Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemia

Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone

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.

Hospital-based Delays to Revascularization Increase Risk of Post-operative Mortality and Short Bowel Syndrome in Acute Mesenteric Ischemia

OBJECTIVE

Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on post-operative morbidity and mortality in AMI.

METHODS

All patients who underwent any surgery for acute mesenteric ischemia (AMI) from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤ 12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and post-operative data was performed. Effect of DR on major post-operative outcomes including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on sub-group analyses.

RESULTS

A total of 212 patients were analyzed. 99 patients received ER while the remaining 113 patients experienced a delay to revascularization after hospital presentation. Among the DR group, 55 (25.9%) patients had delayed vascular consultation while vascular surgery was deferred until after the initial operation in 37 (17.4%) patients. 51 (24.0%) patients were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio (OR) 2.09, 95% confidence interval (CI) [1.4-4.9], P=0.03) and 2-year mortality (hazard ratio (HR) 1.55, CI [1.0-2.3], P= 0.04). DR was also independently associated with increased bowel resection length (OR 7.47, P <0.01) and post-operative short bowel syndrome (OR 2.4, P=0.03) on multivariate analyses. When examined separately on sub-group analysis, both delayed vascular consultation (OR 3.38, P=0.03) and vascular surgery (OR 4.31, P <0.01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR 2.94, P <0.01) and late mortality (HR 1.60, P=0.04).

CONCLUSIONS

Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of post-operative mortality and short bowel syndrome in AMI. Timing-based management protocols which emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Abdominal Pain Caused by Occlusion of the Celiac Trunk and Superior Mesenteric Artery in Addition to Irritable Bowel Syndrome: Case Series and Literature Review

Irritable bowel syndrome (IBS) is a benign condition of the gastrointestinal tract causing abdominal pain, bloating, diarrhea, and/or constipation. Symptoms of IBS usually improve on passing flatus and defecation. There is no known identifiable underlying pathology; however, several risk factors are known to contribute to the development of IBS, which include a stressful lifestyle and certain foods such as bread, coffee, alcohol, pasta, and chocolates. Intestinal bacteria may also contribute to symptoms of IBS. IBS is diagnosed clinically and treated with various medications to control the symptoms. On the other hand, celiac and mesenteric artery thrombosis (CAMAT) is a condition that may cause significantly higher mortality and morbidity if not recognized early. CAMAT leads to the blockage of major blood vessels to the intestine and several abdominal viscera leading to abdominal pain, nausea, sweating, and, in some cases, symptoms of shock. CAMAT is most likely caused by thrombosis; however, occasionally, embolisms from distant sources in patients with atrial fibrillation can also contribute to the development of CAMAT. CAMAT is usually diagnosed with a computed tomography angiogram (CTA) and treated either surgically or medically with anticoagulants. Vascular thrombus in the thoracic and abdominal region causing ischemia of the stomach and abdominal pain in patients with a history of IBS can easily be missed and cause grave complications with high morbidity and mortality. We present two cases who were initially diagnosed and treated for IBS and later diagnosed with serious intra-abdominal pathology of CAMAT thrombosis.

The first case is of a 55-year-old female who was previously diagnosed with IBS and was treated with mebeverine 200mg twice daily and esomeprazole 20mg once daily for 10 weeks. Her pain continued to get worse and she presented to the emergency department by ambulance. She underwent CTA, which showed occlusion of the celiac trunk and superior mesenteric artery causing liver and splenic infarcts. The patient received heparin and underwent a thrombectomy and embolectomy of the superior mesenteric and celiac arteries. No significant abnormality was found in the blood results. Thrombophilia screening was negative. The patient was discharged on warfarin. The second case is of a 53-year-old man who was also initially diagnosed with IBS and was treated with mebeverine 200mg twice daily for eight weeks before presenting to the emergency department with worsening abdominal pain. He underwent a CTA with contrast, which showed occlusion of the common hepatic artery and stenosis of the splenic artery leading to multiple splenic infarcts. No significant abnormality was found in blood test. Thrombophilia screening was negative. He was treated with new anticoagulant medication, dabigatran 150 mg orally twice daily.

Both patients were managed with successful outcomes and were discharged home on anticoagulants. There was no recurrence of symptoms at three-month follow-up.

