Revascularization of acute mesenteric ischemia after creation of a dedicated multidisciplinary center. J Vasc Surg. 2015;62:1251-1256. [PMID: 26243208 DOI: 10.1016/j.jvs.2015.06.204]

Acute mesenteric ischemia due to superior mesenteric artery thrombosis in a patient with protein S deficiency: A case report

INTRODUCTION

Protein S deficiency resulting in mesenteric vein thrombosis has been reported in previous studies however those causing SMA thrombosis has been rarely reported. Multidisciplinary approach involving general surgeon, a vascular surgeon, an interventional radiologist, and an intensivist are crucial for management of SMA thrombosis.

CASE PRESENTATION

A 39-year-old non-smoker hypertensive female who was diagnosed with partially occlusive thrombus in the superior mesenteric artery via Contrast-enhanced computed tomography (CECT) re-presented after 5 days and CECT revealed a partially occlusive thrombus in the superior mesenteric artery and Protein S deficiency (free protein S:15 %). She was managed by lysis of thrombus with streptokinase by interventional radiology team. The patient is on anticoagulants and without abdominal complaints on follow-up at 24 months.

DISCUSSION

Computed tomography angiography should be done immediately in any patient suspected of AMI since delay in diagnosis accounts for high mortality rates of 30-70 %. The surgical treatment of the condition is well established and consists of revascularization and/or resection of nonviable bowel. Endovascular techniques have emerged as an alternative for occlusion of the SMA. Patients with protein C and/or S deficiency treated for AMI require lifelong anticoagulant/antiplatelet therapy to prevent relapse.

CONCLUSION

Hereditary thrombophilia should be suspected in young people with unusual thrombotic presentations. Earlier diagnosis and aggressive antithrombotic therapy in individuals with hypercoagulable states can improve outcomes. Treatment involving a multidisciplinary approach improves outcomes.

Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database

BACKGROUND

Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection.

METHODS AND RESULTS

Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization.

CONCLUSIONS

EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained.

REGISTRATION

URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.

Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study)

BACKGROUND

The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI).

METHODS

All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected.

RESULTS

AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied.

CONCLUSIONS

The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management.

TRIAL REGISTRATION

NCT05218863 (registered 19.01.2022).

Advancements in Revascularization Strategies for Acute Mesenteric Ischemia: A Comprehensive Review

Even with modern advancements in the management of acute mesenteric ischemia over the past decade, morbidity and mortality remain high, and the best primary treatment modality is still debated amongst interventionalists. Traditionally, interventionalists have favored an open surgical approach but are now trending for endovascular interventions due to apparent reduced mortality and complications. Newer studies suggest hybrid approaches, and intestinal stroke centers may be superior to either strategy alone. This narrative review will explore the natural history of acute mesenteric ischemia with the aim of increasing interventionalist awareness of modern advancements in revascularization strategies for this devastating disease.

INT-767-A Dual Farnesoid-X Receptor (FXR) and Takeda G Protein-Coupled Receptor-5 (TGR5) Agonist Improves Survival in Rats and Attenuates Intestinal Ischemia Reperfusion Injury

Intestinal ischemia is a potentially catastrophic emergency, with a high rate of morbidity and mortality. Currently, no specific pharmacological treatments are available. Previous work demonstrated that pre-treatment with obeticholic acid (OCA) protected against ischemia reperfusion injury (IRI). Recently, a more potent and water-soluble version has been synthesized: Intercept 767 (INT-767). The aim of this study was to investigate if intravenous treatment with INT-767 can improve outcomes after IRI. In a validated rat model of IRI (60 min ischemia + 60 min reperfusion), three groups were investigated (n = 6/group): (i) sham: surgery without ischemia; (ii) IRI + vehicle; and (iii) IRI + INT-767. The vehicle (0.9% NaCl) or INT-767 (10 mg/kg) were administered intravenously 15 min after start of ischemia. Endpoints were 7-day survival, serum injury markers (L-lactate and I-FABP), histology (Park-Chiu and villus length), permeability (transepithelial electrical resistance and endotoxin translocation), and cytokine expression. Untreated, IRI was uniformly lethal by provoking severe inflammation and structural damage, leading to translocation and sepsis. INT-767 treatment significantly improved survival by reducing inflammation and preserving intestinal structural integrity. This study demonstrates that treatment with INT-767 15 min after onset of intestinal ischemia significantly decreases IRI and improves survival. The ability to administer INT-767 intravenously greatly enhances its clinical potential.

Acute mesenteric ischemia: which predictive factors of delayed diagnosis at emergency unit?

PURPOSE

Acute mesenteric ischemia (AMI) is frequently diagnosed late, leading to a poor prognosis. Our aims were to identify predictive factors of delayed diagnosis and to analyze the outcomes of patients with AMI admitted in emergency units.

