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Xhepa G, Vanzulli A, Sciacqua LV, Inzerillo A, Faerber P, Ierardi AM, Carrafiello G, Del Grande F, Ricoeur A. Advancements in Treatment Strategies for Chronic Mesenteric Ischemia: A Comprehensive Review. J Clin Med 2023; 12:7112. [PMID: 38002726 PMCID: PMC10672107 DOI: 10.3390/jcm12227112] [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: 10/17/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Chronic mesenteric ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability in patient symptoms and the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduction of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate efficacy, patency rates, and long-term outcomes in CMI patients.
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Affiliation(s)
- Genti Xhepa
- Istituto Di Imaging ella Svizzera Italiana (IIMSI), Clinica Di Radiologia, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland;
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Andrea Vanzulli
- Residency Program in Diagnostic and Interventional Radiology, Università degli Studi di Milano, 20126 Milan, Italy; (A.V.); (L.V.S.)
| | - Lucilla Violetta Sciacqua
- Residency Program in Diagnostic and Interventional Radiology, Università degli Studi di Milano, 20126 Milan, Italy; (A.V.); (L.V.S.)
| | - Agostino Inzerillo
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Pierre Faerber
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Anna Maria Ierardi
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy;
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, IRCCS Ca’ Granda Fondazione Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20126 Milan, Italy;
| | - Filippo Del Grande
- Istituto Di Imaging ella Svizzera Italiana (IIMSI), Clinica Di Radiologia, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland;
- Facoltà Di Scienze Biomediche, Campus Est, Università Della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Alexis Ricoeur
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
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Nana P, Koelemay MJW, Leone N, Brodis A, van den Berg JC, de Bruin JL, Geelkerken RH, Spanos K. A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2023; 66:632-643. [PMID: 37451604 DOI: 10.1016/j.ejvs.2023.07.011] [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] [Received: 03/16/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Mark J W Koelemay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Konstantinos Spanos
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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Alnahhal KI, Sorour AA, Lyden SP, Caputo FJ, Park WM, Rowse JW, Quatromoni JG, Khalifeh A, Dehaini H, Bena JF, Kirksey L. Management of patients with chronic mesenteric ischemia across three consecutive eras. J Vasc Surg 2023; 78:1228-1238.e1. [PMID: 37399971 DOI: 10.1016/j.jvs.2023.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. METHODS A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. RESULTS A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). CONCLUSIONS Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Woosup M Park
- Division of Vascular Surgery, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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Andraska EA, Tran LM, Haga LM, Mak AK, Madigan MC, Makaroun MS, Eslami MH, Chaer RA. Contemporary management of acute and chronic mesenteric ischemia: 10-year experience from a multihospital healthcare system. J Vasc Surg 2021; 75:1624-1633.e8. [PMID: 34788652 PMCID: PMC9038632 DOI: 10.1016/j.jvs.2021.11.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Endovascular and hybrid methods are being increasingly used to treat mesenteric ischemia. However, long-term outcomes and risk of symptom recurrence remain unknown. The objective of this study was to define predictors of post-operative morbidity, mortality, and patency loss in acute (AMI) or chronic mesenteric ischemia (CMI). METHODS Inpatient and follow-up records for all patients who underwent revascularization for AMI and CMI from 2010 to 2020 at a multicenter hospital system were reviewed. Patency and mortality were evaluated with Cox regression, visualized with Kaplan-Meier curves, and compared using log rank testing. Patency was further evaluated with Fine-Gray regression utilizing death as a competing risk. Post-operative major adverse events (MAE) and 30-day mortality were evaluated with logistic regression. RESULTS 407 patients were included; 148 AMI and 259 CMI. In AMI, 30-day mortality was 31%. Open surgery was associated with lower rates of bowel resection (OR 0.23, 95% CI 0.13, 0.61). Etiology of AMI also did not change outcomes (OR 1.30, 95% CI 0.77, 2.19). Adjusted analyses indicates that a history of diabetes (OR 2.77, 95% CI 1.37, 5.61) and sepsis on presentation (OR 2.32, 95% CI 1.18, 4.58) were independently associated with increased risk of 30-day MAE. In CMI, open surgery and CKD were associated with higher MAE (OR 3.03, 95% CI 1.14, 8.05; OR 2.37, 95% CI 1.31, 4.31) while CKD (OR 3.02, 95% CI 1.10, 8.37) and inpatient status prior to revascularization (OR 2.78, 95% CI 1.01, 7.61) were associated with increased 30-day mortality. In CMI, patients in the endovascular cohort had higher rates of symptom recurrence (29% vs. 13%) with faster onset (endovascular 64 days vs. bypass 338 days). CONCLUSIONS AMI remains a morbid disease despite evolving revascularization techniques. An open approach should remain the gold standard as it reduces likelihood of bowel resection. In CMI, endovascular interventions have improved post-operative morbidity but result in early symptom recurrence and re-interventions. An endovascular-first approach should be standard in CMI with close surveillance.
