenclature into the final interpretation report.
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Affiliation(s)
- Esther Sh Kim
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aditya M Sharma
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - David Dawson
- Vascular Surgery, Baylor Scott & White Health, Temple, TX, USA
| | - Robert T Eberhardt
- Department of Medicine, Division of Cardiovascular Medicine, Boston University, Boston, MA, USA
| | - Marie Gerhard-Herman
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steve Knight
- Diagnostic Ultrasound Technology, Bellevue College, Bellevue, WA, USA
| | - Ann Marie Kupinski
- Albany Medical College, Albany, NY, USA.,North Country Vascular Diagnostics, Altamont, NY, USA
| | - Guillaume Mahe
- Vascular Medicine Unit, CHU Rennes, Univ Rennes CIC1414, Rennes, France
| | - Marsha Neumyer
- Vascular Diagnostic Education Services, Harrisburg, PA, USA
| | | | | | - Paul Wennberg
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - David M Williams
- Cardiovascular Surgery, Medical University of South Carolina, Florence, SC, USA
| | - R Eugene Zierler
- Division of Vascular Surgery, University of Washington School of Medicine, Seattle, WA, USA
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Ayoola OO, Bolarinwa RA, Onakpoya UU, Onwuka CC, Adedeji TA, Afolabi BI, Onigbinde SO, Arogundade FA. Doppler ultrasonographic evaluation of celiac and mesenteric arteries in subjects with sickle cell disease. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:501-507. [PMID: 31063231 DOI: 10.1002/jcu.22729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/11/2019] [Accepted: 04/21/2019] [Indexed: 06/09/2023]
Abstract
Vasculopathy, as occurring in sickle cell disease (SCD), can affect celiac and mesenteric arteries and result in stenosis, with elevated peak systolic velocity (PSV) on Doppler ultrasonography. In six subjects with confirmed SCD in steady state, routine Doppler ultrasonographic examination discovered features of celiac artery (CA) or superior mesenteric artery (SMA) stenosis with CA PSV >200 cm/s (median = 222.8 cm/s; range = 201.5-427.1 cm/s) and/or SMA PSV >275 cm/s (median 183.2 cm/s; range = 87.8-289.3 cm/s). Among the six subjects, five had elevated soluble P-selectin values (median 72.55 ng/mL), while all six (100%) had elevated cystatin C levels (median 4.15 mg/L). Peripheral oxygen saturation was suboptimal in five subjects. All subjects had low hemoglobin concentration levels (median 8.5 g/dL) while four had elevated white blood cell count. Although vaso-occlusive crises result from microvessel occlusion, these findings at the macrovascular level suggest that SCD patients may also be vulnerable to mesenteric ischemic injury, especially in the setting of anemic heart failure from hemolysis.
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Affiliation(s)
- Oluwagbemiga O Ayoola
- Department of Radiology, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
- Department of Radiology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Rahman A Bolarinwa
- Department of Hematology and Blood Transfusion, Faculty of Basic Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Uvie U Onakpoya
- Department of Surgery, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Chidiogo C Onwuka
- Department of Radiology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Tewogbade A Adedeji
- Department of Chemical Pathology, Faculty of Basic Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Babalola I Afolabi
- Department of Radiology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Stephen O Onigbinde
- Department of Radiology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Fatiu A Arogundade
- Department of Internal Medicine, Faculty of Clinical Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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19
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Acosta S, Björgell O, Ekberg O. Prospective Study on Diagnostic Performance of Color Doppler Ultrasound Using Trans-stenotic Mean Arterial Pressure Gradient as a Reference in Stented Superior Mesenteric Artery. Ann Vasc Surg 2019; 56:294-302. [DOI: 10.1016/j.avsg.2018.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/07/2018] [Accepted: 09/20/2018] [Indexed: 12/26/2022]
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20
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Lim S, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Contemporary Management of Acute Mesenteric Ischemia in the Endovascular Era. Vasc Endovascular Surg 2018; 53:42-50. [DOI: 10.1177/1538574418805228] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective: Acute mesenteric ischemia is a rare disease entity associated with high morbidity and mortality. Disparate etiologies and nonspecific symptoms make the diagnosis challenging and often result in delayed diagnosis and intervention. Open laparotomy with mesenteric revascularization and resection of necrotic bowel has been considered the gold standard of care. With recent advances in percutaneous catheter-directed techniques, multiple retrospective studies have demonstrated the outcomes of endovascular therapy. Herein, we review the etiology, presentation, and diagnosis of acute mesenteric ischemia with contemporary outcomes associated with both open and endovascular treatments. Methods: The PubMed electronic database was queried in the English language using the search words mesenteric, acute ischemia, embolism, thromboembolism, thrombosis, revascularization, and endovascular in various combinations. Abstracts of the relevant titles were examined to confirm their relevance and the full articles then extracted. References from extracted articles were checked for any additional relevant articles. This systematic review encompassed literature for the past 5 years (between 2011 and 2016). Results: Early diagnosis and intervention improves acute mesenteric ischemia outcomes. Early restoration of mesenteric flow minimizes morbidity and mortality. In comparison to open laparotomy with mesenteric revascularization and resection of necrotic bowel, several retrospective studies using administrative data and single-center chart reviews demonstrate noninferior outcomes of an endovascular first approach in acute arterial mesenteric occlusion. Conclusions: For acute mesenteric arterial occlusive disease, both endovascular and open revascularization techniques are viable options. Although there is lack of level 1 evidence, single-center retrospective studies and administrative database studies demonstrated that an endovascular first approach may have improved outcomes in the immediate postoperative period. However, selection and other bias in these studies necessitate the need for definitive randomized prospective studies between endovascular and open mesenteric intervention. In contrast, mesenteric venous thrombosis may be treated with systemic anticoagulation without surgical revascularization. Catheter-directed thrombectomy and thrombolysis can be considered at the discretion of the clinician.