METHODS

All the patients with AMI (2015-2020), in two Emergency units, were retrospectively included. Two groups were defined according to the time of diagnosis between the arrival at emergency unit and the CT scan: ≤ 6 h (early), > 6 h (delayed).

RESULTS

119 patients (mean age = 71 ± 7 years) were included. The patients with a delayed diagnosis (n = 33, 28%) were significantly associated with atypical presentation, including lower rates of abdominal pain (73 vs 89%, p = 0.003), abdominal tenderness (33 vs 43%, p = 0.03), and plasma lactate (4 ± 2 vs 6 ± 7 mmol/l, p = 0.03) when compared with early diagnosis. After multivariate analysis, the absence of abdominal pain was the only independent predictive factor of delayed diagnosis (Odd Ratio = 0.17; 95% CI = 0.03-0.88, p = 0.03). Patients with delayed diagnosis tended to be associated to lower rates of revascularization (9 vs 17%, p = 0.4), higher rates of major surgical morbidity (90 vs 57%, p = 0.1), longer length of stay (16 ± 23 vs 13 ± 15 days, p = 0.4) and, at the end of follow-up, higher rate of short small bowel syndrome (18 vs 7%, p = 0.095).

CONCLUSION

AMI is a challenge for emergency physicians. History of patient, physical exam, biological data are not sufficient to diagnose AMI. New biomarkers, and awareness of emergency physicians should improve and accelerate the diagnosis of AMI.

Prognostic factors after acute mesenteric ischemia: which patients require specific management?

PURPOSE

Diagnosis and treatment of AMI are a real issue for implicating physicians. In the literature, only one AMI stroke center has reported its results so far, with increasing survival rates. Our aim was to analyze acute mesenteric ischemia (AMI) related mortality and predictive factors, in a single academic center, before creating a dedicated intestinal stroke center.

METHODS

All the patients with an AMI, between January 2015 and December 2020, were retrospectively included. They were divided into 2 groups according to the early mortality: death during the first 30 days and alive. The 2 groups were compared.

RESULTS

173 patients (57% of men), were included, with a mean age of 68 ± 16 years. Overall mortality rate was 61%. Mortality occurred within the first 30 days in 78% of dead cases. Dead patients were significantly older, more frequently admitted from intensive care, with more serious clinical, laboratory and radiological characteristics. We have identified 3 protective factors - history of abdominal surgery (Odd Ratio = 0.1; 95%CI = 0.01-0.8, p = 0.03), medical management with curative anticoagulation (OR = 0.09; 95%CI = 0.02-0.5, p = 0.004) and/or antiplatelets (OR = 0.04; 95%CI = 0.006-0.3, p = 0.001)-, and 2 predictive factors of mortality - age > 70 years (OR = 7; 95%CI = 1.4-37, p = 0.02) and previous history of coronaropathy (OR = 13; 95%CI = 1.7-93, p = 0.01).

CONCLUSIONS

AMI is a severe disease with high morbidity and mortality rates. Even if its diagnosis is still difficult because of non-specific presentation, its therapeutic management needs to be changed in order to improve survival rates, particularly in patients older than 70 years with history of coronaropathy. Developing a dedicated organization would improve the diagnosis and the management of patients with AMI.

Management of acute mesenteric ischaemia: Results of a worldwide survey

BACKGROUND

Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide.

METHODS

A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected.

RESULTS

We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity.

CONCLUSIONS

Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

Immediate postoperative parenteral anticoagulant therapy in patients with mesenteric ischemia after intestinal resection: a retrospective cohort study at a single institute

BACKGROUND

Bowel gangrene represents a major fatal event in acute mesenteric ischemia. Intestinal resection is inevitable in patients with peritonitis and bowel gangrene. This retrospective study aimed to elucidate the benefit of postoperative parenteral anticoagulation in patients with intestinal resection.

METHODS

Patients with acute mesenteric ischemia and bowel gangrene were recruited retrospectively between January 2007 and December 2019. All patients underwent bowel resection. They were categorized into two groups: patients without immediate parenteral anticoagulant therapy (Group A) and those with immediate parenteral anticoagulant therapy (Group B). Thirty-day mortality and survival were analyzed.

RESULTS

A total of 85 patients were included, with 29 patients in Group A and 56 patients in Group B. Patients in Group B had lower 30-day mortality (16.1%) and a higher 2-year survival rate (45.4%) than patients in Group A (30-day mortality: 51.7%, p = 0.001; 2-year survival rate: 19.0%, p = 0.001). In the 30-day mortality multivariate analysis, patients in Group B had a better outcome (odds ratio = 0.080, 95% confidence interval between 0.011 and 0.605, p = 0.014). Patients in Group B also had a better outcome in the survival multivariate analysis (hazard ratio: 0.435, 95% confidence interval between 0.213 and 0.887, p = 0.022).