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Affiliation(s)
- Elizabeth A Andraska
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute.
| | - Lillian M Tran
- University of Pittsburgh Medical Center, Department of Surgery
| | - Lindsey M Haga
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | | | - Michael C Madigan
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Michel S Makaroun
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Mohammad H Eslami
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
| | - Rabih A Chaer
- University of Pittsburgh Medical Center, Department of Surgery, Heart and Vascular Institute
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Awouters J, Jardinet T, Hiele M, Laenen A, Dymarkowski S, Fourneau I, Maleux G. Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia. VASA 2021; 50:431-438. [PMID: 34231372 DOI: 10.1024/0301-1526/a000964] [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: 11/19/2022]
Abstract
Background: To analyse the long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) in the treatment of chronic mesenteric ischemia (CMI), and to assess predictive factors for a better clinical outcome. Patients and methods: Retrospective analysis of 76 consecutive patients, treated percutaneously for CMI between January 1999 and January 2018 and followed up until the end of 2018. Patients' pre-, peri- and post-interventional clinical and radiological data were gathered from the institutional electronic medical records. The Kaplan Meier method with log rank test or the Cox model were used to analyse overall survival; the cumulative incidence function with Pepe and Mori test or the Fine and Grey model were used to analyse relapse-free survival, considering death as a competing event. Results: Seventy-six consecutive patients with a mean age of 72 years were included in the study. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23 (29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical success was achieved in n=68 (89.5%), and procedural complications were observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n=21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0% and 28.2% after two, five and ten years of follow-up, respectively. A trend towards longer relapse-free survival was found in the circumferential stenosis group (78.2% at five years) compared with the non-circumferential stenosis group (55.5%) (P=0.063). Conclusions: Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite a substantial number of patients experiencing clinical relapse over time. Patients with focal, circumferential stenosis might have longer relapse-free survival than patients with non-circumferential stenosis.
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Affiliation(s)
- Joris Awouters
- Department of Radiology, University Hospitals Leuven, Belgium
| | - Thomas Jardinet
- Department of Radiology, University Hospitals Leuven, Belgium
| | - Martin Hiele
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Belgium
| | - Annouschka Laenen
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (L-BioStat), Leuven, Belgium
| | | | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Belgium
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Rebelo A, Partsakhashvili J, John E, Kleeff J, Ukkat J. Current concepts and evidence on open, endovascular and hybrid treatment of mesenteric ischemia: The retrograde open mesenteric stenting. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2020.100022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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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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García-Romera Á, Díaz-Pérez B, Ramírez E, Vallés H, Bravo-Gutiérrez A, Alarcó-Hernández A. Non-surgical treatment of chronic mesenteric ischemia owing to lesion in the SMA through the SMI: An option for consideration in frail patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:624-625. [PMID: 32674881 DOI: 10.1016/j.gastrohep.2020.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/13/2020] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Ángel García-Romera
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España.