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Affiliation(s)
- Sungho Lim
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Pegge M. Halandras
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Carlos Bechara
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Bernadette Aulivola
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Paul Crisostomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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21
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Pillai AK, Kalva SP, Hsu SL, Walker TG, Silberzweig JE, Annamalai G, Baerlocher MO, Mitchell JW, Midia M, Nikolic B, Dariushnia SR. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol 2018; 29:642-647. [PMID: 29574024 DOI: 10.1016/j.jvir.2017.11.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 11/19/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anil K Pillai
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Texas
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven L Hsu
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - T Gregory Walker
- Division of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ganesan Annamalai
- Department of Medical Imaging, University of Toronto, Mt. Sinai Hospital & University Health Network, Toronto, Ontario, Canada
| | - Mark O Baerlocher
- Department of Radiology, Royal Victoria Hospital, Barrie, Ontario, Canada
| | - Jason W Mitchell
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Mehran Midia
- Department of Diagnostic Imaging, McMaster University, Hamilton, Ontario, Canada
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, New York
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia.
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22
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Vlachopoulos C, Georgakopoulos C, Koutagiar I, Tousoulis D. Diagnostic modalities in peripheral artery disease. Curr Opin Pharmacol 2018; 39:68-76. [PMID: 29549715 DOI: 10.1016/j.coph.2018.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Peripheral artery disease (PAD) affects approximately one in five persons older than 70 years of age and it is often present in patients with concomitant vascular disease in different body territories (e.g. coronary artery disease). Diagnosis at an early stage is important in order to achieve improvement in patient's symptoms and prognosis. Remarkable improvements in the field of noninvasive and invasive imaging techniques have led to an advanced level the management of patients with PAD. Throughout this review article, the clinically available diagnostic modalities in PAD are presented. Strong and weaker points are stressed out in a manner that elucidates that no perfect diagnostic method exists. Based on the patient's individual profile, as well as on certain aspects of the disease (e.g. morphology of carotid plaque lesions) the attending physician will ultimately decide which diagnostic path will lead to a prompt and correct diagnosis of PAD with the minimum amount of exams and risk for the patient.
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Affiliation(s)
- Charalambos Vlachopoulos
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
| | - Christos Georgakopoulos
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Iosif Koutagiar
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- Hypertension and Cardiometabolic Syndrome Unit, 1st Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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23
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Paliogiannis P, Ginesu GC, Fancellu A, Pischedda A, Maiore M, Maiore E, Pinna A, Barmina M, Porcu A. Surgical and Endovascular Management of Patients with Chronic Mesenteric Ischemia: A Single Center Experience. Am Surg 2017. [DOI: 10.1177/000313481708301235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Chronic mesenteric ischemia is a rare intestinal disorder, with a potential evolution toward intestinal infraction. The choice of the appropriate treatment is currently the most crucial issue in the management of patients with chronic mesenteric ischemia. We describe our experience with 16 cases, and we discuss the current diagnostic and therapeutic approaches. A retrospective review of the clinical records was performed, and demographic, clinical, therapeutic, and prognostic data were collected. Six patients were females (37%), and the mean age was 62 years. Postprandial pain was present in all the cases, whereas sitophobia and weight loss were detected in 87 per cent of them. Eight patients were treated with open surgery; no perioperative deaths or relevant complications occurred. One patient had a restenosis of the celiac trunk and superior mesenteric artery 10 months after surgery. No deaths or relevant complications occurred in the remaining patients, who underwent an endovascular procedure. One patient presented a restenosis distal to the vascular stent, whereas two patients died due to comorbidities. The low rates of postoperative morbidity, mortality, and restenosis obtained suggest that surgical or endovascular correction of chronic mesenteric ischemia is satisfactory when performed by experienced surgeons, with an adequate selection of the patients.
