Chronic mesenteric ischemia: imaging and percutaneous treatment

Endovascular treatment of chronic mesenteric ischaemia secondary to a superior mesenteric artery pseudoaneurysm: a modified neurointerventional technique

A man in his late 60s presented with intermittent abdominal pain, nausea, vomiting and approximately 40 pounds of weight loss over the course of a year, most concerning for chronic mesenteric ischaemia. Given a prior negative workup, a CT angiogram was performed and revealed a wide neck mid-superior mesenteric artery pseudoaneurysm (PSA). As PSAs are susceptible to thrombus formation and distal emboli, this incidental finding was considered a possible explanation for his intermittent symptoms and thus required treatment. Anatomical constraints precluded traditional coiling or covered stent placement, so the interventional radiology team used a neurointerventional technique and performed a successful balloon-assisted coil embolisation of the PSA with subsequent resolution of the patient's symptoms. More than 3 years postprocedure, the patient remains asymptomatic with no complications.

A Gut-Wrenching Feeling: Overcoming Cognitive Biases in an Atypical Presentation of Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a rare but serious condition that can present with a variety of symptoms, including abdominal pain, diarrhea, and weight loss. Our case report presents a 63-year-old male with a past medical history of generalized anxiety disorder, Barrett's esophagus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD) with active smoking who initially presented with severe diffuse abdominal pain, nausea, vomiting, and chronic diarrhea resulting in malnutrition and 40-pound weight loss over a six-month span. The patient underwent extensive diagnostic evaluation and was diagnosed with Yersinia gastroenteritis via gastroenteritis panel (GI Panel), explaining all of the patient's symptoms. The patient underwent treatment for said gastroenteritis but did not experience remission of symptoms, leading to further diagnostic evaluations; a definitive diagnosis was not found, yet the patient's symptoms persisted. The patient then underwent extensive serologic and endoscopic evaluation, after extensive imaging and diagnostic work-up, the patient was finally diagnosed with chronic mesenteric ischemia (CMI) of the superior mesenteric artery (SMA) with severe celiac and inferior mesenteric artery (IMA) stenosis. The patient initially underwent stenting (7 mm by 26 mm Balloon Mounted Lifestream^TM Covered Stent; Becton Dickson (BD); Franklin Lakes, NJ, USA), which provided temporary relief to his symptoms, however, the relief did not last long. Upon reimaging, the patient was found to have stenosis of the stent, leading to the eventual placement of a bare-metal stent (Express^TM LD 7 x 27 mm balloon mounted bare-metal stent; Boston Scientific; Boston, MA, USA) across the celiac artery as well as the placement of an IMA stent (Innova^TM Self-expanding 5 x 20 mm bare-metal stent; Boston Scientific). This eventually resulted in the resolution of the patient's symptoms, eventual weight gain, and improvement in quality of life.

Mesenteric angina successfully treated by percutaneous angioplasty

A female patient of 47 years was sent to our radiology department for abdominal CT. She had severe epigastric pain very marked to left hypochondrium in postprandial period for a month. The pain was increasingly progressive with critical attacks at night. That forced her into fear and food restriction with an estimated weight loss of 4kg. Drug treatments did not improve symptoms. Abdominal CT highlighted thrombosis of superior mesenteric artery of 90%. Other arterial trunks and intestines were normal. Percutaneous angiography confirmed mesenteric thrombosis. A percutaneous transluminal angioplasty (PTA) was performed with success. Antiplatelets were prescribed. A good clinical evolution was observed within one year.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia

OBJECTIVE

This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications.

RESULTS

Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of "imaging wisely" raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia.

CONCLUSION

Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.