CONCLUSIONS

Immediate postoperative parenteral anticoagulant therapy improves prognosis in patients with acute mesenteric ischemia treated by intestinal resection. Trial registration This research was retrospectively approved by the Institutional Review Board (IRB) I&II of Taichung Veterans General Hospital (TCVGH-IRB No.CE21256B) on July 28th, 2021. The informed consent waiver was also approved by IRB I&II of Taichung Veterans General Hospital. The Declaration of Helsinki and ICH-GCP guidelines were followed during this study.

Potential for intestinal transplantation after acute mesenteric ischemia in patients aged less than 70 years: A population-based study

BACKGROUND AND OBJECTIVE

Acute mesenteric ischemia (AMI) has a high mortality rate due to the development of bowel necrosis. Patients are often ruled outside active care if a large proportion of small bowel is necrotic. With the development of treatment for short bowel syndrome (SBS) and intestinal transplantation methods, long-term survival is possible even after extensive small bowel resections. This study aims to assess the incidence of SBS and potentially suitable candidates for intestinal transplantation among patients treated for AMI.

METHODS

This population-based retrospective study comprised patients aged less than 70 years and diagnosed with AMI between January 2006 and October 2020 in Helsinki and Uusimaa health care district, Finland.

RESULTS

Altogether, AMI was diagnosed in 711 patients, of whom 133 (19%) were aged below 70. An intervention was performed in 110 (83%) patients. Of these 133 patients, 16 (12%) were ruled outside active treatment due to extensive small bowel necrosis at exploratory laparotomy, of whom 6 (5%) were potentially suitable for intestinal transplantation. Two patients were considered as potential candidates for intestinal transplantation at bowel resection but died of AMI. Nine (7%) patients needed parenteral nutrition after resection, and two of them (2%) developed SBS. Only one patient needed long-term parenteral nutrition after hospital discharge. This patient remained dependent on parenteral nutrition but died before evaluation of intestinal transplantation could be carried out while the other patient was able to return to enteral nutrition.

CONCLUSIONS

A small number of patients with AMI below 70 years of age are potentially eligible for intestinal transplantation.

Prediction of need for bowel resection in acute superior mesenteric artery occlusion: A retrospective study of 48 Japanese patients

Aim

This study aimed to predict cases of acute superior mesenteric artery (SMA) occlusion requiring bowel resection using occlusion site and time from symptom onset to diagnosis at five Japanese institutions. Advances in imaging, endovascular treatment, and perioperative management have improved the clinical outcomes of patients with acute SMA occlusion; however, in clinical practice it remains difficult to effectively determine patients requiring bowel resection.

Methods

We retrospectively analyzed the data of 48 patients (mean age: 82.5 y; male: 37.5%) diagnosed with acute SMA occlusion between June 2009 and August 2018. Background data of patients who required and did not require bowel resection were compared. A multivariable predictive model was developed using the time from symptom onset to diagnosis and whether SMA occlusion was proximal, including the origin of the middle colic artery.

Results

Fifteen patients (31.3%) died during the hospital stay. Atrial fibrillation (83.3%) was the most common comorbidity. The median time from symptom onset to diagnosis was 13.0 (interquartile range, 4.75-24.0) h. Laparotomy, bowel resection, and thrombus embolectomy were performed in 41 (85.4%), 26 (54.2%), and 21 (43.8%) patients, respectively. A logistic regression model achieved 78.6% sensitivity in predicting cases not requiring bowel resection. Proximal occlusion was significantly associated with the requirement for bowel resection (P = .039).

Conclusion

The time from symptom onset to diagnosis and occlusion site contributed to high sensitivity in determining the need for bowel resection in patients with acute SMA occlusion. Further prospective studies are warranted to investigate the clinical impact of this model.

Acute mesenteric ischaemia

PURPOSE OF REVIEW

To summarize the recent evidence on acute mesenteric ischaemia (AMI).

RECENT FINDINGS

The overall incidence of AMI is below 10/100 000 person years but increases exponentially with age. The overall mortality of AMI remains high, exceeding 50%, despite continuing progress and increasing availability of imaging and endovascular interventions. However, patients with (early) revascularization have significantly better outcomes. The majority of patients surviving the acute event are still alive at 1 year, but evidence on quality of life is scarce.Clinical suspicion of AMI is the key to timely diagnosis, with biphasic computed tomography-angiography the diagnostic method of choice. Currently, no biomarker has sufficient specificity to diagnose AMI.

SUMMARY

Improved awareness and knowledge of AMI are needed to raise the suspicion of AMI in relevant patients and thereby to achieve better outcomes.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Hyaluronan Regulates Neuronal and Immune Function in the Rat Small Intestine and Colonic Microbiota after Ischemic/Reperfusion Injury

BACKGROUND

Intestinal ischemia and reperfusion (IRI) injury induces acute and long-lasting damage to the neuromuscular compartment and dysmotility. This study aims to evaluate the pathogenetic role of hyaluronan (HA), a glycosaminoglycan component of the extracellular matrix, as a modulator of the enteric neuronal and immune function and of the colonic microbiota during in vivo IRI in the rat small intestine.