These cases highlight that a secondary cause of symptoms such as vascular thrombosis must be sought for patients who fail to improve with conservative management of IBS.

Different Treatment Modality in the Management of Acute Mesenteric Ischemia

Mesenteric ischemia (MI) is a reduction in blood flow of the mesenteric vessels resulting in ischemia or infarction if not treated properly. It is difficult to diagnose and it has a high rate of mortality. Moreover, it is managed either by open surgery or endovascular approach. We present a case of a 79-year-old male patient with MI managed initially by thrombolytic therapy with stent through inferior mesenteric artery which has failed. Few days later he presented with the same complaint. He was treated with heparin for five days and discharged in good condition. Six days later, the patient returned to the ED with MI and managed successfully with retrograde right common ilio-mesenteric artery bypass with no complication and made full recovery. Endovascular revascularization is a minimally invasive approach and it is the initial treatment of choice for mesenteric occlusive disease. However, this approach is not always feasible which explains the role for open approach.

Endovascular management of acute mesenteric ischemia in a young patient with thyrotoxicosis and atrial fibrillation: A case report and review of the literature

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Acute mesenteric ischemia has a high mortality rate of 50%–80%.

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CT angiography is highly valuable in the diagnosis of acute mesenteric ischemia.

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Patients who present with peritonitis or hemodynamic instability should undergo open surgery.

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Endovascular management is increasingly being considered as the main modality of management of AMI in selected cases.

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Endovascular management of AMI involves aspiration thrombectomy, thrombolysis, and/or possible angioplasty and stenting.

Introduction

Acute mesenteric ischemia caused by an embolism resulting from atrial fibrillation in a thyrotoxic young male patient is a rare event. Endovascular intervention is increasingly being considered as the primary modality of treatment in selected patients.

Presentation of case

A 41-years male known to have hyperthyroidism presented with atrial fibrillation, acute mesenteric ischemia, splenic infarction, and left renal infarction. He was successfully managed with endovascular intervention of the superior mesenteric artery.

Discussion

Acute mesenteric ischemia has a high mortality rate. CT angiography is the investigation of choice for diagnosis of the mesenteric vessels occlusion and assessment of bowel ischemia. The clinical presentation guides into the treatment and the choice between open surgery and endovascular intervention as the primary modality of treatment. Thyrotoxicosis is a risky comorbid condition for any procedure to be done, so proper perioperative management is essential to decrease morbidity and mortality.

Conclusion

Prompt diagnosis and management of acute mesenteric ischemia is essential to decrease the morbidity and mortality rates. Endovascular management can be considered as a primary modality of treatment in selected cases.

Still time to perform intestinal revascularization in patients with acute mesenteric ischemia with peritonitis: An analysis of bowel viability in resections

Objective:

Acute mesenteric ischemia is often fatal, and many survivors develop short bowel syndrome. To avoid massive bowel resection, revascularization is recommended for acute mesenteric ischemia patients. However, whether acute mesenteric ischemia patients with clinical peritonitis can be revascularized remains uncertain. Therefore, this study aimed to evaluate the histopathological potential reversibility of resected bowel in acute mesenteric ischemia patients with peritonitis.

Methods:

We retrospectively reviewed the medical records of acute mesenteric ischemia patients treated at the Kameda Medical Center between January 2001 and March 2015. Pathological evaluation regarding bowel resection was performed. Patients with and without peritonitis were compared. The primary outcome was the proportion of patients with reversible or irreversible ischemia. Patients with reversible and irreversible ischemia were characterized.

Results:

Of 41 patients, 17 underwent laparotomy, 6 endovascular surgery, and 18 palliative care. Among 23 patients receiving curative treatment, 7 had peritonitis and 13 did not. Seven patients of each group received bowel resection, but 85.7% of those with peritonitis had reversible ischemia. We categorized patients with ischemia into reversible and irreversible groups. The median time between symptom onset and diagnosis in the reversible group was >27 h. Systemic inflammatory response syndrome was found in 72.2% and 66.7% of the reversible and irreversible groups, respectively.