Robotic Approach for Median Arcuate Ligament Release in Pediatrics

Background: Median arcuate ligament (MAL) syndrome is a rare cause of chronic abdominal pain in adults and children. Release of the MAL has traditionally been performed open or laparoscopically. There have not been any published cases to our knowledge of robotic-assisted MAL release in pediatric patients. Patients and Methods: Two adolescent patients, aged 12 and 15 years, at our institution underwent robotic-assisted MAL release. The procedure involved dissecting the MAL muscle fibers and overlying scar tissue. Patients stayed inpatient postoperatively overnight and with an average outpatient follow-up of 10 months. Results: Both patients had immediate pain relief postoperatively and at 10-month follow-up had no recurrent symptoms. No complications were associated with the procedure. Conclusion: The increasing role of robotic surgery as a new surgical technique is gaining momentum for many procedures. This new approach for MAL release in the pediatric population was explored by our institution. It was found to be successful, safe, and reproducible for future patients.

Superior mesenteric artery endarterectomy for chronic mesenteric ischemia: A viable alternative in poor candidates for endovascular interventions

Background

Chronic mesenteric ischemia can be treated with either endovascular approaches or surgical revascularization. Recent data suggest that surgery leads to more durable symptom relief with similar long-term survival compared to transcatheter angioplasty. Splanchnic vessel endarterectomy has been shown to lead to longer freedom from recurrence compared to the more commonly used surgical bypass procedure.

Methods

We retrospectively reviewed the medical records of patients with chronic mesenteric ischemia who were considered poor candidates for endovascular repair and therefore underwent superior mesenteric artery endarterectomy in our institution. Study period was April 2016 to April 2018.

Results

A 73-year-old female and a 69-year-old male patient fulfilled our inclusion criteria. Extensive stenosis of the celiac axis and the superior mesenteric artery was found in both patients. superior mesenteric artery endarterectomy was performed in both cases. Endarterectomy was closed using a polytetrafluoroethylene patch. Both patients are alive and symptom-free at one year postoperatively with no signs of restenosis.

Conclusions

Our institutional outcomes are in line with recent literature supporting superior mesenteric artery endarterectomy as a viable alternative to surgical bypass in patients with chronic mesenteric ischemia who are suboptimal candidates for endovascular angioplasty and stenting.

Fatal Acute Hemorrhagic Bowel Infarction Caused by Mesenteric Venous Thrombosis

Acute mesenteric venous thrombosis (MVT) is a rare, but life-threatening medical phenomenon. MVT is normally characterized by insidious onset, with nonspecific signs and symptoms. A high index of clinical suspicion is required for diagnosis, and emergency surgery is necessary to optimize the chances of patient survival, especially in the people aged more than 70 years. Surprisingly, based on my review of the literature, no fatal acute MVT case has been reported in the forensic literature. All reported such cases have been documented in medical literature, and most of them have been associated with underlying risk factors for venous thrombosis, such as hypercoagulable state, certain cancers, and stasis of the blood flow. Here, I report the case of a sudden unexpected death due to extensive intestinal ischemia and infarction with massive abdominal hemorrhage caused by acute MVT in a 72-year-old man without known underlying risk factors.

Intestinal angina in a patient with hypertrophic obstructive cardiomyopathy: a case report

Background

Intestinal angina is characterized by recurrent postprandial abdominal pain and anorexia. Commonly, these symptoms are caused by severe stenosis of at least two vessels among the celiac and mesenteric arteries. However, intestinal perfusion is affected not only by the degree of arterial stenosis but also by systemic perfusion. We experienced a unique case of intestinal angina caused by relatively mild stenosis of the abdominal arteries complicated with hypertrophic obstructive cardiomyopathy.

Case presentation

We report an 86-year old Japanese man with hypertrophic obstructive cardiomyopathy and advanced atrioventricular block who was diagnosed with intestinal angina. Computed tomography showed mild stenosis of the celiac artery and severe stenosis of the inferior mesenteric artery, and these lesions were relatively mild compared with other reports. A dual-chamber pacemaker with right ventricular apical pacing was implanted to improve the obstruction of the left ventricular outflow tract. After implantation, the patient’s abdominal symptoms diminished markedly, and improvement of the left ventricular outflow tract obstruction was observed.