METHODS

mesenteric ischemia was induced in anesthetized adult male rats for 60 min, followed by 24 h reperfusion. Injured, sham-operated and non-injured animals were treated with the HA synthesis inhibitor, 4-methylumbelliferone (4-MU 25 mg/kg). Fecal microbiota composition was evaluated by Next Generation Sequencing. Neutrophil infiltration, HA homeostasis and toll like receptor (TLR2 and TLR4) expression in the small intestine were evaluated by immunohistochemical and biomolecular approaches (qRT-PCR and Western blotting). Neuromuscular responses were studied in vitro, in the absence and presence of the selective TLR2/4 inhibitor, Sparstolonin B (SsnB 10, 30 µM).

RESULTS

4-MU significantly reduced IRI-induced enhancement of potentially harmful Escherichia and Enterococcus bacteria. After IRI, HA levels, neutrophil infiltration, and TLR2 and TLR4 expression were significantly enhanced in the muscularis propria, and were significantly reduced to baseline levels by 4-MU. In the injured, but not in the non-injured and sham-operated groups, SsnB reduced both electrical field-stimulated (EFS, 0.1-40 Hz) contractions and EFS-induced (10 Hz) non-cholinergic non-adrenergic relaxations.

CONCLUSIONS

enhanced HA levels after intestinal IRI favors harmful bacteria overgrowth, increases neutrophil infiltration and promotes the upregulation of bacterial target receptors, TLR2 and TLR4, in the muscularis propria, inducing a pro-inflammatory state. TLR2 and TLR4 activation may, however, underlay a provisional benefit on excitatory and inhibitory neuronal pathways underlying peristalsis.

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

Two cases of intestinal perforation due to mesenteric artery embolism during extracorporeal membrane oxygenation and intra-aortic balloon pumping

The patient in case 1 was a 50-year-old man who presented to the emergency department of the local hospital with chest pain and syncope for 3 hours due to acute myocardial infarction. He underwent cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO), and intestinal perforation was detected on day 9. The patient in case 2 was a 58-year-old man who was admitted to the hospital with abdominal pain lasting for 3 days. He also required CPR and ECMO for cardiogenic shock, and intestinal perforation was identified on day 7 of ECMO. We believe that this case report will be important to alert clinicians to the possibility of this complication and to encourage early detection and intervention to improve prognosis. Conventionally, the gastrointestinal tract has received secondary attention in patients receiving ECMO support because the vital organs tend to be considered first. However, this case report illustrates the importance of monitoring gastrointestinal function in patients undergoing ECMO.

A Shifting Trend Towards Endovascular Intervention in the Treatment of Acute Mesenteric Ischemia

Background

Acute mesenteric ischemia (AMI) is a vascular emergency with a quite low incidence, but it is associated with disproportionately more severe morbidity and mortality. The aim of this study was to assess the current trend in the treatment of AMI and to see if endovascular intervention is an effective treatment modality in the selected group of patients.

Methods

A retrospective review of patients admitted with AMI between 2007 and 2018 was performed. Outcome measures were length of stay (LOS) at hospital and intensive care unit (ICU), and post-treatment mortality.

Results

A total of 98 patients with AMI were admitted during the study period. Patients undergoing endovascular treatment compared with surgery were younger (62.9 ± 13.7 years vs. 69.5 ± 12.8 years; p = 0.01). Shorter LOS in hospital and ICU was observed for those treated with endovascular approach (6.8 ± 3.4 and 3.25 ± 0.5 days) compared to the surgical group (25 ± 8.6 and 12.8 ± 26.8 days; p < 0.001). Out of 39 patients requiring ICU admission, 48.7% were surgically treated and 10.2% underwent endovascular intervention (p < 0.001). Mortality associated with surgery was 30.6% compared to only 6.6% with endovascular intervention (p < 0.001). Between 2007 and 2012, only one patient underwent endovascular intervention and 20 underwent surgery compared to 14 patients treated with endovascular approach and 16 with surgery between 2013 and 2018.

Conclusion

In this non-randomized, retrospective case series, patients with endovascular treatment fared clinically better and the intervention was found to be safe and feasible in the selected group of patients. We suggest a preference for this modality where possible. At our hospital, a trend favoring this approach is apparent during the last six years.

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.

Multidisciplinary management of acute mesenteric ischemia: Surgery and endovascular intervention

Acute mesenteric ischemia (AMI) is a rare cause of the “acute abdomen”, characterized by impaired blood flow to the intestine. The principle of treatment is restoration of perfusion to ischemic bowel and resection of any necrotic intestine. Surgery and endovascular intervention are two complementary approaches to mesenteric ischemia. Endovascular intervention is not an alternative to the surgical approach, but it has the potential to improve the prognosis of patients with AMI when judiciously combined with a surgical approach. Due to the need for emergent treatment of patients with acute mesenteric ischemia, the treatment strategy needs to be modified for each facility. This review aims to highlight cutting-edge studies and provide reasonable treatment strategies for patients with acute mesenteric ischemia based on available evidence.