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Affiliation(s)
- Panagiotis Paliogiannis
- Experimental Pathology and Oncology, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giorgio C. Ginesu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Alessandro Fancellu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Aldo Pischedda
- Unit of Radiology, Azienda Ospedaliera Universitaria Di Sassari, Sassari, Italy
| | - Mario Maiore
- Unit of Radiology, Azienda Ospedaliera Universitaria Di Sassari, Sassari, Italy
| | - Eleonora Maiore
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Antonio Pinna
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Michele Barmina
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Alberto Porcu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
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24
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Razumovsky AY, Mitupov ZB, Feoktistova EV, Gurevich AI, Titova EA, Yusufov AA, Svetlov VV, Nagornaya YV. [Laparoscopic decompression of celiac trunk in children]. Khirurgiia (Mosk) 2017:44-51. [PMID: 29076481 DOI: 10.17116/hirurgia20171044-51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
MATERIAL AND METHODS For the period 2013-2016 four patients were treated at the Filatov Children's City Clinical Hospital #13. There were 2 children aged 14 years and 2 children aged 17 years. All patients have been diagnosed via anamnesis, complaints, pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. After comprehensive examination 3 patients underwent laparoscopic decompression of celiac trunk. In all cases celiac trunk compression was predominantly caused by median arcuate ligament of the diaphragm combined with neurofibrotic tissue of celiac plexus. RESULTS All patients were discharged after laparoscopic decompression of celiac trunk. Intra- and postoperative complications, as well as cases of conversion were absent. Mean time of surgery was 65 minutes. In all cases postoperative period was smooth (4 days on the average). Two patients underwent follow-up examination in long-term postoperative period: pulse-wave doppler sonography, contrast-enhanced MDCT and angiography. In both cases reduced severity, incidence and duration of pain syndrome were observed. CONCLUSION Clinical examples show some problems in diagnosis and treatment of compressive stenosis of celiac trunk due to rarity of pathology especially in childhood. Nevertheless, combination of abdominal ischemia and celiac trunk stenosis confirmed by instrumental diagnosis is indication for surgical treatment.
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Affiliation(s)
- A Yu Razumovsky
- Chair of Pediatric Surgery of Pirogov Russian Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - Z B Mitupov
- Chair of Pediatric Surgery of Pirogov Russian Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - E V Feoktistova
- Dmitry Rogachev National Research and Practical Center for Pediatric Hematology, Oncology and Immunology of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A I Gurevich
- Filatov Children's City Clinical Hospital N 13 of Moscow Department of Healthcare, Moscow, Russia
| | - E A Titova
- Filatov Children's City Clinical Hospital N 13 of Moscow Department of Healthcare, Moscow, Russia
| | - A A Yusufov
- Children's Regional Clinical Hospital, Tver, Russia
| | - V V Svetlov
- Children's Regional Clinical Hospital, Tver, Russia
| | - Yu V Nagornaya
- Chair of Pediatric Surgery of Pirogov Russian Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
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25
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Wo K, Morrison BJ, Harada RN. Developing Duplex Ultrasound Criteria for Diagnosis of Arteriovenous Fistula Stenosis. Ann Vasc Surg 2017; 38:99-104. [DOI: 10.1016/j.avsg.2016.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/31/2016] [Accepted: 04/24/2016] [Indexed: 10/21/2022]
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Rosen RJ, Jain A, Drury J. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Amit Jain
- Lenox Hill Heart and Vascular Institute; New York NY USA
| | - Jennifer Drury
- Lenox Hill Heart and Vascular Institute; New York NY USA
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Duplex ultrasound criteria for in-stent restenosis of mesenteric arteries. J Vasc Surg 2016; 64:1366-1372. [DOI: 10.1016/j.jvs.2016.06.103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 06/09/2016] [Indexed: 11/18/2022]
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28
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Heneghan RE, Starnes BW, Nathan DP, Zierler RE. Renal duplex ultrasound findings in fenestrated endovascular aortic repair for juxtarenal aortic aneurysms. J Vasc Surg 2016; 63:915-21. [DOI: 10.1016/j.jvs.2015.10.090] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/21/2015] [Indexed: 01/23/2023]
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Affiliation(s)
- Daniel G Clair
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (D.G.C.) and the Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic (D.G.C., J.M.B.) - both in Cleveland
| | - Jocelyn M Beach
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (D.G.C.) and the Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic (D.G.C., J.M.B.) - both in Cleveland
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Barret M, Martineau C, Rahmi G, Pellerin O, Sapoval M, Alsac JM, Fabiani JN, Malamut G, Samaha E, Cellier C. Chronic Mesenteric Ischemia: A Rare Cause of Chronic Abdominal Pain. Am J Med 2015; 128:1363.e1-8. [PMID: 26291907 DOI: 10.1016/j.amjmed.2015.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia is a rare disease with nonspecific clinical symptoms, such as chronic postprandial abdominal pain and weight loss. Diagnostic modalities and revascularization techniques have evolved during the past 20 years. The significance of stenosis in a single splanchnic vessel remains unclear. Our aims were to assess the outcomes of 2 revascularization techniques and report on the diagnostic modalities of splanchnic vessel stenoses. METHODS The demographic data, medical history, technical characteristics, and outcomes of the revascularization procedures were recorded for all of the patients admitted for endovascular revascularization or open surgical revascularization of the splanchnic vessels as treatment for chronic mesenteric ischemia in our tertiary referral center since 2000. RESULTS Fifty-four patients were included in this study: 43 received endovascular revascularization, and 11 had open surgical revascularization. The symptoms were abdominal pain, weight loss, and diarrhea in 98%, 53%, and 25% of the cases, respectively. Computed tomography angiography was the key diagnostic tool for 60% of the patients. A single-vessel stenosis was found in one-third of the patients. Endovascular and open revascularization had similar early and late outcomes, and no 30-day mortality was observed. However, we did observe higher morbidity in the open revascularization group (73% vs 19%, P <.03). CONCLUSIONS Chronic mesenteric ischemia may be diagnosed in the presence of a splanchnic syndrome and stenosis of a single splanchnic vessel, typically assessed using computed tomography angiography. In selected patients, endovascular revascularization had similar efficacy as, and lower complication rates than open revascularization.
