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Xu R, Tang L, Qin S, Zhang S, Wang M. Percutaneous Mechanical Thrombectomy Using the AcoStream Thrombus Aspiration System for Acute Superior Mesenteric Artery Embolism. Ann Vasc Surg 2024; 106:264-272. [PMID: 38815920 DOI: 10.1016/j.avsg.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/09/2024] [Accepted: 03/06/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND This study was performed to summarize our experience in treating acute superior mesenteric artery embolism (SMAE) by percutaneous mechanical thrombectomy (PMT). METHODS Between January 2023 and October 2023, 18 patients presenting with acute mesenteric ischemia were admitted to our center, including 11 cases of SMAE, 3 cases of superior mesenteric artery thrombosis, and 4 cases of superior mesenteric vein thrombosis. We retrospectively reviewed 8 patients (4 males and 4 females; range, 51-79 years; mean, 62.50 ± 9.67 years) who underwent treatment of acute SMAE using the AcoStream system. The patients had no obvious evidence of intestinal necrosis as shown by peritoneal puncture or computed tomography. Thrombectomy was performed on the superior mesenteric artery (SMA) using an 8F AcoStream thrombus aspiration system (Acotec, China). The demographics, risk factors, therapeutic effect, complications, mortality, and follow-up of the study population were assessed. RESULTS The technical success rate was 100%. After 1-3 passes (2.38 ± 0.92) and aspiration thrombectomy, complete thrombus removal was achieved in 7 (87.50%) patients. One patient received an adjunctive catheter-directed thrombolysis due to partial thrombus removal. Thrombolysis was conducted for 2 days, resulting in complete resolution of the thrombus. The other 7 patients did not receive adjunctive endovascular intervention due to complete thrombus removal and no residual stenosis. No distal embolization or device-related complications were noted during the procedure. After the procedure, sufficient clinical improvement was seen in 6 patients within 1-2 days. Two patients showed no significant improvement of their symptoms. Laparotomy was performed on day 1 and day 2 after thrombectomy in patients 3 and 7, respectively. Intestinal necrosis was diagnosed operatively and intestinal resection was performed. All patients were discharged 6-15 days (9.50 ± 3.07) after admission without perioperative complication or death. The mean follow-up period was 5.00 ± 3.30 months (range, 1-10 months), and the follow-up rate was 100%. During the follow-up, all patients remained symptom-free. Computed tomography angiography images showed good flow in the trunk and branches of the SMA in all patients. CONCLUSIONS PMT using the AcoStream system is a minimally invasive, safe, and effective technique for acute SMAE. Early application of PMT can achieve immediate revascularization of the SMA and have the potential advantage of avoiding laparotomy or reducing the extension of enterectomy, as it could theoretically restore intestinal perfusion in less time than open revascularization. If the symptoms do not improve after PMT, exploratory laparotomy should be scheduled as soon as possible. Further studies are necessary on this field to confirm these findings.
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Affiliation(s)
- Rongwei Xu
- Department of General Surgery, The First Affiliated Hospital to Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Linna Tang
- Department of Hospital Infection Control, The First Affiliated Hospital to Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Shiyong Qin
- Department of General Surgery, The First Affiliated Hospital to Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Shuguang Zhang
- Department of General Surgery, The First Affiliated Hospital to Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Minghai Wang
- Department of General Surgery, The First Affiliated Hospital to Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China.
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Pengermä P, Venesmaa S, Karjalainen J, Ukkonen M, Saari P, Kärkkäinen JM. Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia. J Vasc Surg 2023; 78:1524-1530. [PMID: 37586616 DOI: 10.1016/j.jvs.2023.08.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE To evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients' discharge to home vs nursing facility a decade after an episode of AMI. METHODS The retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR-). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI. RESULTS The mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR- group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR- group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR- patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up. CONCLUSIONS In this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.