| | - Beatriz Díaz-Pérez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | - Ester Ramírez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | - Heliodoro Vallés
- Servicio de Radiología Intervencionista, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | - Alberto Bravo-Gutiérrez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | - Antonio Alarcó-Hernández
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
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Endovascular Pressure Measurements to Assess the Functional Severity of Mesenteric Arterial Stenoses. J Vasc Interv Radiol 2020; 31:430-437. [PMID: 32007405 DOI: 10.1016/j.jvir.2019.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the ability of pressure measurements to discriminate clinically significant celiac artery (CA) or superior mesenteric artery (SMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). MATERIALS AND METHODS Single-center, retrospective cohort study of 41 intra-arterial pressure measurements during mesenteric angiography with intended revascularization, performed in 37 patients (mean age 67.7 ± 10.8 years, 62% female) between April 2015 and May 2017. Simultaneous prestenotic and poststenotic pressure measurements had been obtained before and after intra-arterial administration of nitroglycerin. Revascularization was performed in 38 of 41 procedures. Definitive diagnosis of CMI was defined as patient-reported symptom relief or improvement after successful revascularization. RESULTS Pressure gradients obtained after vasodilator administration were significantly higher in CAs and SMAs with ≥50% stenosis. Pressure ratios (pressure distal [Pd]/pressure aorta [Pa]) obtained after vasodilator administration were significantly higher in CAs with ≥50% stenosis. Subgroup analysis of 22 patients with a ≥50% stenosis of either CA or SMA showed significantly higher pressure gradients and Pd/Pa ratios after vasodilator administration in CMI patients (median pressure gradient: CMI [interquartile ratio] 36 [21-40] mm Hg versus no-CMI 20 [9-21] mm Hg, P = 0.041; Pd/Pa: CMI 0.703 [0.598-0.769] versus no-CMI 0.827 [0.818-0.906], P = .009). A ≤0.8 Pd/Pa cutoff value after administration of a vasodilator best identified a clinically relevant stenosis, with 86% sensitivity and 83% specificity. Complications related to the pressure measurements were not observed. CONCLUSIONS Intra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis.
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Haben C, Park WM, Bena JF, Parodi FE, Lyden SP. Improving midterm results justify the continued use of bare-metal stents for endovascular therapy for chronic mesenteric ischemia. J Vasc Surg 2020; 71:111-120. [DOI: 10.1016/j.jvs.2019.01.094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/01/2019] [Indexed: 10/26/2022]
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Ohtsuka R, Amano H, Hashimoto M, Iwao T. Pancreaticoduodenectomy following total occlusion of the superior mesenteric artery: a case report and literature review. Surg Case Rep 2019; 5:168. [PMID: 31686292 PMCID: PMC6828884 DOI: 10.1186/s40792-019-0718-2] [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: 05/22/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Patients with chronic occlusion of the celiac artery and superior mesenteric artery (SMA) are often asymptomatic, and occlusion may be caused by arteriosclerosis or median arcuate ligament compression. Pancreaticoduodenectomy (PD) is occasionally performed for patients with celiac artery occlusion; however, reports on patients with SMA occlusion are rare. We report a patient with cholangiocarcinoma and total atherosclerotic occlusion of the SMA without preoperative stenting or bypass. Case presentation A 73-year-old man suspected to have lower bile duct carcinoma was admitted to our hospital for further treatment. Three-dimensional computed tomography (3DCT) showed a common bile duct tumor and total occlusion of the SMA with collateral circulation of the gastroduodenal artery (GDA) and inferior mesenteric artery (IMA). We performed a PD. During the operation, we used test clamping of the GDA, which revealed no bowel ischemia. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 30. 3DCT on POD 98 and POD 307 showed development of collateral circulation between the IMA and SMA. Conclusion Here, we report the case of a patient with total occlusion of the SMA who subsequently underwent PD. 3DCT was instrumental in gathering vascular collateral information and thus we conclude that the assessment of collateral circulation before surgery is important.
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Affiliation(s)
- Reo Ohtsuka
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan
| | - Hodaka Amano
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Michiyo Hashimoto
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Toshiyasu Iwao
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
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Robles-Martín ML, Reyes-Ortega JP, Rodríguez-Morata A. A Rare Case of Ischemia–Reperfusion Injury After Mesenteric Revascularization. Vasc Endovascular Surg 2019; 53:424-428. [DOI: 10.1177/1538574419839547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- María L. Robles-Martín
- Department of Angiology and Vascular Surgery, Quirónsalud Málaga Hospital, Málaga, Spain
| | - Juan P. Reyes-Ortega
- Department of Angiology and Vascular Surgery, Quirónsalud Málaga Hospital, Málaga, Spain
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Fidelman N, AbuRahma AF, Cash BD, Kapoor BS, Knuttinen MG, Minocha J, Rochon PJ, Shaw CM, Ray CE, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Mesenteric Ischemia. J Am Coll Radiol 2018; 14:S266-S271. [PMID: 28473083 DOI: 10.1016/j.jacr.2017.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 12/29/2022]
Abstract
Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Nicholas Fidelman
- Principal Author, University of California San Francisco, San Francisco, California.