Conclusions

Although intestinal angina is generally defined by severe stenosis of at least two vessels among the celiac and mesenteric arteries, the present case suggests that hemodynamic changes can greatly affect intestinal perfusion and induce intestinal angina in the presence of mild stenosis of the celiac and mesenteric arteries.

Radiological Evaluation of Bowel Ischemia

Intestinal ischemia, which refers to insufficient blood flow to the bowel, is a potentially catastrophic entity that may require emergent intervention or surgery in the acute setting. Although the clinical signs and symptoms of intestinal ischemia are nonspecific, computed tomography (CT) findings can be highly suggestive in the correct clinical setting. In our article, we review the CT diagnosis of arterial, venous, and nonocclusive intestinal ischemia. We discuss the vascular anatomy, pathophysiology of intestinal ischemia, CT techniques for optimal imaging, key and ancillary radiological findings, and differential diagnosis.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Multidetector computed tomography of mesenteric ischaemia

Mesenteric ischaemia comprises a broad, heterogeneous group of diseases characterised by inadequate blood supply to the small or large bowel. Acute mesenteric ischaemia is a surgical emergency, with significant associated morbidity and mortality. Because the clinical presentation of mesenteric ischaemia is variable and often nonspecific, a high index of clinical and radiologic suspicion is required for early diagnosis. The severity of mesenteric ischaemia ranges from transient, localised ischaemia to frank necrosis of the bowel. The most common causes of acute mesenteric ischaemia are embolic and thrombotic occlusion of the superior mesenteric artery, whereas chronic mesenteric ischaemia is almost always associated with generalised atherosclerotic disease. Multidetector computed tomography (MDCT) angiography is the preferred imaging test for acute and chronic mesenteric ischaemia. MDCT is useful in making a prompt, more precise diagnosis of mesenteric ischaemia, as well as identifying the cause and potential complications, which are key to reducing patient morbidity and mortality. In this article, we review the clinical features and aetiologies of mesenteric ischaemia and illustrate the imaging manifestations on MDCT.

• Acute and chronic mesenteric ischaemia are morbid conditions challenging to diagnose.

• MDCT is the first-line imaging test for evaluating patients with suspected mesenteric ischaemia.

• Bowel findings include wall thickening, abnormal enhancement, pneumatosis and luminal dilation.

• Vascular occlusion, portomesenteric venous gas, mesenteric congestion and free air can be seen.

Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes

OBJECTIVE

Outcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification.

METHODS

The data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting.

RESULTS

The ER patients were significantly older (71 +/- 15 vs 65 +/- 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 +/- 0.5 vs 1.8 +/- 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group (P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 +/- 8 vs 3 +/- 5 days; P < .001). At 5 years, OR had improved (P < .05) recurrence-free survival (89% +/- 4% vs 51% +/- 9%), and primary (88% +/- 3% vs 41% +/- 9%) and secondary patency rates (97% +/- 2% vs 88% +/- 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved (P < .05) recurrence-free survival (91% +/- 3% vs 56% +/- 8% at 5 years) and better primary and secondary patency rates (93% +/- 2% and 98% +/- 1% vs 52% +/- 8% and 93% +/- 4% at 3 years).

CONCLUSION

OR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.

Intestinal Ischemia: US-CT findings correlations

Background

Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.

Methods

Basing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).

Results

To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.

Conclusion

At present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Chronic mesenteric ischemia: critical review and guidelines for management

BACKGROUND

CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist.