Retrograde Open Mesenteric Stenting for Acute and Chronic Mesenteric Ischaemia: Results from an Intestinal Stroke Centre

OBJECTIVE

To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia.

METHODS

Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan-Meier time to event method.

RESULTS

During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% - 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 - 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 - 94) and 92.4% (95% CI 72.8 - 98), respectively.

CONCLUSION

ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.

A clinical approach to acute mesenteric ischemia

PURPOSE OF REVIEW

To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management.

RECENT FINDINGS

A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved.

SUMMARY

Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI.

Bowel ischemia and gangrene-primary true enterolith

Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field. Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made. The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.

Evaluation of mesenteric artery disease in patients with severe aortic valve stenosis

The aim of this study is to evaluate the mesenteric artery stenosis (MAS) in routinely performed CT angiography (CTA) of patients with severe aortic stenosis (AS) planned for transcatheter aortic valve implantation (TAVI) before the procedure. Patients with AS (AS group) who routinely underwent CTA before the TAVI procedure due to severe AS and patients who had CTA for other indications (control group) were retrospectively and sequentially scanned. The demographic characteristics of the patients in both groups were similar. Calcification and stenosis in the mesenteric arteries were recorded according to the localization of celiac truncus, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Class 0-3 classification was used for calcification score. Stenoses with a stenosis degree ≥50% were considered as significant. A total of 184 patients, 73 patients with severe AS and 111 control groups, were included in the study. SMA and IMA calcification scores of patients with AS were significantly higher than the control group (p=0.035 for SMA and p=0.020 for IMA). In addition, the rate of patients with significant MAS in at least 1 artery (45.2% vs 22.5%, p=0.001) and the rate of patients with significant stenosis in multiple arteries were also significantly higher in the AS group (8.2% vs 1.8%, p=0.037). According to the study results, patients with AS are at a higher risk for MAS. Chronic mesenteric ischemia should be kept in mind in patients with AS who have symptoms such as non-specific abdominal pain and weight loss.

Revascularization of Isolated Superior Mesenteric Artery Dissection for Post-Mesenteric Infarction Exudative Enteropathy: The Contribution of a Multidisciplinary Care Teamwork

BACKGROUND

Isolated dissection of the superior mesenteric artery (SMA) is increasingly diagnosed; the conservative treatment appears to be the best option when blood supply is maintained. However, some patients require a more invasive attitude, due to acute or chronic ischemic complication. Multidisciplinary care within a health-care network improves medical and surgical support. We present a case of chronic complication of isolated SMA dissection requiring a revascularization, followed by bowel resection.

CASE PRESENTATION

A 49-year-old man presented abdominal pain secondary to necrotizing enterocolitis of unknown cause. An isolated small bowel resection with immediate restoration of continuity was first performed to remove the necrotic tissue. The patient developed post-ischemic exudative enteropathy and small intestinal bacterial overgrowth (SIBO). Re-examination of the first computed tomography (CT) scan revealed an isolated dissection of the SMA that had not been diagnosed. The patient was then successfully treated by superior mesenteric revascularization, and after recovering, he underwent small bowel resection for chronic ischemia.

CONCLUSIONS

SMA revascularization has to be performed in case of SMA dissection complicated of bowel ischemia. Enteropathy is a rare complication of chronic mesenteric ischemia requiring digestive and vascular management in a dedicated health-care team.

Ischemic gastrointestinal complications of COVID-19: a systematic review on imaging presentation

Background

Limited data is available addressing gastrointestinal (GI) ischemia in coronavirus disease 2019 (COVID-19). We reviewed the clinical and radiologic features of GI ischemia and its related complications in thirty-one COVID-19 patients reported in literature.

Methods

A systematic literature review was performed using a search strategy on all studies published from January 1, 2020, to June 13, 2020, and updated on September 6, 2020, on databases from PubMed, Scopus, Embase, Web of Science, and Google Scholar. Every study with at least one presentation of COVID-19-related GI ischemia complication and one GI imaging finding was included.

Results

In total, twenty-two studies and thirty-one patients with the mean age of 59 ± 12.7 (age range: 28–80) years old were included, of which 23 (74.2%) patients were male, 7 (22.5%) female, and one unknown gender. The significant GI imaging findings include mesenteric arterial or venous thromboembolism, followed by small bowel ischemia. Nine patients (29%) presented with arterial compromise due to superior mesenteric thromboembolism, resulting in bowel ischemia. Also, 6 patients (19.3%) demonstrated occlusive thrombosis of the portal system and superior mesenteric vein. More than two-thirds of patients (20, 64.5%) required laparotomy and bowel resection. Eventually, five (16.1%) patients were discharged, of whom four cases (12.9%) readmitted. Five (16.1%) patients remained ICU hospitalized at the report time and 12 (38.7%) patients died.