Conclusion:

Acute mesenteric ischemia patients with clinical peritoneal signs may have potentially reversible ischemia. As a result, revascularization should be considered, even in the case of peritonitis.

Severe peripheral arterial diseases in hemodialysis patient: A case report

RATIONALE

Peripheral arterial diseases (PADs) is defined as a systemic arterial disorders involving the lower extremity arteries, iliac, and carotid, which is developed more common in patients with chronic kidney disease (CKD) than individual with normal renal function. Concurrence of mesenteric artery disease and lower extremity artery disease (LEAD) is rare. The presence of PADs in patients receiving hemodialysis leads to a dramatic increase in risk of cardiovascular mortality. However, the early diagnosis of PADs in patient with CKD remains a challenge to nephrologists, which adds an adverse effect on prognosis.

PATIENT CONCERNS

A 48-year-old man received regular hemodialysis due to end-stage renal failure caused by type 2 diabetes mellitus (T2DM) for 7 years, who was admitted into hospital for acute, severe rest pain of the right lower extremity at the first time. The computed tomography angiography showed severe, diffuse stenosis of the distal third of femoral artery. After discharged, he was readmitted into hospital for abdominal pain and the recurred right lower limb pain. A diagnostic angiography confirmed the initial occlusion of superior mesenteric artery, severe obstruction of the distal segment of femoral artery and diffuse, irregular stenosis of arteria peronea and arteria tibialis posterior.

DIAGNOSIS

The patient was diagnosed as PADs including LEAD and mesenteric artery disease.

INTERVENTIONS

The percutaneous transulminal angioplasty (PTA) combined with antiplatelet therapy and beraprost were performed. Moreover, the cinacalcet and lanthanum carbonate were prescribed to control calcium-phosphorus- parathyroid hormone metabolism.

OUTCOMES

The patient was free of abdominal pain and partly relieved from the ache of lower limb after PTA. However, he finally succumbed to acute myocardial infarction.

LESSONS

The incidence of PADs is higher in dialysis patients due to a unique set of biochemical and endocrine abnormalities. As there is a high uremic status and PADs burden in patients with hemodialysis, the short term risk of cardiovascular disesase mortality markedly increases. There is a need for nephrologists and cardiovascular physicians to identify these patients and then provide early and proper treatment.

Decision Tool for Predicting Outcomes in Geriatric Acute Mesenteric Ischemia

Acute mesenteric ischemia is a morbid disease process that is most common in elderly patients who often have multiple medical comorbidities. Intervention can progress to costly and futile care. The goal of this study was to develop a tool for practitioners to assess the risk of mortality. Patients treated at our institution over the past decade diagnosed with acute mesenteric ischemia were identified. Patients aged less than 65 years were excluded. Data were collected by retrospective chart review. Univariate analysis was used to identify significant risk factors for death. Decision tree analysis yielded a prognostic tool to assess death risk. Univariate analysis demonstrated that lactate (P ≤ 0.001) and pressor requirement (P ≤ 0.001) were predictive of death. Decision tree analysis showed that 79 per cent of patients with day of surgery (DOS) lactate ≥5.4 died postoperatively. Seventy per cent of patients with DOS lactate <5.4 progressed to death if they required pressors and had a creatinine >1.18. Only 6.1 per cent patients with a DOS lactate <5.4, creatinine <1.54, and no pressor requirement progressed to death. Several variables can be used to set expectations for families and help guide decision-making. Our tool was predictive of outcomes in 82 per cent of our study population.

Acute mesenteric ischemia (Part II) - Vascular and endovascular surgical approaches

The modern treatment of acute mesenteric ischemia (AMI) requires seamless collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. The treatment strategy is straightforward aiming at rapid restoration of blood flow to the intestine. Bowel resection is performed on demand. The first thing to consider is the patient's clinical condition at presentation, whether there are signs of peritonitis or not, and whether the patient is hemodynamically stable or not. Second, there are four etiologies of AMI that need to be distinguished as they differ in treatment: superior mesenteric artery embolism, mesenteric arterial occlusive disease, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. In this review, we describe the basic vascular and endovascular treatment modalities accompanied by a simple algorithm for the various situations in AMI. Furthermore, the indications for damage control and primary definitive surgery are discussed.