METHODS

A systematic literature review of the last 25-years was conducted through MEDLINE, Embase, and Cochrane Review/Trials register to identify studies reporting on CMI treatment with more than 10 patients. Primary outcomes were perioperative mortality and morbidity rates. Secondary outcomes were survival rates, primary and secondary patency rates, vessels treated, CMI recurrence, follow-up (FU), technical success (TS), and in-hospital length of stay (InH-LOS). Patients were divided into endovascular treatment (ET) or open treatment (OT) groups. Subsequently, primary and secondary outcomes were analyzed by study publication year for the interval periods 1986-2000 ("A") and 2001-2010 ("B"). Differences were assessed using the t-test and the χ(2) test.

RESULTS

Forty-three articles with 1,795 patients were included. Perioperative mortality and morbidity rates were lower in the ET group. No difference in survival rate was observed. Primary and secondary patencies were superior in the OT group. A greater number of vessels were revascularized in the OT group. CMI recurrence was more frequent in the ET group. FU was longer in the OT group. TS was superior in the OT group and InH-LOS was shorter in the ET group. A higher number of patients were treated by ET in the period "A." No differences in mortality and morbidity were observed between period "A" and "B" in ET and OT groups.

CONCLUSIONS

Considering the lower periprocedural mortality and morbidity after ET, this approach should be considered as the first treatment option in most CMI patients, especially in those with severe malnutrition. Primary OT should be restricted to cases that do not qualify for ET or good surgical risk patients with long life expectancy. Considering better long-term results of OT, ET treatment should be considered as a bridge therapy to OT in some patients requiring retreatment if ET does not preclude subsequent OT.

Atherosclerotic inferior mesenteric artery stenosis resulting in large intestinal hypoperfusion: a paradigm shift in the diagnosis and management of symptomatic chronic mesenteric ischemia

Symptomatic chronic mesenteric ischemia results from intestinal hypoperfusion and is classically thought to result from involvement of two or more mesenteric arteries. The celiac artery and superior mesenteric artery are most frequently implicated in this disease process, and their involvement usually results in symptoms of small intestinal ischemia. Symptomatic chronic mesenteric ischemia resulting predominantly from inferior mesenteric artery involvement has largely been overlooked but does gives rise to its own, unique clinical presentation with symptoms resulting from large intestinal ischemia. We present four patients with atherosclerotic inferior mesenteric artery stenosis with symptomatic chronic mesenteric ischemia that have unique clinical presentations consistent with large intestinal ischemia that resolved following percutaneous endovascular treatment of the inferior mesenteric artery stenosis. These cases represent a novel approach to the diagnosis and management of this disease process and may warrant a further subclassification of chronic mesenteric ischemia into chronic small intestinal ischemia and chronic large intestinal ischemia.

Chronic mesenteric ischemia: diagnosis and management

Chronic mesenteric ischemia (CMI) is the most common vascular disorder involving the intestines, however it is unusual in clinical practice. The redundancy of the visceral circulation with multiple interconnections between the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA) is the most likely explanation for the infrequent occurrence of CMI in clinical practice. Atherosclerosis is by the far the most common etiology of CMI. The increased utilization of diagnostic abdominal cross-sectional imaging has increased the recognition of atherosclerotic mesenteric stenoses. CMI is a clinical diagnosis, based upon symptoms and consistent anatomic findings. The classic setting for CMI is a female patient presenting with post-prandial abdominal discomfort that results in significant weight loss. Endovascular therapy with stenting has become the most common method chosen for revascularization having replaced open surgery with its associated morbidity and mortality.

Intestinal ischemia

Ischemic changes of the abdominal organs are crucial since they develop slowly and are therefore often diagnosed at a late stage. Due to this general aspect, mortality from this disease could not be significantly reduced over the last decade. One of the main causes of these high mortality rates is the insufficient integration of the overall clinical picture into the diagnostic work-up. Acute mesenteric ischemia should be differentiated from chronic visceral ischemia. Acute intestinal ischemia is a vascular emergency with a mortality rate of 60-80%. The incidence of chronic visceral vascular disorders accounts for approximately 1-2% of all abdominal conditions and has to be differentiated from the acute form, since intestinal ischemia has a progressive nature and usually is related to general atherosclerotic disease. Therefore, this condition is associated with an increase of arteriosclerotic-related multimorbidity in an increasingly elderly population. Due to excellent collateralization, extensive chronic occlusion processes affecting the visceral arteries can be asymptomatically treated on a long-term basis.