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Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France.
| | - Chloé Martineau
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Gabriel Rahmi
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Olivier Pellerin
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Marc Sapoval
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Jean-Marc Alsac
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Jean-Noël Fabiani
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Georgia Malamut
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Elia Samaha
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France
| | - Christophe Cellier
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
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Shah AS, Schwartz LB, Moawad J, Gewertz BL. Technique profile: mesenteric reconstructions for occlusive disease. Expert Rev Cardiovasc Ther 2015; 13:1445-58. [DOI: 10.1586/14779072.2015.1094376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Margiotta A, Gray BH. Assessment of recurrent mesenteric ischemia after stenting with a pressure wire. Vasc Med 2014; 19:137-141. [DOI: 10.1177/1358863x14524852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic mesenteric artery ischemia can be difficult to evaluate after stent placement. This case describes the use of a pressure wire to demonstrate the hemodynamic significance of in-stent restenosis. Papaverine was used to vasodilate the mesenteric bed, mimicking the post-prandial state. The study (arteriography with pressure wire) and retreatment (covered balloon-expandable stent) was driven by recurrent symptoms avoiding unnecessary ancillary testing.
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Affiliation(s)
- Alyssa Margiotta
- University of South Carolina School of Medicine/Greenville, Department of Surgery, Greenville Health System, Greenville, South Carolina, USA
| | - Bruce H Gray
- University of South Carolina School of Medicine/Greenville, Department of Surgery, Greenville Health System, Greenville, South Carolina, USA
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33
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François CJ. Noninvasive Imaging Workup of Patients with Vascular Disease. Surg Clin North Am 2013; 93:741-60, vii. [DOI: 10.1016/j.suc.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Oliva IB, Davarpanah AH, Rybicki FJ, Desjardins B, Flamm SD, Francois CJ, Gerhard-Herman MD, Kalva SP, Ashraf Mansour M, Mohler ER, Schenker MP, Weiss C, Dill KE. ACR Appropriateness Criteria ® imaging of mesenteric ischemia. ABDOMINAL IMAGING 2013; 38:714-9. [PMID: 23296712 DOI: 10.1007/s00261-012-9975-2] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mesenteric ischemia is a rare disease associated with high morbidity and mortality. Acute mesenteric ischemia is most commonly secondary to embolism followed by arterial thrombosis, nonocclusive ischemia, and less commonly venous thrombosis. Chronic mesenteric ischemia is almost always caused by atherosclerotic disease, with rare causes including fibromuscular dysplasia and vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Patients with mesenteric ischemia usually present with nonspecific abdominal symptoms and laboratory findings. This document evaluates and rates the appropriateness of imaging to evaluate patients with clinically suspected mesenteric ischemia. While catheter-based angiography has been considered the reference standard and enables diagnosis and treatment, advances in computed tomography have made it a first-line test in many patients because it is a fast, widely available, and noninvasive study. Abdominal radiographs and ultrasound have a limited role in diagnosing mesenteric ischemia but are commonly the first ordered tests in patients with abdominal pain and may diagnose more common pathologies.