Conclusion

Macrovascular arterial/venous thrombosis is identified in almost half of COVID-19 patients with bowel ischemia. Overall mortality in COVID-19 patients with GI ischemia and radiologically evident mesenteric thrombotic occlusion was 38.7% and 40%, retrospectively.

Non-Occlusive Mesenteric Ischemia Due to Hirudotherapy: A Case Report

Leech therapy, which can lead to complications such as anemia and bleeding, has been used to treat many diseases since ancient times. Furthermore, some substances in leech saliva are known to have anticoagulant effects. Acute mesenteric ischemia, which develops due to mesenteric vascular obstruction, can be treated medically or surgically. Non-occlusive mesenteric ischemia (NOMI) occurs as a result of decreased blood flow in mesenteric vessels due to hypovolemia, hypotension, etc. In this report, we mentioned a 57-year-old male patient who was admitted to the emergency department with syncope and weakness. In his medical history, the patient was stated to have used leech therapy to treat diabetic wounds on his feet, and prolonged and unstoppable bleeding was seen after leech bites. On his physical examination, there was tenderness in all quadrants of the abdomen. Abdominal computed tomography without contrast agent showed hepatic portal venous gas and pneumatosis cystoides intestinalis (PSI). The patient underwent laparotomy owing to the development of acute abdomen during the follow-up. Necrosis was seen in the terminal ileum and entire colon. Low flow in mesenteric vascular vessels of these necrotic segments was indicated with intraoperative Doppler ultrasonography. All necrotic segments were resected and open end-ileostomy was performed. The patient was discharged on the 17th day of follow-up. In conclusion, excessive bleeding caused by leech therapy can cause NOMI.

Contrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia

OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.

Impact of a multidisciplinary care bundle for necrotizing skin and soft tissue infections: a retrospective cohort study

BACKGROUND

Necrotizing skin and soft tissue infections (NSTIs) require both prompt medical and surgical treatment. The coordination of multiple urgent interventions by care bundles has improved outcome in other settings. This study aimed to assess the impact of a multidisciplinary care bundle on management and outcome of patients with NSTIs.

METHODS

Patients with NSTIs admitted between 2006 and 2017 were compared according to admission before or after bundle implementation (2012-2013). This bundle consisted mainly in (1) the creation of a multidisciplinary task force; (2) management guidelines on empirical antibiotics, intensive care unit admission criteria, a triage algorithm to accelerate operating room access; and (3) an active communication policy. Patient recruitment and management were compared between pre- and post-implementation periods. Main outcome was day 60-censored hospital survival.

RESULTS

Overall, 224 patients were admitted: 60 before, 35 during, and 129 after bundle implementation. Admission after implementation was associated with increased yearly admissions (10 [8-13] vs 30 [24-43] patients/year, p = 0.014) and decreased mortality (30 vs 15%, HR = 0.49 [0.26-0.92]; p = 0.026) but was no longer a protective factor for mortality after adjustment on confounding factors (adjusted HR = 0.90 [0.43-1.88], p = 0.780). There was no significant difference regarding time to surgery (0 [0-1] vs 0 [0-1] days, p = 0.192) or rate of antibiotic treatment within 24 h (98% vs 99%, p > 0.99).

CONCLUSIONS

Implementation of a multidisciplinary care bundle for NSTIs was feasible, but in a retrospective study from an already experienced center was not associated with significantly increased survival after adjustment.

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

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

Short bowel syndrome in children and adults: from rehabilitation to transplantation

Short bowel syndrome (SBS) is a dramatic clinical condition in both children and adults; the residual bowel length is not sufficient to avoid intestinal failure, with subsequent malnutrition and growth retardation, and intravenous support is required to provide the nutrients normally coming from the intestine. Apart from the primary disease, the medical status can be worsened by complications of intestinal failure: if there are irreversible, the prognosis is poor unless a successful intestinal rehabilitation is achieved. Areas covered: The rescue of the remnant small bowel requires a multidisciplinary expertise to achieve digestive autonomy. The use of intestinal trophic factors has shown encouraging results in improving the intestinal adaptation process. Whenever the residual bowel length is inadequate, in a well-selected population weaning parenteral nutrition (PN) off could be attempted by surgery through lengthening procedures. A further subset of patients, with total and irreversible intestinal failure and severe complications on PN, may have an indication to intestinal transplantation. This procedure is still affected by poor long-term results. Expert commentary: Novel approaches developed through a multidisciplinary team work, such as manipulation of microbiota or tissue bioengineering, should be added to current therapies to treat successfully SBS.

Outcomes of antegrade and retrograde open mesenteric bypass for acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass.