Endovascular treatment is effective against acute mesenteric ischemia complicated with metabolic diseases

A 77-year-old man with hypertension, diabetes mellitus, ischemic heart disease and a smoking habit presented at our hospital with sudden abdominal pain. Computed tomography indicated edematous swelling and pneumatosis of the intestinal wall in a localized area of the ascending colon with inflamed adipose tissue. Acute mesenteric ischemia was diagnosed. Abdominal angiography showed stenosis of the mesenteric arteries. Virtual histology-intravascular ultrasound imaging indicated a fibrous change in the superior mesenteric artery with a necrotic core. Endovascular treatment with stent placement after percutaneous transluminal angioplasty was effective. Surgery would usually be considered as the first choice for treating patients with acute mesenteric ischemia; however, when this condition is complicated with metabolic diseases, stenotic changes in the mesenteric arteries that would normally be found in patients with chronic mesenteric ischemia need to be considered to ensure optimal treatment.

Compression of the celiac trunk caused by median arcuate ligament in children and adolescent subjects: evaluation with contrast-enhanced MR angiography and comparison with Doppler US evaluation

PURPOSE

Compression of the celiac trunk by the median arcuate ligament can lead to clinically significant reduction in celiac blood flow and cause clinical symptoms. Doppler ultrasound (US) can be used to screen for stenoses of the celiac trunk and to reduce unnecessary catheter angiography. A noninvasive alternative method is magnetic resonance (MR) angiography.

MATERIALS AND METHODS

A series of 32 children and adolescent patients were evaluated retrospectively; 22 had a positive history of abdominal angina and the other 10 were referred for abdominal imaging including MR angiography for other reasons and were used as a control group.

RESULTS

In the patient group, all evaluated patients showed the typical hook-shaped appearance of the celiac trunk and focal narrowing with high-grade stenosis on MR angiography, which were eliminated after laparoscopic treatment. In the control group, no typical signs of median arcuate ligament syndrome were detected. US measurement of the mean preoperative peak velocity in the patient group was 304 cm/s ± 49. The mean postoperative peak velocity was 163 cm/s ± 29. In the control group without symptoms, the mean peak velocity was 140 cm/s ± 25. The difference in pre- and postoperative peak velocities in the patient group was highly significant (P <.0001).

CONCLUSIONS

MR angiography can confirm the diagnosis of median arcuate ligament syndrome by demonstrating the characteristic focal narrowing of the celiac artery in children presenting with the appropriate clinical symptoms and is an excellent alternative to catheter angiography, especially in a pediatric population.

Chronic mesenteric ischemia

Clinical manifestations of chronic mesenteric ischemia (CMI) can range from vague abdominal pain to debilitating states of intestinal angina resulting in significant weight loss and morbidity. Once the condition has been diagnosed, treatment usually is elective, except in rare cases of rapid progression to acute mesenteric ischemia. Medical management of CMI is mostly supportive. However, in disorders of coagulation, antiplatelet agents and warfarin may be helpful to prevent further thrombosis, and these disorders may require lifelong therapy. For decades, the mainstay of therapy for CMI has been surgery. Extensive disease often requires complete revascularization, although bypass of the superior mesenteric artery alone also has been shown to be effective. Multiple variations of surgical bypass have been advocated but require further evaluation to determine efficacy. Transaortic endarterectomy is a viable option for limited disease. Minimally invasive vascular procedures such as percutaneous endovascular angioplasty and stenting are proving to be effective for short-segment atherosclerotic stenosis, particularly near the origin of the vessels. Although endovascular therapy has less long-term durability compared with open surgical procedures, these treatments prove simpler, with shortened hospital stays and reduced morbidity. Furthermore, angiographic therapy is a feasible alternative for patients in whom surgery is deemed precarious.

