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Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases. Biomedicines 2023; 11:biomedicines11020267. [PMID: 36830803 PMCID: PMC9952883 DOI: 10.3390/biomedicines11020267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/04/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.
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Abstract
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.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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Freitas B, Bausback Y, Schuster J, Ulrich M, Bräunlich S, Schmidt A, Scheinert D. Thrombectomy Devices in the Treatment of Acute Mesenteric Ischemia: Initial Single-Center Experience. Ann Vasc Surg 2018; 51:124-131. [PMID: 29455017 DOI: 10.1016/j.avsg.2017.11.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND To report our preliminary experience with endovascular revascularization of patients with acute mesenteric ischemia (AMI), using thrombectomy devices. METHODS It is a retrospective analysis of patients admitted to our hospital due to AMI and who were subjected to concomitant or exclusive endovascular treatment, from January 2011 to January 2016. Patients were admitted at the emergency department, underwent imaging investigation, and were referred to the endovascular specialist. Endovascular treatment was performed through left brachial artery access and selective catheterization and thrombectomy with a 6F Rotarex Debulking Device (Straub Medical, Wangs, Switzerland). Laparotomy was performed based on clinical and radiologic sings and at the discretion of the surgeon. Demographic, clinical/periprocedural, postoperative, complication, and adjunct intervention data were reviewed. Technical success was defined as recanalization of the Riolan's arcade on angiographic control. RESULTS Twenty patients (mean age: 69.8 ± 11.3 years) underwent endovascular revascularization for AMI using thrombectomy devices, during the period of the study. Abdominal pain was the most common complain on admission (65%), with ileus (35%), sepsis (25%), and myocardial infarction as the main clinical referral presentation at admission. Fifteen patients (75%) had suggestive computer tomography (CT) signs of AMI on admission. Endovascular revascularization was successfully performed in all patients through the left brachial artery with a mean procedural time of 28 ± 17 min. Superior mesenteric artery (SMA) was the main vessel involved in 75% on a solely basis. The majority of the SMA occlusions were in the periosteal (30%) and proximal to middle colic artery offspring (35%). Primary use of thrombectomy devices was performed in all patients, associated with balloon angioplasty (7/20; 50%), stent deployment (5/20; 25%), intraoperative selective thrombolysis (4/20; 20%) and catheter-assisted aspiration in 10% (2/20) of patients. Average time between admission and computed tomography angiography was 1.5 ± 0.5 hr, between admission and angiographic procedure was 2.5 ± 1 hr, and between admission and surgery was 9 ± 5 hr. Following recanalization, 14 patients (70%) underwent open surgery. Laparotomy with intestinal resection (enterectomy, colectomy) and transit deviation was the most common procedure. Complications directly related to the endovascular procedure occurred in 2 patients, represented by self-limited small perforations. Overall 30-day mortality was 40% (n = 8). During the period of this study, no patient died as a result of complications related to the use of rotational thrombectomy. CONCLUSIONS Endovascular treatment of the AMI with the use of thrombectomy devices proved to be technically feasible and reasonably fast procedure. Early diagnosis and adequate treatment remains the cornerstone of the treatment. Early surgical evaluation and close integration between surgical and endovascular specialists are crucial to faster treatment and consequently lower extensive surgical resections and mortality. Further studies are necessary on this field to confirm these findings.
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Affiliation(s)
- Bruno Freitas
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany; Division of Surgery, Faculty of Medicine, Federal University of Alagoas, Arapiraca, Brazil; Faculty of Medicine, State University of Health Sciences-UNCISAL, Alagoas, Brazil.
| | - Yvonne Bausback
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
| | - Johannes Schuster
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
| | - Matthias Ulrich
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
| | - Sven Bräunlich
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
| | - Dierk Scheinert
- Department of Interventional Angiology, University Hospital, University of Leipzig, Leipzig, Germany
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Bala M, Kashuk J, Moore EE, Kluger Y, Biffl W, Gomes CA, Ben-Ishay O, Rubinstein C, Balogh ZJ, Civil I, Coccolini F, Leppaniemi A, Peitzman A, Ansaloni L, Sugrue M, Sartelli M, Di Saverio S, Fraga GP, Catena F. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12:38. [PMID: 28794797 PMCID: PMC5545843 DOI: 10.1186/s13017-017-0150-5] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process. Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.