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The influence of respiration on criteria for transabdominal duplex examination of the splanchnic arteries in patients with suspected chronic splanchnic ischemia. J Vasc Surg 2013; 57:1603-11, 1611.e1-10. [DOI: 10.1016/j.jvs.2012.11.120] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/17/2022]
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Baker AC, Chew V, Li CS, Lin TC, Dawson DL, Pevec WC, Hedayati N. Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization. J Vasc Surg 2012; 56:1364-71; discussion 1371. [DOI: 10.1016/j.jvs.2012.03.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 02/16/2012] [Accepted: 03/19/2012] [Indexed: 10/27/2022]
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AbuRahma AF, Scott Dean L. Duplex ultrasound interpretation criteria for inferior mesenteric arteries. Vascular 2012; 20:145-9. [DOI: 10.1258/vasc.2011.oa0349] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
There is no specific duplex ultrasound (DUS) criteria for the diagnosis of inferior mesenteric artery (IMA) stenosis. This study will define the optimal duplex velocity values with the best overall accuracy (OA) in detecting ≥50% stenosis of the IMAs. Eighty-five IMAs with both DUS and mesenteric arteriography were analyzed. Eighty-five IMAs were examined: 45 were normal, 12 with <50% stenosis, eight with ≥50–69% stenosis and 15 with ≥70% stenosis (including occlusion) based on angiography. The mean peak systolic velocities (PSVs) for a normal IMA, <50% and ≥50% stenosis was 105, 215 and 392 cm/second, respectively ( P < 0.0001). The most accurate PSV in detecting ≥50% stenosis was ≥250 cm/second with a sensitivity of 90%, a specificity of 96% and an OA of 95%. The most accurate end-diastolic velocity (EDV) in detecting ≥50% stenosis was ≥80% or ≥90 cm/second, with an OA of 86%, a sensitivity of 60% and a specificity of 100%. The most accurate ratio in detecting ≥50% stenosis was ≥4 or ≥4.5 with an OA of 93%.Receiver operator curves analysis showed that the PSV was not better than EDV and PSV ratio in detecting ≥50% stenosis ( P = 0.1661 and 0.4568, respectively). In conclusion, specific IMA PSVs, EDVs and IMA/aortic systolic ratios can be used in detecting significant IMA stenosis with reasonable accuracy.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, Robert C Byrd Health Sciences Center, West Virginia University, 3110 MacCorkle Avenue, SE, Charleston, WV 25304
| | - L Scott Dean
- Charleston Area Medical Center, Charleston, WV 25301, USA
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Duplex velocity criteria for native celiac/superior mesenteric artery stenosis vs in-stent stenosis. J Vasc Surg 2012; 55:730-8. [PMID: 22301212 DOI: 10.1016/j.jvs.2011.10.086] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/14/2011] [Accepted: 10/14/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Duplex velocity criteria (DVC) to identify in-stent celiac artery (CA) and superior mesenteric artery (SMA) stenosis is not well defined. Only one study has been published which concluded that DVC for native SMA stenosis overestimated stenosis in stented SMAs. The purpose of this study was to analyze DVC in detecting CA/SMA in-stent stenosis (ISS). METHODS Forty-three patients with 62 stents (32 SMAs and 30 CAs), who had concurrent postoperative duplex ultrasound scan and angiograms for significant ISS by DVC were analyzed. A receiver operator curve (ROC) analysis was used to determine optimal DVC (peak systolic velocity [PSV], end-diastolic velocity [EDV], and CA or SMA/aortic systolic ratios) for detecting ≥50% and ≥70% ISS. These were compared to duplex velocities obtained from 97 native CAs and 74 native SMAs with ≥50% stenosis done in the same study period. RESULTS The mean stented celiac PSV (cm/s), EDV, and systolic ratio for ≥50% ISS were 447, 136, and 7.1 vs 379, 104, and 5.2 for ≥50% native stenosis (P = .067, .106, and < .01). The mean stented SMA PSV, EDV, and ratio for ≥50% ISS were 410, 114, and 6.2 vs 405, 76, and 2.0 for ≥50% native stenosis (P = .885, .037, and < .0001). The PSV cutpoints for detecting ≥50% SMA ISS was 325 cm/s (sensitivity 89%, specificity 100%, and overall accuracy 91%) vs 295 cm/s for ≥50% native SMA and for ≥70% SMA ISS was 412 (sensitivity 100%, specificity 95%, and overall accuracy 97%) vs 400 for native stenosis. The PSV cutpoints for ≥50% CA ISS was 274 cm/s (sensitivity 96%, specificity 86%, and overall accuracy 93%) vs 240 cm/s for ≥50% native stenosis and for ≥70% CA ISS was 363 (sensitivity 88%, specificity 92%, and overall accuracy 90%) vs 320 cm/s for native stenosis (sensitivity 80, specificity 89%, and overall accuracy 85%). ROC analysis also showed that both PSVs and EDVs were equal predictors for SMA and CA ≥50% and ≥70% ISS. For ≥50% SMA ISS, the area under the curve (AUC) for PSV equals 0.91, EDV = 0.81, P = .341. For CA, PSV, AUC = 0.99, EDV = 0.88, P = .063. CONCLUSIONS There is a tendency toward higher velocities in stented CA/SMAs in comparison to native arteries. Caution must be exercised in using duplex velocity cutoffs for native CA/SMA stenosis for stented CA/SMA. Further prospective validation studies are needed.