Mesenteric ischemia

Mesenteric ischemia is classified as either acute or chronic. The former is a life-threatening emergency in which a sudden reduction in intestinal blood flow may ultimately result in bowel infarction. The most common causes are arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia, and mesenteric venous thrombosis. A high index of suspicion, early diagnosis and rapid intervention are necessary so that normal mesenteric perfusion is restored before fatal bowel infarction can occur. Chronic mesenteric ischemia is usually caused by stenotic or occlusive disease involving the proximal segments of the mesenteric arterial supply to the bowel, usually as a result of atherosclerosis. Intestinal angina is the classic presentation, defined as recurrent postprandial abdominal pain that subsides in 1 to 2 hours, with associated weight loss and aversion to food. When combined with the clinical presentation, physical examination, and laboratory data, imaging plays a key role in the diagnosis of either acute or chronic mesenteric ischemia. Recognition of pertinent imaging findings and various treatment options may aid in preventing the serious and possibly fatal sequelae that may occur in cases of mesenteric ischemia.

Acute and chronic mesenteric ischemia: MDCT findings

Mesenteric ischemia is caused by a reduction in mesenteric blood flow. It can be divided into acute and chronic, based upon the rapidity and the degree to which the blood flow is compromised. The authors retrospectively reviewed 22 cases of mesenteric ischemia, diagnosed by multidetector computed tomography (MDCT) in our service, and confirmed by surgery or clinical follow-up. The frequency of the diagnostic findings of chronic and acute mesenteric ischemia was evaluated. The improvement of three-dimensional (3D) MDCT allows accurate assessment of mesenteric vessels. Therefore, it demonstrates changes in ischemic bowel segments helpful in determining the primary cause of the disease, and can identify the complications in patients with acute and chronic mesenteric ischemia.

Chronic atherosclerotic mesenteric ischemia (CMI)

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.

Chronic mesenteric ischemia: how to select patients for invasive treatment

Chronic mesenteric ischemia (CMI) remains a well-described disease process that is difficult to diagnose. Since its initial description more than a century ago, a myriad of diagnostic and treatment modalities have been applied to ameliorate the classic symptoms of postprandial abdominal pain and weight loss. It is estimated that mesenteric occlusive disease affects approximately 1% to 18% of the population, with a majority of these patients manifesting no symptoms of CMI. While associated with a small prevalence, the potential economic impact of this disease process, with the increasing age of the population and the catastrophic outcomes associated with no treatment, is significant. The primary etiology of CMI is atherosclerotic occlusive disease involving the ostia of the mesenteric arteries. Several studies have investigated the pathophysiology of the postprandial abdominal pain associated with ischemia focusing on transport mechanisms, claudication of the intestinal musculature, and ischemia of the visceral nerves. The process of diagnosing CMI involves assimilation of the presentation, typical history and physical examination findings, and results of imaging modalities. At the end of this diagnostic process, the decision to offer a patient surgical intervention is primarily based on symptomatology and results of duplex and other imaging modalities. There are specific criteria for which to offer symptomatic patients interventions. Patients who are asymptomatic do not need to undergo revascularization, which may disrupt collateral arterial circulation to the mesentery. They should be followed conservatively.