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Affiliation(s)
- Pasi Pengermä
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Sari Venesmaa
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Ukkonen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Petri Saari
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
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Treffalls RN, Stonko DP, DeMartino RR, Morrison JJ. Acute management of mesenteric emergencies: Tailoring the solution to the problem. Semin Vasc Surg 2023; 36:234-249. [PMID: 37330237 DOI: 10.1053/j.semvascsurg.2023.04.007] [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: 03/17/2023] [Revised: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 06/19/2023]
Abstract
Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.
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Affiliation(s)
- Rebecca N Treffalls
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - David P Stonko
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
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Bötticher G. Akute mesenteriale Durchblutungsstörung – arterielle Thrombose. COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-023-00691-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Jing Y, Xu J, Chen B, Xia D, Xia D, Tian Y, Xia W, Lu C, Wu Y. Superior mesenteric artery embolism after radiofrequency ablation in regularly anticoagulated patients with paroxysmal atrial fibrillation: a case report. BMC Cardiovasc Disord 2023; 23:56. [PMID: 36710320 PMCID: PMC9885642 DOI: 10.1186/s12872-023-03066-5] [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] [Received: 09/07/2022] [Accepted: 01/12/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Superior mesenteric artery embolism (SMAE) is a rare cause of acute abdomen, and the fatality rate is extremely high if it is not diagnosed and treated in time. Due to the lack of knowledge and experience of nonspecialist physicians, it is easy to misdiagnose. Radiofrequency ablation (RFA) has become the first-line treatment strategy for atrial fibrillation (AF). Thromboembolic events are some of the major complications after RFA, whereas SMAE is rarely reported. CASE PRESENTATION A 70 year-old woman with paroxysmal AF who regularly took anticoagulant drugs for 3 months experienced abdominal pain after RFA. At the outset, she was misdiagnosed as mechanical intestinal obstruction. When the patient presented with blood in the stool, abdominal enhancement computed tomography was conducted and showed a small bowel perforation. Immediate laparotomy was performed, and the final diagnosis was SMAE. CONCLUSION It is suggested that for unexplained abdominal pain after RFA of AF, the possibility of SMAE should be considered, and a targeted examination should be carried out in time to confirm the diagnosis and give appropriate treatment.
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Affiliation(s)
- Yongle Jing
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Jianqiang Xu
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Bingwei Chen
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Dasheng Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Dachuan Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Yunpeng Tian
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Wei Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Chengzhi Lu
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Yuli Wu
- grid.417024.40000 0004 0605 6814Department of Anesthesiology, Tianjin First Central Hospital, No. 24, Fukang Road, Tianjin, 300192 China
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Abstract
The surgical treatment of occlusive acute mesenteric ischemia (AMI) without revascularization is associated with an 80% overall mortality. Early diagnosis is crucial, and revascularization may reduce overall mortality in AMI by up to 50%. A diagnosis of AMI requires a high index of clinical suspicion and the collaborative effort of emergency department physicians, general and vascular surgeons, and radiologists. This article provides an overview of the etiology, physiology, evaluation, and management of acute mesenteric ischemia.
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Affiliation(s)
| | | | - James Keck
- Colorectal Department, St. Vincent's Health, Melbourne, Australia
- Department of Colorectal Surgery, Eastern Health, Melbourne, Australia
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Chen C, Li YW, Shi PF, Qian SX. Acute Mesenteric Ischemia in Patients with COVID-19: Review of the literature. J Natl Med Assoc 2021; 114:47-55. [PMID: 34973847 PMCID: PMC8715336 DOI: 10.1016/j.jnma.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/19/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a global health emergency. In addition to common respiratory symptoms, some patients with COVID-19 infections may experience a range of extra-pulmonary manifestations, such as digestive system involvement. Patients with COVID-19 have been reported to suffer from acute mesenteric ischemia (AMI) that is associated with disease-related severity and mortality. However, in the context of COVID-19, the exact cause of AMI has yet to be clearly defined. This review provides a comprehensive overview of the available data and elucidates the possible underlying mechanisms linking COVID-19 to AMI, in addition to highlighting therapeutic approaches for clinicians. Finally, given the severe global impact of COVID-19, we emphasize the importance of coordinated vaccination programs.