| | - Ali F AbuRahma
- West Virginia University, Charleston, West Virginia; Society of Vascular Surgery
| | - Brooks D Cash
- University of South Alabama, Mobile, Alabama; American Gastroenterological Association
| | | | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Paul J Rochon
- University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | - Colette M Shaw
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Charles E Ray
- Specialty Chair, University of Illinois Hospital and Health Science System, Chicago, Illinois
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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: 29] [Impact Index Per Article: 4.8] [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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15
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Roussel A, Nuzzo A, Pellenc Q, Castier Y, De Blic R, Cerceau P, Boulitrop C, Coblence M, Aguir S, Mordant P, Maggiori L, Huguet A, Sibert A, Joly F, Corcos O. Surgical revascularization of the celiac artery for persistent intestinal ischemia in short bowel syndrome. Int J Surg 2018; 49:39-44. [DOI: 10.1016/j.ijsu.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/30/2017] [Accepted: 12/08/2017] [Indexed: 01/19/2023]
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Abstract
Mesenteric ischemia is an uncommon disease most often seen in the elderly. This disease results from blood flow in the mesenteric circulation that inadequately meets metabolic needs of the visceral organs and, if untreated, eventually leads to necrosis of the bowel wall. Mesenteric ischemia is divided into 2 types: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Delayed diagnosis of CMI can lead to AMI. AMI is associated with extremely high mortalities. Early diagnosis via computed tomography angiography and prompt revascularization via endovascular therapy are recommended for symptomatic patients who have not developed bowel ischemia and necrosis.
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Affiliation(s)
- Robin M Lawson
- Academic Programs, The University of Alabama, Capstone College of Nursing, 650 University Boulevard, East, Tuscaloosa, AL 35401, USA.
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17
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Guo B, Guo D, Xu X, Chen B, Jiang J, Yang J, Shi Z, Fu W. Endovascular Management for Symptomatic Chronic Mesenteric Ischemia: A Single-Center Experience. Vasc Endovascular Surg 2017; 51:453-459. [PMID: 28764609 DOI: 10.1177/1538574417720364] [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: 01/16/2023]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to classical intestinal ischemia, although a clear pathophysiology has yet to be elucidated. Here, we have presented our institution's experience in the management of symptomatic CMI. METHODS From February 2007 to February 2016, a retrospective study was performed of all consecutive patients with symptomatic CMI managed by endovascular treatment (ET). We reviewed these patients' demographics, comorbidities, clinical presentations, and treatment modalities. Perioperative and midterm outcomes included technical success, clinical symptom relief, complications, symptomatic recurrence, mortality, restenosis, and reintervention. RESULTS Thirty-five mesenteric arteries (74.3% stenotic/25.7% occluded) identified in 32 patients (12 females, 20 males) were treated with endovascular procedures. There were no 30-day deaths; the perioperative complication rate was 12.5%. Overall, the median postprocedural time to symptom relief was 7.6 days (range: 1-30 days). Twenty-two (68.8%) had complete remission of symptom, whereas 7 (21.9%) had partial improvement in symptom after ET. After a mean follow-up of 35.4 (25.9) months, 5 (15.6%) patients developed recurrent symptoms, with 4 requiring reinterventions. The primary patency was 93.7%, 82.6%, and 73.1% at 12, 24, and 36 months, respectively, and the freedom from symptomatic recurrence was 90.6%, 84.0%, 84.0%, and 84.0% at 6, 12, 24, and 36 months, respectively. CONCLUSIONS Endovascular treatment for patients with CMI had a high technical success rate and satisfactory clinical outcomes. Symptomatic recurrence was not frequent but found mainly within 12 months following the initial procedure.