METHODS

A single-center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier estimation and Cox proportional hazards regression were used to analyze all end points.

RESULTS

Eighty-two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9-35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In-hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30-day mortality, 26%). The median follow-up was 8 months (interquartile range, 1-26 months). The 1- and 3-year primary patency rates were both 82% ± 6% (95% confidence interval, 71%-95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in-hospital mortality (log-rank, P = .3), or overall survival (log-rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9-11.0; P = .08).

CONCLUSIONS

OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention.

The Ongoing Challenge of Acute Mesenteric Ischemia

Background

The lethality of acute mesenteric ischemia (AMI) remains quite high with 50-70%. The main reasons for that are the fact that AMI is rarely taken into consideration by the differential diagnosis of acute abdomen, the time-consuming diagnostic process, and the lack of a standardized therapeutic concept. The present interdisciplinary review aims to increase awareness among physicians and to help improve clinical outcomes.

Methods

This clinical therapeutic review is based on author expertise as well as a selective literature survey in PubMed based on the term 'mesenteric ischemia', combined with the terms 'arterial', 'clinical presentation', 'diagnosis', 'therapy', 'surgery', and 'interventional radiology'. Based on these search results as well as on the guidelines of the German Society of Vascular Surgery, the American College of Cardiology, and the American Heart Association, we present an interdisciplinary treatment concept.

Results

AMI is a vascular emergency that can be successfully treated only within the first hours after the onset of symptoms. Computed tomography angiography is the diagnostic method of choice. Intensive care unit treatment can prevent the occurrence of multiple organ failure. Treatment primarily consists of the revascularization of the mesenteric arteries. Endovascular techniques should be given priority, whereas signs of peritonitis or a central arterial occlusion with high thrombus load primarily require a surgical approach in order to save time and increase patient safety. Additional bowel resections can play a significant role in the treatment of intestinal sepsis.

Conclusion

Prompt and goal-oriented diagnosis and consistent treatment of AMI within 4-6 h from the onset of symptoms can be decisive for the reduction of AMI-associated lethality. In order for this to happen, a standardized concept of emergency treatment needs to be implemented.

A case of extreme weight loss due to mesenteric ischemia and antiphospholipid syndrome

Mesenteric ischemia and antiphospholipid syndrome is a rare combination but should be suspected as a differential diagnosis. This may be presented as diffuse abdominal pain typically after food intake, diarrhea, and weight loss. Early recognition is warranted, and nutrition, stenting, and anticoagulant treatments are indicated.

Inter-reader agreement of CT features of acute mesenteric ischemia

PURPOSE

To evaluate the inter-reader agreement of the CT features of acute mesenteric ischemia (AMI).

METHODS

Between 2006 and 2014, 109 patients (57 men, 52%, mean age 50 years old [17-83]) admitted to our institution with a diagnosis of AMI were included. CT scans (42% were initially performed in our institution) were reviewed by two abdominal radiologists. Inter-observer agreement of the imaging features of vascular insufficiency and bowel ischemia was assessed by the percentage of agreement and the kappa value.

RESULTS

The final population included, Inter-observer agreement varied according to the different features (κ = 0.25-0.98). Inter-observer agreement for decreased/absent bowel wall enhancement was moderate (κ = 0.52), but was almost perfect (κ = 0.82) in the 47 patients (43%) with both unenhanced and arterial-phase images without positive oral contrast agent and excellent CT images quality.

CONCLUSION

Inter-reader agreement was moderate to substantial for most CT features of AMI. Multiphasic CT scan protocol, including unenhanced, arterial phase and venous phase images, without positive oral contrast agent, and excellent CT images quality improve inter-observer agreement of imaging features of AMI, especially for decreased/absent bowel wall enhancement, and should be performed in patients with suspected AMI.

Human Adipose Stromal Cells Increase Survival and Mesenteric Perfusion Following Intestinal Ischemia and Reperfusion Injury

OBJECTIVE

Intestinal ischemia can quickly escalate to bowel necrosis and perforation. Transplantation of stem cells presents a novel treatment modality for this problem. We hypothesized that: human adipose-derived stromal cells (hASCs) would increase survival and mesenteric perfusion to a greater degree compared with differentiated cellular controls following ischemic intestinal injury, and improved outcomes with hASC therapy would be associated with preservation of intestinal histological and tight junction architecture, and lower levels of systemic inflammation following intestinal injury.