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Affiliation(s)
- Can Chen
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China
| | - Yi-Wei Li
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China
| | - Peng-Fei Shi
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China
| | - Shen-Xian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China.
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Yang F, Guo XC, Rao XL, Sun L, Xu L. Acute appendicitis complicated by mesenteric vein thrombosis: A case report. World J Clin Cases 2021; 9:11400-11405. [PMID: 35071571 PMCID: PMC8717517 DOI: 10.12998/wjcc.v9.i36.11400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 06/29/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute appendicitis with mesenteric vein thrombosis (MVT) is an uncommon condition and usually lacks specific clinical manifestations, which leads to a high rate of misdiagnosis or delayed diagnosis, especially when it is accompanied by other abdominal diseases. Prompt and accurate recognition is vital for treatment and prognosis.
CASE SUMMARY A 37-year-old woman had a history of acute metastatic right lower abdominal pain, nausea, and fever. A contrast-enhanced computed tomography (CT) scan showed a filling defect in the mesenteric vessels. The patient was diagnosed with acute appendicitis complicated by MVT and was treated with anticoagulation and intravenous antibiotics. The follow-up CT scan showed full resolution of the thrombosis and inflammation.
CONCLUSION Clinical awareness is essential for recognizing MVT, especially when it is accompanied by other common acute abdominal diseases, such as acute appendicitis. Contrast-enhanced CT is helpful for the diagnosis of MVT and is recommended for patients with acute abdominal diseases.
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Affiliation(s)
- Fan Yang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, Beijing Province, China
| | - Xiao-Chao Guo
- Department of Radiology, Peking University First Hospital, Beijing 100034, Beijing Province, China
| | - Xiao-Long Rao
- Endoscopy Center, Peking University First Hospital, Beijing 100034, Beijing Province, China
| | - Lie Sun
- Department of General Surgery, Peking University First Hospital, Beijing 100034, Beijing Province, China
| | - Ling Xu
- Breast Disease Center, Peking University First Hospital, Beijing 100034, Beijing Province, China
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Yadong S, Haobo S, Liang C, Hao H, Zhaoxuan L, Jianping G. Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone. J Vasc Interv Radiol 2021; 33:295-303. [PMID: 34915163 DOI: 10.1016/j.jvir.2021.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/05/2021] [Accepted: 12/04/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the outcomes of stent thrombectomy combined with aspiration versus aspiration alone in acute mesenteric ischemia (AMI). METHODS This was a single-center, retrospective cohort study. Between 1 May 2012 and 1 January 2021, 41 patients (mean age, 73.8±7.9 years) with AMI who underwent stent thrombectomy plus aspiration (Group 1, n=14) or aspiration alone (Group 2, n=27) were included. Patients' treatment regimens, clinical and follow-up outcomes were reviewed and analyzed. The group differences were compared using a Chi square test, Fisher's exact test, independent t test, or Mann-Whitney U test. The cumulative survival rate was calculated using a Kaplan-Meier curve. RESULTS The overall clinical success rate was 78.0% (32/41), and no significant difference was found between Group 1 and Group 2 (78.6% vs. 77.8%, p = 1.00). Whereas Group 1 was associated with a higher complete clearance rate (78.6% vs. 44.4%, p = 0.04), less adjunctive local thrombolysis (14.3% vs. 48.1%, p = 0.03), and shorter length of hospital stay (5.7±4.7 vs. 10.7±9.0 days, p = 0.03). The estimated survival rate at 1 month, 3 months, 6 months, 1 year, and 2 years was 73.2%, 72.5%, 71.4%, 65.3%, and 59.8%, respectively. No significant difference was found in survival rate between the groups (log-rank, p = 0.96). The recurrence rate for Group 1 and Group 2 were 8.3% (1/12) and 4.0% (1/25), respectively. CONCLUSIONS Compared with aspiration alone, additional stent thrombectomy showed superiorities in higher complete clearance rate, reduced adjunctive thrombolysis, and shorter length of hospital stay.