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Affiliation(s)
- Baolei Guo
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Daqiao Guo
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Xin Xu
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Bin Chen
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Junhao Jiang
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Jue Yang
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Zhenyu Shi
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Weiguo Fu
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
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18
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Trends in Treatment and Mortality for Mesenteric Ischemia in the United States from 2000 to 2012. Ann Vasc Surg 2017; 42:111-119. [PMID: 28359796 DOI: 10.1016/j.avsg.2017.01.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/03/2017] [Accepted: 01/07/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND It is unknown whether increased endovascular treatment of chronic mesenteric ischemia has led to decreases in open surgery, acute mesenteric ischemia, or overall mortality. The present study evaluates the trends in endovascular and open treatment over time for chronic and acute mesenteric ischemia. METHODS We identified patients with chronic or acute mesenteric ischemia in the Nationwide Inpatient Sample and Center for Disease Control and Prevention database from 2000 to 2012. Trends in revascularization, mortality, and total deaths were evaluated over time. Data were adjusted to account for population growth. RESULTS There were 14,810 revascularizations for chronic mesenteric ischemia (10,453 endovascular and 4,358 open) and 11,294 revascularizations for acute mesenteric ischemia (4,983 endovascular and 6,311 open). Endovascular treatment increased for both chronic (0.6-4.5/million, P < 0.01) and acute mesenteric ischemia (0.6-1.8/million, P < 0.01). However, concurrent declines in open surgery did not occur (chronic: 1-1.1/million, acute: 1.8-1.7/million). Among patients with acute mesenteric ischemia, the proportion with atrial fibrillation (18%) and frequency of embolectomy (1/million per year) remained stable. In-hospital mortality rates decreased for both endovascular (chronic: 8-3%, P < 0.01; acute: 28-17%, P < 0.01) and open treatment (chronic: 21-9%, P < 0.01; acute: 40-25%, P < 0.01). Annual population-based mortality remained stable for chronic mesenteric ischemia (0.7-0.6 deaths per million/year), but decreased for acute mesenteric ischemia (12.9-5.3 deaths per million/year, P < 0.01). CONCLUSIONS Population mortality from acute mesenteric ischemia declined from 2000 to 2012, correlated with dramatic increases in endovascular intervention for chronic mesenteric ischemia, and in spite of a stable rate of embolization. However, open surgery for both chronic and acute ischemia remained stable.
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19
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Bulut T, Oosterhof-Berktas R, Geelkerken RH, Brusse-Keizer M, Stassen EJ, Kolkman JJ. Long-Term Results of Endovascular Treatment of Atherosclerotic Stenoses or Occlusions of the Coeliac and Superior Mesenteric Artery in Patients With Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2017; 53:583-590. [PMID: 28254161 DOI: 10.1016/j.ejvs.2016.12.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/25/2016] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Over the past decade, primary percutaneous mesenteric artery stenting (PMAS) has become an alternative to open revascularisation for treatment of mesenteric ischaemia. Institutes have presented favourable short-term outcomes after PMAS, but there is a lack of data on long-term stent patency. METHODS One hundred and forty-one patients treated by PMAS for acute and chronic mesenteric ischaemia over an 8 year period were studied. Anatomical success was assessed by duplex ultrasound and/or CT angiography. A stenosis ≥70% was considered to be a failure. RESULTS Eighty-six coeliac arteries (CA) and 99 superior mesenteric arteries (SMA) were treated with PMAS in 141 patients. Nine CAs (10%) and 30 SMAs (30%) were occluded at the time of treatment. Median follow-up was 32 months (IQR 20-46). The overall primary patency rate at 12 and 60 months was 77.0% and 45.0%. The overall primary assisted patency rate was 90.3% and 69.8%. Overall secondary patency was 98.3% and 93.6%. CONCLUSION This study shows excellent long-term secondary patencies after PMAS, comparable with published data on long-term patencies after open surgical revascularisation.