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Affiliation(s)
- Miklosh Bala
- Acute Care Surgery and Trauma Unit, General Surgery Department, Hadassah - Hebrew University Medical Center, Kiriat Hadassah, POB 12000, 91120 Jerusalem, Israel
| | - Jeffry Kashuk
- Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, USA
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter Biffl
- Department of Surgery, Queens Medical Center, Honolulu, Hi USA
| | - Carlos Augusto Gomes
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Chen Rubinstein
- Department of Vascular Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Ian Civil
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | | | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Letterkenny, Ireland
| | | | | | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinica, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fausto Catena
- Emergency Department, Maggiore University Hospital, Parma, Italy
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Tilsed JVT, Casamassima A, Kurihara H, Mariani D, Martinez I, Pereira J, Ponchietti L, Shamiyeh A, Al-Ayoubi F, Barco LAB, Ceolin M, D'Almeida AJG, Hilario S, Olavarria AL, Ozmen MM, Pinheiro LF, Poeze M, Triantos G, Fuentes FT, Sierra SU, Soreide K, Yanar H. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg 2016; 42:253-70. [PMID: 26820988 PMCID: PMC4830881 DOI: 10.1007/s00068-016-0634-0] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria. METHODS A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group. RESULTS The resultant recommendations are presented in this paper. CONCLUSIONS The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.
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Affiliation(s)
- J V T Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK.
| | - A Casamassima
- Emergency Department, Istituto Clinico Città Studi, Milan, Italy
| | - H Kurihara
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - D Mariani
- Department of General Surgery, Ospedale di Legnano, Milan, Italy
| | - I Martinez
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Torrevieja, Torrevieja, Spain
| | - J Pereira
- Surgery 1-Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - L Ponchietti
- Department of Surgery, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - A Shamiyeh
- 2nd Surgical Department, Kepler University Clinic Linz, Linz, Austria
| | - F Al-Ayoubi
- Division of Trauma and Acute Care Surgery, Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - L A B Barco
- Department of Angiology and Vacular Surgery, University Hospital of Torrevieja, Torrevieja, Spain
| | - M Ceolin
- Emergency Surgery and Trauma Unit, Humanitas Research Hospital, Rozzano, Italy
| | - A J G D'Almeida
- Department of General Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - S Hilario
- 2nd Surgical Department, Santo André Hospital, Leiria, Portugal
| | - A L Olavarria
- Servicio de Cirugía General y Digestiva, Hospital Galdakao Usansolo, Vizcaya, Spain
| | - M M Ozmen
- Department of Surgery, Medical School, Hacettepe University, 06100, Ankara, Turkey
| | - L F Pinheiro
- General Surgery Department, Hospital São Teotónio, Viseu, Portugal
| | - M Poeze
- Department of Surgery/Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Triantos
- Department of General Surgery, Rhodes General Hospital, Rhodes, Greece
| | - F T Fuentes
- General Surgery 2 and Emergency Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
| | - S U Sierra
- Department of Surgery, Galdakao-Usansolo Hospital, Galdakao, Vizcaya, Spain
| | - K Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - H Yanar
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Çapa, Istanbul, Turkey
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Yun WS, Lee KK, Cho J, Kim HK, Huh S. Treatment outcome in patients with acute superior mesenteric artery embolism. Ann Vasc Surg 2013; 27:613-20. [PMID: 23540675 DOI: 10.1016/j.avsg.2012.07.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 06/18/2012] [Accepted: 07/08/2012] [Indexed: 02/08/2023]
Abstract
PURPOSE The goals of this study were to investigate the treatment outcomes of acute mesenteric ischemia caused by superior mesenteric artery (SMA) embolism and identify the posttreatment prognostic factors. METHODS The clinical data of 32 episodes of acute SMA embolism in 30 patients, including 2 recurrent cases, between April 2003 and March 2011 were retrospectively reviewed. RESULTS Median patient age was 74 years (range, 39-89 years), and 50% were male. Conservative treatment, including bowel rest, nasogastric drainage, intravenous fluid therapy, parenteral nutritional support, and anticoagulation therapy, was undertaken in 5 patients with no clinical evidence of bowel gangrene, including 1 with recurrent ischemia. No deaths occurred among patients treated conservatively. A total of 27 patients were treated with open surgical repair (25 embolectomies and 2 bowel resections alone). Among 25 patients treated with embolectomy, 14 required bowel resection. Most bowel resections (94%, 15/16) were limited, with the remaining length of small bowel greater than 150 cm, which could not cause short bowel syndrome. In-hospital mortality of surgery was 30%. No variables were associated with mortality after surgical intervention, including, age, gender, presence of bowel gangrene, and symptom duration. The overall 1-, 3-, and 5-year survival rates after initial successful treatment were 96%, 73%, and 44%, respectively, regardless of treatment type. CONCLUSIONS Prompt diagnosis and treatment before extensive irreversible gangrene is the mainstay in the treatment of SMA embolism. Limited bowel gangrene was not associated with mortality.