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Affiliation(s)
- Shi Yadong
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Su Haobo
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Chen Liang
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Huang Hao
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Lu Zhaoxuan
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China
| | - Gu Jianping
- The Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Nanjing 210006, China.
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de Holanda GS, dos Santos Valença S, Carra AM, Lichtenberger RCL, de Castilho B, Franco OB, de Moraes JA, Schanaider A. Translational Application of Fluorescent Molecular Probes for the Detection of Reactive Oxygen and Nitrogen Species Associated with Intestinal Reperfusion Injury. Metabolites 2021; 11:metabo11120802. [PMID: 34940560 PMCID: PMC8705498 DOI: 10.3390/metabo11120802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/23/2021] [Accepted: 11/23/2021] [Indexed: 02/07/2023] Open
Abstract
Acute mesenteric ischemia, caused by an abrupt interruption of blood flow in the mesenteric vessels, is associated with high mortality. When treated with surgical interventions or drugs to re-open the vascular lumen, the reperfusion process itself can inflict damage to the intestinal wall. Ischemia and reperfusion injury comprise complex mechanisms involving disarrangement of the splanchnic microcirculatory flow and impairment of the mitochondrial respiratory chain due to initial hypoxemia and subsequent oxidative stress during the reperfusion phase. This pathophysiologic process results in the production of large amounts of reactive oxygen (ROS) and nitrogen (RNS) species, which damage deoxyribonucleic acid, protein, lipids, and carbohydrates by autophagy, mitoptosis, necrosis, necroptosis, and apoptosis. Fluorescence-based systems using molecular probes have emerged as highly effective tools to monitor the concentrations and locations of these often short-lived ROS and RNS. The timely and accurate detection of both ROS and RNS by such an approach would help to identify early injury events associated with ischemia and reperfusion and increase overall clinical diagnostic sensitivity. This abstract describes the pathophysiology of intestinal ischemia and reperfusion and the early biological laboratory diagnosis using fluorescent molecular probes anticipating clinical decisions in the face of an extremely morbid disease.
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Affiliation(s)
- Gustavo Sampaio de Holanda
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
- Correspondence: ; Tel.: +55-21-9657-13794
| | - Samuel dos Santos Valença
- Redox Biology Laboratory, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil; (S.d.S.V.); (J.A.d.M.)
| | - Amabile Maran Carra
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
| | - Renata Cristina Lopes Lichtenberger
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
| | - Bianca de Castilho
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
| | - Olavo Borges Franco
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
| | - João Alfredo de Moraes
- Redox Biology Laboratory, Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil; (S.d.S.V.); (J.A.d.M.)
| | - Alberto Schanaider
- Centre of Experimental Surgery, Post Graduate Program in Surgical Sciences, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro 219491-590, Brazil; (A.M.C.); (R.C.L.L.); (B.d.C.); (O.B.F.); (A.S.)
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11
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Olson KA, Teixeira PG. Mesenteric Ischemia: When and How to Revascularize. Adv Surg 2021; 55:75-87. [PMID: 34389101 DOI: 10.1016/j.yasu.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kristofor A Olson
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, 1500 Red River Street, Annex, Austin, TX 78701, USA
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, 1500 Red River Street, Annex, Austin, TX 78701, USA.