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Biolato M, Grieco A. Comment on "the role of endoscopic ultrasound in the evaluation of chronic mesenteric ischaemia". Dig Liver Dis 2012; 44:86. [PMID: 21856260 DOI: 10.1016/j.dld.2011.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/14/2011] [Indexed: 12/11/2022]
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AbuRahma AF, Stone PA, Srivastava M, Dean LS, Keiffer T, Hass SM, Mousa AY. Mesenteric/celiac duplex ultrasound interpretation criteria revisited. J Vasc Surg 2011; 55:428-436.e6; discussion 435-6. [PMID: 22195765 DOI: 10.1016/j.jvs.2011.08.052] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 08/10/2011] [Accepted: 08/10/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several published studies with a small sample size have reported differing results of duplex ultrasound (DUS) utilizing different threshold velocities in detecting significant stenosis of superior mesenteric (SMA) or celiac arteries (CA). The present study is based on the largest number of mesenteric duplex/angiography correlations reported to date for the diagnosis of SMA/CA stenosis. METHODS One hundred fifty-three patients (151 SMA and 150 CA) had both DUS and arteriography. Receiver operator curves (ROC) were used to analyze peak systolic velocity (PSV), end diastolic velocity (EDV), and SMA or CA/aortic PSV ratio in detecting ≥50% and ≥70% stenosis. RESULTS For SMA (151 arteries: 84 with ≥50% stenosis [54 of which had ≥70% stenosis] based on angiography): the PSV threshold that provided the highest overall accuracy (OA) for detecting ≥50% SMA stenosis was ≥295 cm/s (sensitivity [sens.] 87%, specificity [spec.] 89%, and OA 88%); and for detecting ≥70% SMA, it was ≥400 cm/s (sens. 72%, spec. 93%, and OA 85%). The EDV threshold that provided the highest OA for detecting ≥50% stenosis was ≥45 cm/s (sens. 79%, spec. 79%, and OA 79%); and for ≥70% stenosis was ≥70 cm/s (sens. 65%, spec. 95%, and OA 84%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of SMA (P = .003 and P = .0005). For celiac arteries (150 arteries: 105 with ≥50% stenosis [62 of which had ≥70% stenosis]): the PSV threshold that provided the highest OA for ≥50% stenosis was ≥240 cm/s (sens. 87, spec. 83%, and OA 86%); and for ≥70% stenosis was ≥320 cm/s (sens. 80%, spec. 89%, and OA 85%). The EDV threshold that provided the highest OA for ≥50% stenosis was ≥40 cm/s (sens. 84%, spec. 48%, and OA 73%); and for ≥70% stenosis was ≥100 cm/s (sens. 58%, spec. 91%, and OA 77%). ROC analysis showed that PSV was better than EDV and SMA/aortic PSV ratio for ≥50% stenosis of CA (P < .0001 and P = .0410.) CONCLUSIONS PSV values can be used in detecting ≥50% and ≥70% SMA/CA stenosis and were better than EDVs and ratios. Previously published data must be validated in individual vascular laboratories. Our results will need prospective validation.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
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Catalini R, Alborino S, Giovagnoli A, Zingaretti O. Color Duplex evaluation of the mesenteric artery(). J Ultrasound 2010; 13:118-22. [PMID: 23396804 DOI: 10.1016/j.jus.2010.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ischemic colitis is the most common form of intestinal ischemia. Diagnosis is made at clinical examination and endoscopy and completed by vascular imaging, but color Doppler US may become a first-line imaging technique for the evaluation of the mesenteric circulation.We present the case of an 80-year-old woman hospitalized for recurrent ischemic colitis of the sigmoid. At a previous hospitalization, color Doppler US examination showed medium to severe stenosis at the origin of the inferior mesenteric artery. However, CT angiography was negative and the condition was therefore misdiagnosed. Eight months later the patient was admitted again with abdominal pain and rectal hemorrhage. Rectosigmoidoscopy documented the presence of ischemia of the sigmoid mucosa. Angiography showed the presence of severe stenosis at the origin of the inferior mesenteric artery so revascularization was carried out by percutaneous transluminal angioplasty (PTA) during the same session. Follow-up showed normal patency of the inferior mesenteric artery after revascularization, and subsequent endoscopic evaluation documented gradual colonic mucosal ischemia resolution. Blood flow at the level of the inferior mesenteric artery was assessed using color Doppler US. The presented case confirms that color Doppler US is a valid first-line imaging technique in the assessment of ischemic intestinal lesions. It is reliable in the evaluation of the mesenteric arterial circulation, and it also allows assessment of blood flow alterations caused by stenosis and identification of localized hemodynamic stenosis which may be missed at CT-angiography or MR-angiography. Arteriography remains the examination of choice in case of discrepancy between first-and second-line imaging techniques and in all cases which offer the possibility of endovascular revascularization.
