Endovascular treatment of arterial mesenteric ischaemia: a retrospective review

The role of endovascular therapy in acute mesenteric ischemia

Background

Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes.

Methods

An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016.

The following variables were extracted

number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel.

Results

Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively.

Conclusions

Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

Management of Acute Mesenteric Ischemia

Background:

Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence.

Methods:

A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate.

Results:

Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review.

Conclusion:

Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

Endovascular recanalisation of an acute superior mesenteric artery occlusion. A case report and review of the literature

Introduction

Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%.

Presentation of case

A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis.

Discussion

We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI.

Conclusion

Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection.

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Early diagnosis by CT angiography is essential in acute mesenteric ischaemia.

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CT is limited in detecting non-specific secondary signs of bowel ischaemia.

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Endovascular interventions are safe alternatives to surgical revascularisation.

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Laparotomy is often required to determine bowel viability and need for resection.

Atherosclerotic disease of the abdominal aorta and its branches: prognostic implications in patients with heart failure

Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.

Endovascular techniques in acute arterial mesenteric ischemia

Rapid developments in preoperative noninvasive imaging as well as advanced endovascular techniques have made endovascular treatment of acute arterial mesenteric ischemia a feasible treatment option in many patients. Multidetector computed tomographic angiography will provide the diagnosis and guide treatment in most cases. The use of mechanical and aspiration embolectomy, sometimes in combination with thrombolytic therapy, is often successful in offering these very sick patients a good treatment option to open surgical revascularization. Underlying occlusive lesions can be treated in the same setting. Hybrid techniques using open abdominal exploration in combination with endovascular tools have the possibility of offering minimally invasive treatment to even more patients. Access to a hybrid operating room is very advantageous when performing these operations because it allows for performing both open and endovascular interventions in the same setting. A fixed angiographic system also minimizes radiation exposure and improves the imaging capabilities compared to a conventional, mobile C-arm. These tools must be used in conjunction with wise, careful clinical evaluation of the patient.

Superior mesenteric artery syndrome caused by celiac axis compression syndrome: a case report and review of the literature

Celiac axis compression syndrome (CACS) is a rare entity of mesenteric ischemia, secondary to inadequate blood supply to the intestine, resulting in weight loss because of postprandial abdominal pain. Superior mesenteric artery (SMA) syndrome is an uncommon cause of intestinal obstruction manifesting with epigastric pain, bilious vomiting, and postprandial discomfort. Although the coexistence of both syndromes is very rare and has been reported only in eight patients in the literature, the CACS as a rare etiology of SMA syndrome has not yet been reported. Herein, we describe an uncommon case of SMA syndrome secondary to the CACS. The 27-year-old woman presented with epigastric pain, postprandial vomiting, and rapid body weight loss. The diagnosis of SMA syndrome was made by hypotonic duodenography and multidetector computer tomographic angiography. The CACS was also suspected by multidetector computer tomographic angiography. Surgical intervention was performed and the presence of CACS was confirmed. Her symptoms subsided shortly after operation and she was in good health at 1-year follow-up.

Acute thrombosis of a mesenteric artery drug-eluting stent following clopidogrel cessation

LEARNING OBJECTIVE

To describe thrombosis of sirolimus-coated mesenteric arterial stents following cessation of clopidogrel therapy.

BACKGROUND

Cardiac drug-eluting stent thrombosis following cessation of antiplatelet therapy with clopidogrel has been associated with increased mortality. The application of such stents in the mesenteric arterial system and the subsequent need for clopidogrel therapy has not been studied. This is the first case report of acute thrombosis of a drug-coated stent in the mesenteric circulation.

CLINICAL FINDINGS

Acute mesenteric ischemia secondary to thrombosis of a mesenteric arterial stent following clopidogrel cessation is described.

CONCLUSION

Drug-eluting stents represent an option for mesenteric revascularization in the surgically complicated abdomen. As in the setting of cardiac stenting, acute thrombosis of these devices following cessation of clopidogrel therapy is a concern. Indefinite clopidogrel therapy following deployment of drug-coated stents should be considered.

Management of chronic mesenteric ischemia. The role of endovascular therapy

Chronic mesenteric ischemia is an uncommon disorder manifested most commonly as abdominal pain. Surgical revascularization has traditionally been the treatment of choice. Endovascular management of this entity was originally attempted as an alternative for high-risk patients. Improvements in stent technology, refinement in technique, and increased efficiency of antiplatelet regimens have, over time, increased the popularity of this minimally invasive approach. We present a review of the available series on endovascular treatment of chronic mesenteric ischemia, with emphasis on short- and long-term outcome and morbidity and mortality results. Principles of operative technique and controversial issues and topics of interest are also discussed.

Endovascular interventional treatment of superior mesenteric arteries stenosis

AIM: To discuss the diagnosis and treatment of ischemic enteropathy resulted from superior mesenteric arteries (SMA) stenosis and evaluate the safety and efficacy of endovascular interventional technique for SMA stenosis.

METHODS: Four cases with SMA stenoses were treated with percutaneous transluminal balloon angioplasty (PTA) and stent placement. During 3 to 32 mo of following up, we observed the efficacy of endovascular interventional technique for SMA stenosis as well as the prognosis of patients.

RESULTS: PTA and stent placement were technically successful in all the cases. Among the 4 cases, 3 cases were implanted 1 stent respectively and 1 case was implanted 2 stents. After procedure, the symptoms were relieved in 3 cases within 1 week and their body weights increased to the ideal level during 3 to 6 months. The remaining one case obtained conspicuous alleviation of abdominal pain, but she still had the intermittent abdominal discomfort and her body weight didn't increased markedly. One patient died from acute myocardial infarction in the 32^th month after procedure and didn't have recurrent symptoms when she was alive. During the following up, re-stenosis didn't occur in all the cases which assessed by duplex sonography.

CONCLUSION: Computerized tomographic angiograms, magnetic resonance angiograms (MRA) and selective angiogram of SMA are important methods for the diagnosis of SMA stenosis. Stent-assisted angioplasty is safe and effective in the therapy of mensenteric arterial occlusive diseases, with a low incidence of complications and high technical success rate, especially fit for the patients with high surgical risk.