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12
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Tolonen M, Lemma A, Vikatmaa P, Peltola E, Mentula P, Björkman P, Leppäniemi A, Sallinen V. The implementation of a pathway and care bundle for the management of acute occlusive arterial mesenteric ischemia reduced mortality. J Trauma Acute Care Surg 2021; 91:480-488. [PMID: 34086659 PMCID: PMC8404963 DOI: 10.1097/ta.0000000000003305] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a disease with high mortality and requires a multidisciplinary approach for effective management. A pathway and care bundle were developed and implemented with the objective to reduce mortality. The aim of this retrospective comparative study was to analyze the effects of the pathway on patient management and outcome. METHODS All consecutive patients operated in a secondary and tertiary referral center because of occlusive arterial AMI were identified between 2014 and April 2020. The pathway aimed to increase overall awareness, and hasten and improve diagnostics and management. Patients treated before implementation of the pathway (pregroup, years 2014-2017) were compared with patients treated using the pathway (postgroup, May 2018 to April 2020). Univariate and multivariate analyses were used to compare the groups. RESULTS There were 78 patients in the pregroup and 67 patients in the postgroup with comparable baseline characteristics and disease acuity. The postgroup was more often diagnosed with contrast-enhanced computed tomography (58 [74%] vs. 63 [94%], p = 0.001) and had shorter mean in-hospital delay to operating room (7 hours [interquartile range, 3.5-12.5] vs. 3 hours [interquartile range, 2-11], p = 0.023). Revascularization was done more often in the postgroup (53 [68%] vs. 56 [84%], p = 0.030) especially using endovascular treatment (26 [33%] vs. 43 [64%], p < 0.001). Thirty-day mortality was lower in the postgroup (23 [51%] vs. 17 [25%], p = 0.001). Being managed in the postgroup remained as a protective factor (odds ratio, 0.32; 95% confidence interval, 0.14-0.75; p = 0.008) for 30-day mortality in the multivariate analysis. CONCLUSION Implementing a pathway and care bundle resulted in enhanced regional and in-hospital awareness of AMI, more appropriate computed tomography imaging, shorter in-hospital delays, increased number of revascularizations, and, hence, lower mortality. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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13
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Kärkkäinen JM. Acute Mesenteric Ischemia: A Challenge for the Acute Care Surgeon. Scand J Surg 2021; 110:150-158. [PMID: 33866891 PMCID: PMC8258713 DOI: 10.1177/14574969211007590] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/11/2021] [Indexed: 11/27/2022]
Abstract
Acute mesenteric ischemia is considered uncommon, but it appears to be more frequent cause of acute abdomen than appendicitis or ruptured abdominal aortic aneurysm in elderly patients. Surgical treatment without revascularization is associated with high overall mortality, up to 80%. The modern treatment of acute mesenteric ischemia requires collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. Early revascularization may reduce the overall mortality associated with acute mesenteric ischemia by up to 50%. Clinical suspicion and contrast-enhanced computed tomography performed at early stage are keys to improve outcomes of acute mesenteric ischemia treatment. This review summarizes what the acute care surgeon needs to know about acute mesenteric ischemia with special emphasis on slowly progressing "acute on chronic" mesenteric ischemia.
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Hyperspectral imaging and indocyanine green fluorescence angiography in acute mesenteric ischemia: A case report on how to visualize intestinal perfusion. Int J Surg Case Rep 2021; 82:105853. [PMID: 33838488 PMCID: PMC8045037 DOI: 10.1016/j.ijscr.2021.105853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 01/06/2023] Open
Abstract
First case of HSI and ICG in Acute mesenteric ischemia. Similar results of moth modalities with regard to well perfused intestine. ICG shows exact vascular blood supply and intestinal perfusion. Hyperspectral imaging can distinguish necrotic and vital intestinal segments in AMI. Combined use helps surgeons to evaluate intestinal perfusion intraoperatively in AMI.
