Management of chronic visceral ischemia

Chronic Mesenteric Ischemia Resulting from Isolated Lesions of the Superior Mesenteric Artery

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.

Bypass grafting for chronic mesenteric ischemia

A critical analysis of the literature suggests that there is no clearly superior technique for mesenteric revascularization and that the choice of operation must be individualized. Bypass grafting using either an antegrade or retrograde technique with prosthetic or autogenous conduits should produce excellent long-term results for most patients with this complex surgical problem. In most situations multiple vessel revascularizations are preferred. Surgeons caring for such patients must have the ability to utilize all available techniques to ensure optimal outcomes.

[Significance of revascularization in arterially-induced mesenteric infarct]

Until 1957 the only treatment of occlusion of mesenteric arteries was resection of the ischemic part of the bowel. A reduction of the extremely high mortality can be reached by the combination of mesenteric revasularisation with an optional resection of the necrotic parts of the bowel. Based on the experience with 57 patients operated on between 1970 and 1987, the survival rate (greater than 60 days after operation) could be improved by performing this regime. Reasons for this improvement are both the salvage of bowel length and the avoidance of the leak of bowel anastomosis. The latter was observed only in patients treated by bowel resection alone without revascularisation leading to death in three out of four cases.