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Affiliation(s)
- Woo-Sung Yun
- Division of Vascular/Endovascular Surgery, Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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Abstract
Chronic mesenteric ischemia (CMI) is most likely caused by atherosclerosis and less frequently by external compression and vasculitis. Symptomatic CMI is an uncommon, potentially under-diagnosed condition caused by fixed stenoses or occlusion of, in most conditions, at least two visceral arteries. If only one of the three major bowel-providing arteries — the celiac trunk, and the superior and inferior mesenteric arteries — is affected, the patient is usually asymptomatic due to a tight collateral network. The only exception is the celiac artery compression syndrome which represents primarily a compression syndrome of celiac plexus nerves by the arcuate ligament in conjunction with a compression of the celiac trunk. CMI of atherosclerotic origin is associated with a high morbidity and mortality. During the last decade, endovascular revascularization has replaced surgical revascularization as the therapy of choice in most centers. This article reviews the most relevant clinical aspects of the disease and the current practice of diagnosis and treatment of CMI.
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Okamura S, Fujiwara H, Sonoyama T, Ochiai T, Ikoma H, Kubota T, Nakanishi M, Kikuchi S, Ichikawa D, Okamoto K, Sakakura C, Kokuba Y, Taniguchi H, Otsuji E. Management of Acute Superior Mesenteric Artery Occlusion by Thrombolytic Therapy. Case Rep Gastroenterol 2009; 3:300-305. [PMID: 21103245 PMCID: PMC2988921 DOI: 10.1159/000239293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Acute occlusion of the superior mesenteric artery (SMA) causes extensive bowel necrosis, resulting in a poor prognosis with an extremely high mortality rate. An 82-year-old woman was admitted to our hospital with the complaint of abdominal pain. She was diagnosed as having acute SMA occlusion by enhanced CT. Five hours from onset, the first thrombolytic therapy with urokinase was performed, but failed to complete thrombolysis and recanalization of peripheral blood flow. An exploratory laparotomy following the first thrombolytic therapy showed a mild ischemic change in the affected intestine and mesentery, but no sign of necrosis. After the laparotomy, local thrombolytic therapy with angiographic evaluation of blood flow at 24, 36 and 48 h from the first thrombolysis was performed. As a result, the residual thrombus disappeared and all branches of the SMA became well visualized. The patient was discharged well without a second-look operation or major bowel resection. Sequential intermittent thrombolytic therapy with meticulous angiographic evaluation of blood flow is effective for early-stage acute SMA occlusion.
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Affiliation(s)
- Shinichi Okamura
- Department of Surgery, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Successful treatment of acute occlusion in superior mesenteric artery of an elderly man by thrombus aspiration. J Clin Gastroenterol 2007; 41:933-4. [PMID: 18090165 DOI: 10.1097/mcg.0b013e31802c2f66] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006; 47:1239-312. [PMID: 16545667 DOI: 10.1016/j.jacc.2005.10.009] [Citation(s) in RCA: 740] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463-654. [PMID: 16549646 DOI: 10.1161/circulationaha.106.174526] [Citation(s) in RCA: 2177] [Impact Index Per Article: 120.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive Summary. Circulation 2006. [DOI: 10.1161/circulationaha.106.173994] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.02.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Schoots IG, Levi MM, Reekers JA, Lameris JS, van Gulik TM. Thrombolytic therapy for acute superior mesenteric artery occlusion. J Vasc Interv Radiol 2005; 16:317-29. [PMID: 15758127 DOI: 10.1097/01.rvi.0000141719.24321.0b] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of this review is to evaluate thrombolytic therapy for acute superior mesenteric artery occlusion as an alternative or adjunctive treatment modality to surgical therapy and to provide current knowledge for timely and informed decisions regarding treatment of acute mesenteric ischemia. A systematic analysis of the available literature from 1966 to 2003 regarding thrombolytic therapy for superior mesenteric artery thromboembolism was performed. A total of 20 case reports and seven small series covered 48 patients with acute superior mesenteric artery thromboembolism. In the herein reviewed series, thrombolytic therapy of acute superior mesenteric artery thromboembolism resulted in angiographic resolution of the thromboembolism in 43 patients, in clinical success without requiring additional surgical intervention in 30 patients, and in survival in 43 patients, with similar complication rates as in thrombolytic treatment of peripheral vascular occlusions. Remission of abdominal pain during the first few hours of treatment formed the most important indicator of therapeutic success. Insufficient evidence from reviewed literature is available to determine the relative effectiveness and safety of thrombolytic treatment for acute superior mesenteric artery thromboembolism; however, initial results appear to be promising. Thrombolytic therapy can be effective relatively quickly, may obviate surgery, and has the potential to resolve the clot completely. In some cases it can be used as an alternative or neo-adjunctive treatment modality to surgery. A treatment guideline for thrombolysis of acute superior mesenteric artery thromboembolism should be developed.