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Affiliation(s)
- T Bulut
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - R Oosterhof-Berktas
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Radiology Martini Ziekenhuis, Groningen, The Netherlands
| | - R H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Faculty Science and Technology, Experimental Centre of Technical Medicine, University of Twente, Enschede, The Netherlands
| | - M Brusse-Keizer
- Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - E J Stassen
- Department of Radiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J J Kolkman
- Department of Gastroenterology, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Gastroenterology University Medical Centre, Groningen, The Netherlands
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20
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Goldman MP, Reeve TE, Craven TE, Edwards MS, Corriere MA, Hurie JB, Garg N, Velazquez-Ramirez G. Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions. Ann Vasc Surg 2017; 38:29-35. [DOI: 10.1016/j.avsg.2016.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/08/2016] [Accepted: 08/18/2016] [Indexed: 11/30/2022]
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21
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Columbo JA, Kang R, Goodney PP. Endovascular-First for Chronic Mesenteric Ischemia and the Importance of Long-Term Surveillance. Angiology 2016; 68:841-842. [PMID: 27856668 DOI: 10.1177/0003319716679342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ravinder Kang
- 2 Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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22
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Rajaratnam K, Paraskevas KI, Ramli AH, Shehata A, Jackson R, Clarke MJ. Celiac and Superior/Inferior Mesenteric Angioplasty and Stenting for Chronic Mesenteric Ischemia: A Single-Center Experience. Angiology 2016; 68:571-574. [DOI: 10.1177/0003319716662424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angioplasty and stenting emerged as the less invasive treatment options compared to open surgical revascularization for the management of patients with chronic mesenteric ischemia (CMI). However, endovascular techniques may not achieve symptomatic relief in many patients with CMI. We report our results from the endovascular management of patients with CMI. Data were reviewed from 45 patients undergoing celiac and/or mesenteric angioplasty and stenting for CMI, from October 2006 to January 2016. Angioplasty and stenting of celiac and/or mesenteric arteries were successful in relieving symptoms completely in 29 of 45 and partially in 6 of 45 patients. Only 10 of 45 patients mentioned no improvement, while symptom recurrence occurred in another 3 of 45 patients between 3 and 36 months postprocedurally due to stent occlusion. Angioplasty and stenting of celiac and/or mesenteric arteries provide symptomatic relief in a considerable percentage of patients with CMI. If symptoms fail to improve, an open surgical revascularization procedure should be considered.
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Affiliation(s)
- Kanapathi Rajaratnam
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Kosmas I. Paraskevas
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ahmad Hariz Ramli
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Amro Shehata
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ralph Jackson
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michael J. Clarke
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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23
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Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure. J Vasc Surg 2016; 63:1582-7. [DOI: 10.1016/j.jvs.2016.02.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/10/2016] [Indexed: 11/17/2022]
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24
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Jaster A, Choudhery S, Ahn R, Sutphin P, Kalva S, Anderson M, Pillai AK. Anatomic and radiologic review of chronic mesenteric ischemia and its treatment. Clin Imaging 2016; 40:961-9. [PMID: 27232932 DOI: 10.1016/j.clinimag.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 01/01/2023]
Abstract
Chronic mesenteric ischemia (CMI) is a vascular occlusive disease process that generally affects the elderly population. Clinical presentation occurs when two of the three mesenteric arteries are affected and includes non-specific abdominal pain and weight loss. The most common cause of CMI is atherosclerotic arterial occlusion. The aim of this review is to present the vascular anatomy of the mesenteric arterial circulation including the different collateral pathways. The imaging findings and the different treatment options with a brief review of the literature is presented.
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Affiliation(s)
- Adam Jaster
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX.