Prevalência da estenose aterosclerótica do tronco celíaco e da artéria mesentérica superior na arteriopatia oclusiva dos membros inferiores

Contexto: A eventual relação entre a aterosclerose das artérias dos membros inferiores com a aterosclerose das artérias intestinais foi pouco estudada. Objetivo: Avaliar pela ecografia vascular (Doppler) presença de lesões com estenose 70% na artéria mesentérica superior e/ou tronco celíaco em doentes com arteriopatia obstrutiva crônica dos membros inferiores. Método: Foram estudados dois grupos, cada um com 60 doentes (40 homens e 20 mulheres). O grupo-caso foi composto por doentes com arteriopatia obstrutiva crônica dos membros inferiores, claudicação intermitente limitante ou dor de repouso e/ou lesões tróficas de extremidade, sem queixas gastrintestinais. O grupo-controle foi constituído por enfermos sem doença arterial obstrutiva dos membros inferiores e sem queixas gastrintestinais. Consideraram-se fatores de risco presença de diabetes melito, hipertensão arterial, obesidade, angina/infarto, tabagismo e dislipidemia. Todos os doentes foram submetidos a ecografia vascular do tronco celíaco e da artéria mesentérica superior. Os doentes do grupo-caso foram separados pela presença de claudicação intermitente limitante (N = 12) ou lesão trófica e/ou dor de repouso (N = 48). Resultados: Houve associação significante entre idade (p = 0,04) e cardiopatia isquêmica (p = 0,04) com aterosclerose da artéria mesentérica superior. Os fatores de risco não mostraram associação significante com presença de estenose do tronco celíaco. Observou-se associação significante entre arteriopatia dos membros inferiores e lesão estenótica da artéria mesentérica superior (p = 0,006) e do tronco celíaco (p < 0,001). Conclusões: Na ecografia vascular, o achado de arteriopatia periférica sugere presença de lesão estenótica em artéria mesentérica superior e/ou tronco celíaco. A aterosclerose na artéria mesentérica superior está associada com cardiopatia isquêmica e idade avançada.

Abdominal angina

Abdominal angina is an underrecognized cause of postprandial abdominal pain and weight loss. Diagnosis is often delayed and requires both a careful exclusion of more common causes and a high degree of clinical suspicion, based on the patient's age, the coexistence of multiple risk factors for atherosclerosis, and the presence of vasculopathy in other districts. Appropriate investigations include duplex ultrasound, traditional angiography, magnetic resonance angiography, computed tomography angiography, and tonometry. The purpose of this review is to discuss the pathophysiology and clinical presentation of chronic mesenteric ischemia and to suggest a diagnostic flowchart for this complex condition.

MDCT angiography of mesenteric bypass surgery for the treatment of chronic mesenteric ischemia

OBJECTIVE

Chronic mesenteric ischemia (CMI) is a serious condition that requires surgical or endovascular intervention. Surgical revascularization for the treatment of CMI uses different operative techniques including endarterectomy, vessel reimplantation, and mesenteric bypass. A basic understanding of the operative techniques is essential for the adequate interpretation of imaging studies in patients who have undergone surgery for CMI. In this article, we review the different operative techniques used in the treatment of CMI, discuss the results of surgical intervention for CMI, and illustrate how MDCT angiography (MDCTA) can be used for follow-up and for the detection of early and late complications after surgery.

CONCLUSION

MDCTA is a powerful tool for the postoperative evaluation of patients with CMI. Early detection of graft dysfunction is critical to prevent graft occlusion and the development of potentially fatal mesenteric ischemia. MDCTA can detect early and late complications after surgery and guide additional surgical or endovascular interventions.

Role for endovascular therapy in chronic mesenteric ischemia

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.

Open and endovascular revascularization for chronic mesenteric ischemia: tabular review of the literature

Chronic mesenteric ischemia is an uncommon disease in vascular surgery practice worldwide. Open revascularization remains the best treatment for low-risk patients due to durability and efficacy. Endovascular revascularization for chronic mesenteric ischemia was primarily indicated for elderly and higher-risk patients, but this has changed over the past 10 years due to development of more precise devices and lower morbidity and mortality rates despite the higher recurrence and restenosis rates. Our purpose was to summarize the data on endovascular and open revascularization for chronic mesenteric ischemia in a schematic tabular presentation.