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Affiliation(s)
- Ivo G Schoots
- Department of Surgery, Academic Medical Center, University of Amsterdam, Department of Surgery, IWO-1-155, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
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Tabriziani H, Frishman WH, Brandt LJ. Drug therapies for mesenteric vascular disease. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:306-14. [PMID: 12350243 DOI: 10.1097/00132580-200209000-00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mesenteric vascular disease has been increasingly diagnosed in the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population and increasing number of critically ill patients, and to a greater clinical recognition of the condition. While surgical revascularization and resection has long been the standard of treatment, medical management also plays an important role. Early diagnosis before irreversible bowel damage, which may occur within 6 to 8 hours after insult, is the goal of successful medical treatment without surgical intervention. Even in the presence or irreversible bowel ischemia, perioperative medical treatment may reduce the progression of further ischemia, and bowel resection may be limited. This article outlines the appropriate medical management of ischemic disorders of the intestine, with an emphasis on the drug treatments presently used in clinical practice and those being studied in the laboratory.
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Affiliation(s)
- Hossein Tabriziani
- Department of Medicine, St. Barnabas Hospital Center, Bronx, New York, USA
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Barakate MS, Cappe I, Curtin A, Engel KD, Li-Kim-Moy J, Poon MSF, Sandeman MD. Management of acute superior mesenteric artery occlusion. ANZ J Surg 2002; 72:25-9. [PMID: 11906420 DOI: 10.1046/j.1445-2197.2002.02289.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND This review examines the surgical management of acute superior mesenteric artery (SMA) occlusion and the impact of interventional radiology techniques. METHODS Eight consecutive patients with SMA occlusion were treated at the Lismore Base Hospital, Lismore, NSW, Australia, from 1996 through to 2001 and of these, one patient was managed successfully with catheter-directed lytic therapy. The study group included five male and three female patients with a mean age of 71.3 (range 57-88) years. The records of these patients were reviewed to determine demographic characteristics, clinical features, predisposing factors and the duration of symptoms before intervention, management details and final outcome. RESULTS Embolic phenomena due to atrial fibrillation were the most frequently identifiable cause of acute SMA occlusion, present in six of eight patients. Seven patients were managed with open surgery in the first instance and of these, four died. Three patients remain alive and well at a mean 2.8 years follow-up. Patient number eight developed acute SMA occlusion from embolism secondary to atrial fibrillation and was managed initially with SMA urokinase thrombolysis. This patient's pain was relieved 1 h after initiation of the procedure. Delayed films after 18 h from initiation of thrombolysis demonstrated re-opening of all the ileo-colic branches and at 6 weeks' follow-up the patient remains well with normal bowel function. CONCLUSIONS There is a role for selective SMA cannulation and urokinase thrombolysis in the management of patients with acute SMA thrombosis.
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Affiliation(s)
- Michael S Barakate
- University of Sydney, Departments of Surgery and Interventional Radiology, University of Sydney, Lismore Base Hospital, Lismore, New South Wales, Australia.
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18
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Kandarpa K, Becker GJ, Hunink MG, McNamara TO, Rundback JH, Trost DW, Sos TA, Poplausky MR, Semba CP, Landow WJ. Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part I. J Vasc Interv Radiol 2001; 12:683-95. [PMID: 11389219 DOI: 10.1016/s1051-0443(07)61438-9] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This two-part review identifies the existing evidence supportive of the application of transcatheter treatments for peripheral atherosclerotic lesions. The first part addresses the treatment of obstructive lesions that cause limb claudication and critical ischemia, renovascular hypertension and azotemia, and mesenteric ischemia. Studies were identified via a search of MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, a preference was given to studies with at least 50 patients per treated group and a minimum mean follow-up duration of 6 months. Data presented in tables are proportionally weighted averages from included studies. For each application, the authors assessed the quality of evidence (QOE; efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. There is higher QOE supporting the more established treatments such as lower limb percutaneous transluminal angioplasty (PTA) with stent placement and thrombolysis. Treatments such as renal artery PTA and stent placement and mesenteric and brachiocephalic PTA are in wide use, but high QOE supporting general application is lacking. Blanket recommendations based on established efficacy and cost-effectiveness cannot be made. However, the use of transcatheter therapies can be supported in specific circumstances based on an expected reduction in procedure-related morbidity and/or mortality rates. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.