| | - Sadia Choudhery
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Richard Ahn
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Patrick Sutphin
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Sanjeeva Kalva
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Matthew Anderson
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Anil K Pillai
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
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25
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Christofi G, Donas KP, Pitoulias GA, Torsello G, Schwindt AG, Stavroulakis K. Endovascular treatment of occluded and stenotic visceral vessels in patients with chronic mesenteric ischemia. Vascular 2015; 25:3-9. [PMID: 26438613 DOI: 10.1177/1708538115608579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Current evidence in the literature about endovascular treatment (ET) of visceral vessels in patients with chronic mesenterial ischemia (CMI) based on morphological characteristics is limited. The aim of this study was the evaluation of ET in occluded and stenotic visceral vessels. Methods Patients undergoing ET for CMI between November 2000 and November 2012 were included in this retrospective study. Primary measure outcome was the symptom-free survival (SFS). Secondary outcomes were primary (PPR), secondary patency (SPR) rates and technical success rate (TSR). A Cox-regression analysis identified risk factors for the primary and secondary measure outcomes. Results Forty patients were included in the present study (men: 21, mean age: 68). The overall number of vessels with intention-to-treat was 62. Fifty-two visceral arteries (18 occlusions and 34 stenoses) were successfully treated by endovascular means. The overall TSR was 84%. Visceral vessel occlusions and atherosclerotic disease of the superior mesenteric artery (SMA) were identified as independent risk factors for poorer TSR ( p < 0.05). The 12-month SFS was 60%. The overall 12-month PPR and SPR were 71% and 94%, respectively. No significant differences were observed between occluded and stenotic vessels ( p > 0.05) concerning the PPR. On the other hand, the subgroup analysis revealed higher SPR among occluded visceral vessels ( p < 0.001) and coeliac axis lesions ( p < 0.001). Conclusions ET was associated with high incidence of symptoms recurrence despite the satisfying patency rates in both occluded and stenotic vessels. Additionally, visceral vessel occlusion and presence of atherosclerotic lesions in the SMA were associated with poorer TSR.
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Affiliation(s)
- Georgia Christofi
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Konstantinos P Donas
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Georgios A Pitoulias
- 2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany.,3 Division of Vascular Surgery, G. Gennimatas General Hospital, Aristotle University, Thessaloniki, Greece
| | - Giovanni Torsello
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Arne G Schwindt
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
| | - Konstantinos Stavroulakis
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Germany.,2 Department of Vascular Surgery, St. Franziskus-Hospital GmbH Münster, Germany
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Abstract
PURPOSE OF REVIEW Diagnosis of acute mesenteric ischemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischemia may be treated with urgent intestinal revascularization. RECENT FINDINGS The establishment of a hybrid operation room is most important to be able to perform explorative laparotomy for evaluation of the extent of mesenteric ischemia and successful intestinal revascularization. Endovascular recanalization and stenting has become an important alternative, especially in patients with both acute and chronic thrombotic superior mesenteric artery (SMA) occlusion. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. The concept of damage-control surgery is recommended after intestinal revascularization. SUMMARY Intestinal revascularization in patients with arterial occlusive mesenteric ischemia reduces bowel morbidity and mortality. Observational studies report that both endovascular and open vascular therapy options are effective, but endovascular technique may be preferred in these often elderly and fragile patients.
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27
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Zanow J, Settmacher U. [Management of complications after reconstruction of mesenteric arteries]. Chirurg 2015; 86:650-4. [PMID: 26041150 DOI: 10.1007/s00104-015-0031-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Because of the low ischemia tolerance of abdominal organs and the comorbidities of patients with abdominal ischemic syndromes, complications after the reconstruction of visceral arteries are often severe and associated with a significant mortality rate. The possible complications after interventions on the visceral arteries and their treatment are presented. Endovascular procedures have gained an increasingly important role in many primary interventions as well as in the treatment of complications.
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Affiliation(s)
- Jürgen Zanow
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland,
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28
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Radiology and mesenteric ischaemia. Clin Radiol 2015; 70:698-705. [PMID: 25812475 DOI: 10.1016/j.crad.2015.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 10/29/2014] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
Abstract
This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.
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29
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Image findings in celiac artery stenosis due to median arcuate ligament compression: a crucial diagnosis when planning for pancreaticoduodenectomy. J Gastrointest Surg 2014; 18:638-40. [PMID: 24402607 DOI: 10.1007/s11605-013-2445-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/17/2013] [Indexed: 01/31/2023]
Abstract
Celiac axis stenosis caused by extrinsic compression by the median arcuate ligament (MAL) is present in up to 5% of patients undergoing pancreaticoduodenectomy. Failure to identify and manage MAL compression can lead to potentially devastating postoperative consequences that include frank liver necrosis and death. We report an incidental discovery of celiac axis stenosis by MAL in a patient prepared for pancreaticoduodenectomy. Image findings and operative management are discussed.
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30
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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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