Introduction and importance Acute mesenteric ischemia is a challenging acute condition which is often caused by occlusion of an intestinal vessel. Therapeutic algorithms include revascularization of the occluded vessel and a surgical procedure to remove necrotic intestine. Sometimes necrotic intestine is hard to identify visually. Therefore, tools such as hyperspectral imaging (HSI) and indocyanine green fluorescence angiography (ICGFA) might be helpful for objective intraoperative evaluation of intestinal perfusion. Case presentation We present a case of an 80-year-old woman with an acute superior mesenteric artery occlusion and subsequent intestinal gangrene. After endovascular arterial revascularization, we performed an explorative laparotomy in which we assessed intestinal perfusion by HSI and ICGFA. Both HSI and ICGFA showed a sharp perfusion borderline in the proximal jejunum. The distal intestine showed low tissue oxygenation (HSI) and inhomogeneous perfusion (ICGFA). Clinical discussion Both methods showed reproducible results for tissue perfusion and, thus, could provide additional information on the extent of necrotic bowel with need for resection. Therefore, both modalities might be used in future image-guided surgery in cases of acute mesenteric ischemia where visual discrimination of intestinal perfusion is challenging in order to resect as much bowel as necessary to improve patient outcome. Both methods exert different strengths: i.e. ICGFA is real-time angiography, whereas HSI may expose intestinal necrosis in spectroscopy. Conclusion We show, for the first time, simultaneous imaging of HSI and ICGFA in a case of acute mesenteric ischemia. Both imaging modalities reveal similar results reliably concerning intestinal perfusion.
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Mehdorn M, Köhler H, Rabe SM, Niebisch S, Lyros O, Chalopin C, Gockel I, Jansen-Winkeln B. Hyperspectral Imaging (HSI) in Acute Mesenteric Ischemia to Detect Intestinal Perfusion Deficits. J Surg Res 2020; 254:7-15. [DOI: 10.1016/j.jss.2020.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/19/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
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Madurska MJ, Anderson RG, Anderson DJ, McNeill CJ, Jansen JO, Stuart WP, Morrison JJ. Mesenteric vascular disease: A population-based cohort study. Vascular 2020; 29:54-60. [PMID: 32605533 DOI: 10.1177/1708538120937954] [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: 11/15/2022]
Abstract
OBJECTIVES Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime. METHODS This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation. RESULTS From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R2 = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014. CONCLUSIONS The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | | | | | - Jan O Jansen
- University of Alabama at Birmingham Hospital, Birmingham, USA
| | | | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
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Jagielski M, Piątkowski J, Jackowski M. Challenges Encountered during the Treatment of Acute Mesenteric Ischemia. Gastroenterol Res Pract 2020; 2020:5316849. [PMID: 32328096 PMCID: PMC7150694 DOI: 10.1155/2020/5316849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/17/2020] [Indexed: 01/16/2023] Open
Abstract
RESULTS Acute ischemia of the bowel mesentery was diagnosed in 41 patients (27 women and 14 men; mean age, 65.4 years). All patients underwent laparotomy. For 13 (31.71%) patients, surgery was performed within the first 24 hours of the clinical symptom onset. Mesenteric artery embolectomy without intestine resection was performed for 7 (17.07%) patients. Partial intestine resection due to necrosis was performed for 21 (51.22%) patients. Exploratory laparotomy without a therapeutic procedure was performed for 13 (31.71%) patients. Fifteen (36.59%) patients were discharged home in good general condition. Twenty-six (63.41%) patients died. The time from the clinical symptom onset until intervention exceeded 24 hours for all patients who died. Surgery within the first 24 hours reduced mortality associated with acute mesenteric ischemia (P = 0.001). Female sex, age older than 65 years, obesity (body mass index > 30), diabetes, chronic kidney disease, and smoking were adverse prognostic factors for increased mortality for patients with acute bowel ischemia. CONCLUSION The time from clinical symptoms to acute mesenteric ischemia treatment was the main prognostic factor and helped determine appropriate management. Early diagnosis and rapid intervention improved treatment outcomes and survival.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Toruń, Poland
| | - Jacek Piątkowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Toruń, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Toruń, Poland
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Abstract
PURPOSE OF REVIEW Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders. RECENT FINDINGS There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.