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Affiliation(s)
- K Kandarpa
- Department of Radiology, Weill Medical College, Cornell University, New York, USA.
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19
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Mellander S, Hellberg R, Karlqvist PA, Svahn M. Local Fibrinolysis in Acute Thromboembolism of the Superior Mesenteric Artery. ACTA ACUST UNITED AC 2001; 167:308-11. [PMID: 11354326 DOI: 10.1080/110241501300091589] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- S Mellander
- Department of Surgery, Mälarsjukhuset, Eskilstuna, Sweden
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20
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Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 25, 1999, and by the AGA Governing Board on November 25, 1999.
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Affiliation(s)
- L J Brandt
- Montefiore Medical Center/Albert Einstein College of Medicine Bronx, New York, USA
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21
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Venbrux AC. Mesenteric Ischemia and Gastrointestinal Bleeding. J Vasc Interv Radiol 1999. [DOI: 10.1016/s1051-0443(99)71175-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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22
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Sharafuddin MJ, Hicks ME. Current status of percutaneous mechanical thrombectomy. Part III. Present and future applications. J Vasc Interv Radiol 1998; 9:209-24. [PMID: 9540903 DOI: 10.1016/s1051-0443(98)70260-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- M J Sharafuddin
- Section of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO 63110, USA
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23
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Yamada K, Saeki M, Yamaguchi T, Taira M, Ohyama Y, Ashida H, Sakuyama K, Ishikawa T. Acute mesenteric ischemia. CT and plain radiographic analysis of 26 cases. Clin Imaging 1998; 22:34-41. [PMID: 9421653 DOI: 10.1016/s0899-7071(97)00071-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to assess the computed tomography (CT) and plain radiographic findings of acute mesenteric ischemia, in an effort to elucidate its poor prognostic signs. The study group consisted of 26 cases with pathologically or angiographically proven mesenteric ischemia. The pathologically proven longitudinal extent of the bowel ischemia was graded using six degrees, and correlated with the radiographic findings. The mortality of the patients depended primarily on the extent of infarctions and the age of the patient. Patients with bowel dilation or abnormal gas in the bowel wall or portal system were prone to have wider extents of ischemia.
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Affiliation(s)
- K Yamada
- Department of Radiology, St. Marianna University School of Medicine, Kanagawa, Japan
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24
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Venbrux AC. Mesenteric Ischemia and Gastrointestinal Bleeding. J Vasc Interv Radiol 1998. [DOI: 10.1016/s1051-0443(98)70162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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25
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Gallego AM, Ramírez P, Rodríguez JM, Bueno FS, Robles R, Capel A, Parrilla P. Role of urokinase in the superior mesenteric artery embolism. Surgery 1996; 120:111-3. [PMID: 8693413 DOI: 10.1016/s0039-6060(96)80249-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- A M Gallego
- Department of Surgery, Hospital Virgen de la Arrixaca, University of Murcia, Spain
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26
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Bradbury AW, Brittenden J, McBride K, Ruckley CV. Mesenteric ischaemia: a multidisciplinary approach. Br J Surg 1995; 82:1446-59. [PMID: 8535792 DOI: 10.1002/bjs.1800821105] [Citation(s) in RCA: 177] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Mesenteric ischaemia may result from a wide range of pathological processes, each possessing unique clinical features, diagnostic difficulties, management strategies and outcome. Regardless of aetiology, prognosis depends crucially on rapid diagnosis and institution of treatment to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is required and is frequently life saving. Percutaneous transcatheter techniques are increasingly employed in both diagnosis and treatment. Close cooperation between radiologists, physicians and surgeons is therefore necessary if clinical outcome is to be optimized. This paper reviews the modern interdisciplinary management of mesenteric ischaemia in the light of recent advances.
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Affiliation(s)
- A W Bradbury
- University Department of Surgery, Royal Infirmary, Edinburgh, UK
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27
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Turégano-Fuentes F, De Tomás-Palacios J, Pérez-Díaz D, Echenagusia-Belda A, Simó-Muerza G, Camuñez F. Acute arterial syndromes in mesenteric ischemia. Dis Colon Rectum 1995; 38:778-9. [PMID: 7607044 DOI: 10.1007/bf02048041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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28
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Tytle TL, Prati RC. Percutaneous recanalization in chronic occlusion of the superior mesenteric artery. J Vasc Interv Radiol 1995; 6:133-6. [PMID: 7703579 DOI: 10.1016/s1051-0443(95)71078-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- T L Tytle
- Department of Radiological Sciences, University of Oklahoma Health Sciences Center, Oklahoma City 73190-3020, USA
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