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Affiliation(s)
- R Catalini
- Division of Vascular Medicine, Department of Internal Medicine, "Ospedali Riuniti" Hospital, Ancona, Italy
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Seidl H, Tuerck J, Schepp W, Schneider AR. Splanchnic arterial blood flow is significantly influenced by breathing-assessment by duplex-Doppler ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:1677-1681. [PMID: 20800960 DOI: 10.1016/j.ultrasmedbio.2010.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Revised: 06/10/2010] [Accepted: 07/20/2010] [Indexed: 05/29/2023]
Abstract
Duplex ultrasound is established for the assessment of mesenteric ischemia but potential influences of breathing on mesenteric arterial blood velocity have not been investigated so far. In 100 patients without abdominal diseases (39 men; age 59.4 ± 18.0 years), peak systolic (PSV), end diastolic velocity (EDV) and resistance index (RI) were assessed in the celiac trunk (CT) and the superior mesenteric artery (SMA) by Doppler ultrasound during expiration and deep inspiration. Expiratory PSVs in the CT and the SMA (153.4 ± 42.5 and 145.3 ± 39.5 cm/s) were significantly higher than inspiratory velocities (135.4 ± 36.8 and 131.9 ± 42.2 cm/s, p < 0.0001 and p = 0.0002), with expiratory PSVs exceeding inspiratory PSVs in more than 75% of patients. The mean percentage of PSV-variation was 21.5% ± 15.3% and 24.6% ± 19.1%, respectively. The study demonstrates that breathing may exert considerable periodic effects on splanchnic arterial hemodynamics. We, therefore, recommend that to prevent an underestimation of arterial stenosis, mesenteric Doppler ultrasound should be performed during expiration.
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Affiliation(s)
- Holger Seidl
- Department of Gastroenterology, Hepatology and Gastroenterological Oncology, Bogenhausen Academic Teaching Hospital, Klinikum Muenchen GmbH, Munich, Germany
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Chandra A, Quinones-Baldrich WJ. Chronic mesenteric ischemia: how to select patients for invasive treatment. Semin Vasc Surg 2010; 23:21-8. [PMID: 20298946 DOI: 10.1053/j.semvascsurg.2009.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chronic mesenteric ischemia (CMI) remains a well-described disease process that is difficult to diagnose. Since its initial description more than a century ago, a myriad of diagnostic and treatment modalities have been applied to ameliorate the classic symptoms of postprandial abdominal pain and weight loss. It is estimated that mesenteric occlusive disease affects approximately 1% to 18% of the population, with a majority of these patients manifesting no symptoms of CMI. While associated with a small prevalence, the potential economic impact of this disease process, with the increasing age of the population and the catastrophic outcomes associated with no treatment, is significant. The primary etiology of CMI is atherosclerotic occlusive disease involving the ostia of the mesenteric arteries. Several studies have investigated the pathophysiology of the postprandial abdominal pain associated with ischemia focusing on transport mechanisms, claudication of the intestinal musculature, and ischemia of the visceral nerves. The process of diagnosing CMI involves assimilation of the presentation, typical history and physical examination findings, and results of imaging modalities. At the end of this diagnostic process, the decision to offer a patient surgical intervention is primarily based on symptomatology and results of duplex and other imaging modalities. There are specific criteria for which to offer symptomatic patients interventions. Patients who are asymptomatic do not need to undergo revascularization, which may disrupt collateral arterial circulation to the mesentery. They should be followed conservatively.
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Affiliation(s)
- Ankur Chandra
- Division of Vascular Surgery, UCLA Medical Center, Los Angeles, CA 90095-6908, USA
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Reis WP, Gaio J, Reis Júnior C, Waisberg DR, Klug M, Miranda RB, Waisberg J. Prevalência da estenose aterosclerótica do tronco celíaco e da artéria mesentérica superior na arteriopatia oclusiva dos membros inferiores. J Vasc Bras 2010. [DOI: 10.1590/s1677-54492010000100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Contexto: A eventual relação entre a aterosclerose das artérias dos membros inferiores com a aterosclerose das artérias intestinais foi pouco estudada. Objetivo: Avaliar pela ecografia vascular (Doppler) presença de lesões com estenose 70% na artéria mesentérica superior e/ou tronco celíaco em doentes com arteriopatia obstrutiva crônica dos membros inferiores. Método: Foram estudados dois grupos, cada um com 60 doentes (40 homens e 20 mulheres). O grupo-caso foi composto por doentes com arteriopatia obstrutiva crônica dos membros inferiores, claudicação intermitente limitante ou dor de repouso e/ou lesões tróficas de extremidade, sem queixas gastrintestinais. O grupo-controle foi constituído por enfermos sem doença arterial obstrutiva dos membros inferiores e sem queixas gastrintestinais. Consideraram-se fatores de risco presença de diabetes melito, hipertensão arterial, obesidade, angina/infarto, tabagismo e dislipidemia. Todos os doentes foram submetidos a ecografia vascular do tronco celíaco e da artéria mesentérica superior. Os doentes do grupo-caso foram separados pela presença de claudicação intermitente limitante (N = 12) ou lesão trófica e/ou dor de repouso (N = 48). Resultados: Houve associação significante entre idade (p = 0,04) e cardiopatia isquêmica (p = 0,04) com aterosclerose da artéria mesentérica superior. Os fatores de risco não mostraram associação significante com presença de estenose do tronco celíaco. Observou-se associação significante entre arteriopatia dos membros inferiores e lesão estenótica da artéria mesentérica superior (p = 0,006) e do tronco celíaco (p < 0,001). Conclusões: Na ecografia vascular, o achado de arteriopatia periférica sugere presença de lesão estenótica em artéria mesentérica superior e/ou tronco celíaco. A aterosclerose na artéria mesentérica superior está associada com cardiopatia isquêmica e idade avançada.