MR angiography with parallel acquisition for assessment of the visceral arteries: comparison with conventional MR angiography and 64-detector-row computed tomography

The purpose of the study was to retrospectively compare three-dimensional gadolinium-enhanced magnetic resonance angiography (conventional MRA) with MRA accelerated by a parallel acquisition technique (fast MRA) for the assessment of visceral arteries, using 64-detector-row computed tomography angiography (MDCTA) as the reference standard. Eighteen patients underwent fast MRA (imaging time 17 s), conventional MRA (29 s) and MDCTA of the abdomen and pelvis. Two independent readers assessed subjective image quality and the presence of arterial stenosis. Data were analysed on per-patient and per-segment bases. Fast MRA yielded better subjective image quality in all segments compared with conventional MRA (P = 0.012 for reader 1, P = 0.055 for reader 2) because of fewer motion-induced artefacts. Sensitivity and specificity of fast MRA for the detection of arterial stenosis were 100% for both readers. Sensitivity of conventional MRA was 89% for both readers, and specificity was 100% (reader 1) and 99% (reader 2). Differences in sensitivity between the two types of MRA were not significant for either reader. Interobserver agreement for the detection of arterial stenosis was excellent for fast (kappa = 1.00) and good for conventional MRA (kappa = 0.76). Thus, subjective image quality of visceral arteries remains good on fast MRA compared with conventional MRA, and the two techniques do not differ substantially in the grading of arterial stenosis, despite the markedly reduced acquisition time of fast MRA.

Chronic mesenteric ischemia: efficacy and outcome of endovascular therapy

Chronic mesenteric ischemia is a rare condition caused by occlusive disease of the mesenteric vessels and manifested most commonly as abdominal pain. While the traditional therapy in symptomatic patients has been surgery, recent improvements in interventional devices and refinement in techniques have increased the popularity of endovascular treatment. The high procedural success and the low complication rate make the catheter-based approach an interesting alternative to surgery. Percutaneous angioplasty and stenting is now recognized as a minimally invasive means of obtaining good long-term results and is consequently suggested for the primary treatment of chronic mesenteric ischemia. This article presents a review of the literature on indications and technical aspects of endovascular treatment, with emphasis on short- and long-term outcomes.

Abdominal angina in occlusive mesenteric vascular disease: a case report

INTRODUCTION

Abdominal angina is a descriptive term for abdominal pain that can occur postprandially in patients with occlusive mesenteric vascular disease due to insufficient increase in blood flow.

CASE PRESENTATION

In this case a 60-year-old Caucasian woman with a 2 year history of abdominal angina presented to hospital for elective mesenteric revascularization surgery. Postoperative recovery was complicated by graft occlusion resulting in hepatic ischemia as well as splenic and small bowel infarction.

CONCLUSION

This case highlights the importance of keeping this differential diagnosis in mind when dealing with patients who have a long history of abdominal pain and discusses some of the complications that may occur after surgical treatment.

Reperfusion hemorrhage following superior mesenteric artery stenting

Percutaneous transluminal angioplasty and stent placement is now an established treatment option for chronic mesenteric ischemia and is associated with low mortality and morbidity rates. We present a case of reperfusion hemorrhage complicating endovascular repair of superior mesenteric artery stenosis. Although a recognized complication following repair of carotid stenosis, hemorrhage has not previously been reported following mesenteric endovascular reperfusion. We describe both spontaneous cessation of bleeding and treatment with coil embolization.

Multidetector CT angiography in the diagnosis of mesenteric ischemia

Multidetector CT is an ideal tool for the diagnosis of acute and chronic mesenteric ischemia. Advanced CT scanners and expertise in three-dimensional imaging are becoming increasingly widespread, opening the door to new opportunities and challenges in the evaluation of patients suspected of having mesenteric ischemia. This article reviews contrast administration and image acquisition protocols, the anatomy of the mesenteric vasculature, the etiology of acute and chronic mesenteric ischemia, and CT findings diagnostic for these conditions.