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Affiliation(s)
| | - Paul Feuerstadt
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA. .,Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, CT, USA.
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Chernookov AI, Kuznetsov MR, Ataian AA, Iarkov SA, Ivanova MI, Khachatrian ÉO. [Endovascular surgery in treatment of patients with acute impairment of mesenteric circulation in the stage of intestinal ischaemia]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:67-73. [PMID: 30994610 DOI: 10.33529/angio2019109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Analysed herein are the results of endovascular revascularization of the superior mesenteric artery (SMA). The study included a total of 18 patients with acute impairment of mesenteric circulation in the stage of intestinal ischaemia. The patients underwent multispiral computed tomography (MSCT) and once impairments of blood flow in the SMA were revealed, we performed endovascular revascularization of the artery. Patency of the SMA was assessed by repeat contrast-enhanced MSCT. Thirteen (72.2%) patients were found to have occlusion in the system of the SMA and five (27.8%) were diagnosed as having significant stenoses of the SMA. All 13 patients with occlusion of the SMA underwent vacuum thrombextraction followed by transluminal balloon angioplasty (TBA). Of these, thrombotic masses were obtained in 11 (84.6%) patients. Stents were implanted in 3 cases wherein TBA turned out inefficient. The patients with haemodynamically significant stenoses of the SMA were subjected to TBA followed by stent implantation. Good roentgenoendovascular results of restoration of blood flow through the SMA and its branches were obtained in 83.4% of cases. Assessing blood parameters and patients' condition severity revealed positive dynamics or a tendency towards improvement. The mortality rate amounted to 16.6%. A conclusion drawn is that this technique is efficient and appropriate for SMA lesions of any localization.
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Affiliation(s)
- A I Chernookov
- First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health (Sechenov University), Moscow, Russia
| | - M R Kuznetsov
- Municipal Clinical Hospital #29 named after N.E. Bauman, Moscow, Russia; Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia
| | - A A Ataian
- First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health (Sechenov University), Moscow, Russia; Municipal Clinical Hospital #29 named after N.E. Bauman, Moscow, Russia
| | - S A Iarkov
- Municipal Clinical Hospital named after S.S. Yudin, Moscow, Russia
| | - M I Ivanova
- Municipal Clinical Hospital #29 named after N.E. Bauman, Moscow, Russia
| | - É O Khachatrian
- First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health (Sechenov University), Moscow, Russia
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Erben Y, Protack CD, Jean RA, Sumpio BJ, Miller SM, Liu S, Trejo G, Sumpio BE. Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia. J Vasc Surg 2018; 68:459-469. [DOI: 10.1016/j.jvs.2017.11.078] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/09/2017] [Indexed: 01/23/2023]
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Abstract
The incidence of atherosclerotic mesenteric ischemia increases gradually with the aging of the population and rising of the incidence of atherosclerosis. In the last decade, mesenteric atherosclerosis has become the most common cause of acute and chronic mesenteric ischemia. Atherosclerotic mesenteric ischemia often presents with an insidious onset and slow evolvement, and is easily overlooked. The CT manifestations of advanced mesenteric ischemia are classic with high diagnostic accuracy, and the specific findings of CT angiography include: thromboembolus and stenotic or occlusive mesenteric artery in acute stage, single or multiple calcified or non-calcified plaques, and multiple stenotic and stiff mesenteric arteries with reduced branching vessels in chronic stage. Early mesenteric ischemia, however, has no or nonspecific CT sign and is difficult to detect. This article discusses the diagnostic value and limitations of multi-slice CT in atherosclerotic mesenteric ischemia as well as some new imaging techniques for diagnosis of this condition.
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Affiliation(s)
- Xiao-Jun Ren
- Department of Radiology, Xidian Group Hospital Affiliated to Shaanxi University of Chinese Medicine, Xi'an 710077, Shaanxi Province, China
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