METHODS

hASCs and keratinocytes (differentiated cellular control) were cultured on polystyrene flasks at 37°C in 5% CO2 in air. Adult male C57Bl6J mice were anesthetized and a midline laparotomy performed. The intestines were eviscerated, the small bowel mesenteric root identified, and intestinal ischemia was established by temporarily occluding the superior mesenteric artery for 60 min with a noncrushing vascular clamp. Following ischemia, the clamp was removed, and the intestines were returned to the abdominal cavity. Before abdominal closure, 2 million hASCs or keratinocytes in 250 μL of phosphate-buffered saline (carrier for cells and control solution) were infused into the peritoneum. Animals were allowed to recover for 12 or 24 h (perfusion, histology, cytokine, and immunofluoresence studies), or 7 days (survival studies). Intestinal perfusion was assessed by laser Doppler imaging. Intestinal tissue segments were stained with hematoxylin and eosin, as well as antibodies for the tight junction protein claudin-1. Separate aliquots of intestine, liver, and lung tissue were homogenized and assessed for inflammatory cytokines via multiplex beaded assay.

RESULTS

Animals administered hASCs following intestinal ischemia and reperfusion (I/R) injury had significantly greater 7-day survival and better postischemic recovery of mesenteric perfusion compared with vehicle or keratinocyte therapy. hASCs also abated intestinal mucosal destruction, facilitated preservation of intestinal tight junctions, and decreased the systemic inflammatory response to injury.

CONCLUSIONS

Human adipose-derived stromal cells improved survival and mesenteric perfusion and attenuated the mucosal damage associated with intestinal I/R injury. hASCs should be considered as a plausible cell source for novel cellular treatment plans following intestinal ischemia.

Stem Cell Therapies in Peripheral Vascular Diseases — Current Status

Peripheral artery diseases include all arterial diseases with the exception of coronary and aortic involvement, more specifically diseases of the extracranial carotids, upper limb arteries, mesenteric and renal vessels, and last but not least, lower limb arteries. Mononuclear stem cells, harvested from various sites (bone marrow, peripheral blood, mesenchymal cells, adipose-derived stem cells) have been studied as a treatment option for alleviating symptoms in peripheral artery disease, as potential stimulators for therapeutic angiogenesis, thus improving vascularization of the ischemic tissue. The aim of this manuscript was to review current medical literature on a novel treatment method — cell therapy, in patients with various peripheral vascular diseases, including carotid, renal, mesenteric artery disease, thromboangiitis obliterans, as well as upper and lower limb artery disease.

[Management of mesenteric ischemia in the era of intestinal stroke centers: The gut and lifesaving strategy]

Mesenteric ischemia is a gut and life-threatening, medical and surgical, digestive and vascular emergency. Mesenteric ischemia is the result of an arterial or venous occlusion, a vasospasm secondary to low-flow states in intensive care patients, aortic clamping during vascular surgery or intestinal transplantation. Progression towards mesenteric infarction and its complications is unpredictable and correlates with high rates of mortality or a high risk of short bowel syndrome in case of survival. Thus, mesenteric ischemia should be diagnosed and treated at an early stage, when gut injury is still reversible. Diagnostic workup lacks sensitive and specific clinical and biological marker. Consequently, diagnosis and effective therapy can be achieved by a high clinical suspicion and a specific multimodal management: the gut and lifesaving strategy. Based on the model of ischemic stroke centers, the need for a multidisciplinary and expert 24/24 emergency care has led, in 2016, to the inauguration of the first Intestinal Stroke Center (Structure d'urgences vasculaires intestinales [SURVI]) in France. This review highlights the pathophysiological features of chronic and acute mesenteric ischemia, as well as the diagnosis workup and the therapeutic management developed in this Intestinal Stroke Center.

Mesenteric vascular treatment 2016: from open surgical repair to endovascular revascularization

The rise of endovascular techniques has improved the outcome of mesenteric ischemia. Key principle in reduction of morbidity and mortality is "revascularization first, resection later". We believe that mesenteric ischemia is a clinical challenge demanding 24/7 multidisciplinary team availability. This article describes the current insights into treatment of mesenteric ischemia.

Ascending Aorta to Hepatic and Mesenteric Artery Bypassing, in Patients with Chronic Mesenteric Ischemia and Extensive Aortic Disease-A Case Report and Review of the Literature

Chronic mesenteric ischemia (CMI) is a rare disorder caused by severe stenosis of the mesenteric arterial supply that results in postprandial pain and weight loss. Treatment options are surgical or endovascular. Surgical bypass can be performed in an antegrade fashion from the supraceliac abdominal aorta (AA) or the distal descending thoracic aorta or in a retrograde fashion from the infrarenal aorta or the common iliac artery. However, in some patients with disease of the descending thoracic aorta or the AA, another site for the proximal anastomosis needs to be found. In this article, we report the case of a 69-year-old man with a thoracoabdominal aortic aneurysm and CMI in whom we performed bypass grafts to the hepatic and superior mesenteric arteries using the ascending aorta as the site for the proximal anastomoses via a median sternolaparotomy. In addition, we performed a literature review of all similar cases and provide an analysis of this technique and an assessment of the success rates.

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

Mesenteric ischemia (MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI (CMI), with the first being subdivided into four categories. Therefore, acute MI (AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography (CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.