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Affiliation(s)
| | | | | | | | | | | | - Jaques Waisberg
- Instituto de Assistência Médica ao Servidor Público Estadual
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Abstract
Abdominal angina is an underrecognized cause of postprandial abdominal pain and weight loss. Diagnosis is often delayed and requires both a careful exclusion of more common causes and a high degree of clinical suspicion, based on the patient's age, the coexistence of multiple risk factors for atherosclerosis, and the presence of vasculopathy in other districts. Appropriate investigations include duplex ultrasound, traditional angiography, magnetic resonance angiography, computed tomography angiography, and tonometry. The purpose of this review is to discuss the pathophysiology and clinical presentation of chronic mesenteric ischemia and to suggest a diagnostic flowchart for this complex condition.
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Affiliation(s)
- Marco Biolato
- Department of Internal Medicine, Catholic University of Rome, Rome, Italy
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46
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Duplex criteria for native superior mesenteric artery stenosis overestimate stenosis in stented superior mesenteric arteries. J Vasc Surg 2009; 50:335-40. [DOI: 10.1016/j.jvs.2008.12.071] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 12/11/2008] [Accepted: 12/29/2008] [Indexed: 11/22/2022]
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[Circulatory disorders of the renal and mesenteric arteries]. Internist (Berl) 2009; 50:952-7. [PMID: 19575169 DOI: 10.1007/s00108-009-2368-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Symptomatic mesenteric circulatory disorders are potentially life-threatening diseases with an increasing frequency due to the demographic population development. Renal artery stenosis is a well accepted cause of hypertension or at least deterioration of blood pressure control as well as the cause of a progressive course of renal insufficiency if of an atherosclerotic nature. Further consequences of renal artery stenosis, such as left ventricle hypertrophy and hypertensive encephalopathy are topics of recent research. Due to progress in percutaneous techniques during the last decade interventional therapy has replaced surgery as the treatment method of choice for lesions located near the origin. The only randomized study comparing endovascular stent revascularization with best medical therapy (ASTRAL) failed to show a benefit of revascularization of renal artery stenoses.
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Pellerito JS, Revzin MV, Tsang JC, Greben CR, Naidich JB. Doppler sonographic criteria for the diagnosis of inferior mesenteric artery stenosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:641-650. [PMID: 19389903 DOI: 10.7863/jum.2009.28.5.641] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The purpose of this study was to define the optimal Doppler criteria for the diagnosis of inferior mesenteric artery (IMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). METHODS A retrospective review of 205 dedicated color and pulsed Doppler sonographic studies of mesenteric arteries was performed in 205 patients. All studies were performed in patients with suspected CMI. Correlative angiography was available in 50 patients. RESULTS The IMA was visualized in 176 of 205 Doppler sonographic examinations (86%) and in 92% of the correlative studies. The visualization rate for the detection of a patent IMA by Doppler sonography in this series was 90%. The ranges of the peak systolic velocity (PSV), end-diastolic velocity (EDV), and mesenteric-aortic velocity ratio (MAR) in the nonstenotic IMA were 70 to 200 cm/s, 0 to 33 cm/s, and 0.7 to 3.7, respectively. The ranges of the PSV, EDV, and MAR in IMA stenosis were 200 to 485 cm/s, 0 to 177 cm/s, and 0.69 to 8.1. The threshold values for severe IMA stenosis by logistic regression analysis (n = 42) were as follows: PSV, greater than 200 cm/s; EDV, greater than 25 cm/s; and MAR, greater than 2.5, with sensitivities of 90%, 40%, and 80%; specificities of 97%, 91%, and 88%; positive predictive values (PPVs) of 90%, 57%, and 67%; negative predictive values (NPVs) of 97%, 83%, and 93%; and accuracy of 95%, 79%, and 86%, respectively. CONCLUSIONS We found that a PSV of greater than 200 cm/s was the best criterion for the diagnosis of IMA stenosis. The sensitivity, specificity, PPV, NPV, and accuracy for the PSV were 90%, 97%, 90%, 97%, and 95%, respectively.
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Affiliation(s)
- John S Pellerito
- Department of Radiology, North Shore University Hospital, Manhasset, NY 11030, USA.
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Abstract
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.
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Affiliation(s)
- Charles J Shanley
- Department of Surgery, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Abstract
This article briefly reviews the various etiologies, presentation, and diagnosis of different types of mesenteric ischemia. Operative management techniques and the applicability of percutaneous endovascular intervention are discussed. Finally, the authors explore emerging technologies that have the potential to further improve diagnosis and treatment of this frequently lethal disease process.
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Affiliation(s)
- Garth S Herbert
- Madigan Army Medical Center, Department of Surgery, Fort Lewis, Tacoma, WA 98431, USA
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