Bowel necrosis following endovascular revascularization for chronic mesenteric ischemia: a case report and review of the literature

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery

BACKGROUND

Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis.

METHODS

The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus.

RESULTS

Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion.

CONCLUSIONS

These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.

[Urinary long non-coding RNA H19 may serve as a biomarker for early diagnosis of acute intestinal necrosis]

OBJECTIVE

To explore the value of urinary long non-coding RNA(lncRNA) H19 in the differential diagnosis of acute intestinal necrosis against other abdominal emergencies.

METHODS

Surgical specimens of necrotic intestinal tissues, adjacent normal intestinal tissues, and serum and urine samples were collected from 51 patients with acute intestinal necrosis, and analyzed along with the serum and urine samples from 51 healthy controls, patients with 10 different acute abdominal conditions(35 cases for each condition), and patients with breast cancer, gastric cancer, bladder cancer, acute myeloid leukemia, and lung cancer(10 cases for each malignancy). The expression levels of H19 were measured with quantitative PCR in the collected samples. Receiver-operating characteristic(ROC)curves were used to determine the diagnostic value of serum and urine H19 levels for acute intestinal necrosis.

RESULTS

The 51 patients with acute intestinal necrosis included 35 women and 26 men(mean age of 74.4 years) with arterial thrombosis as the dominant etiology(26 cases). Compared with that in normal intestinal tissues, H19 was significantly overexpressed by 11.2 times in necrotic intestinal tissues(P < 0.001). Serum and urine H19 expression levels did not differ significantly among the healthy controls, patients with other acute abdominal conditions and malignancies(P > 0.05). Serum and urine H19 levels were significantly up-regulated in patients with acute intestinal necrosis as compared with those in the other subjects included in the analysis(P < 0.001). In patients with acute intestinal necrosis, H19 levels in the necrotic intestinal tissue, serum and urine samples were significantly correlated with correlation coefficients of 0.974(tissue vs serum), 0.967(serum vs urine), and 0.917(tissue vs urine). In ROC curve analysis, the areas under curves(AUCs)of serum and urine H19 for diagnosis of acute intestinal necrosis were 0.951 and 0.915, respectively; their diagnostic sensitivities were 94% and 79.6%, respectively, and they both had a diagnostic specificity of 100%.

CONCLUSIONS

In patients with acute intestinal necrosis, H19 is overexpressed in necrotic intestinal tissues, from which it is released into the blood circulation and urine. Urinary H19 may serve as a novel and non-invasive biomarker that assists in early diagnosis of acute intestinal necrosis.

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

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

[Management of complications after reconstruction of mesenteric arteries]

Because of the low ischemia tolerance of abdominal organs and the comorbidities of patients with abdominal ischemic syndromes, complications after the reconstruction of visceral arteries are often severe and associated with a significant mortality rate. The possible complications after interventions on the visceral arteries and their treatment are presented. Endovascular procedures have gained an increasingly important role in many primary interventions as well as in the treatment of complications.

Successful endovascular treatment of severe chronic mesenteric ischemia by concurrent triple-vessel mesenteric artery revascularization

A 52-year-old man presenting with severely symptomatic chronic mesenteric ischemia had proximal occlusion of the celiac and superior mesenteric arteries and critical stenosis of the inferior mesenteric artery ostium. Concurrent percutaneous revascularization with stenting of all three mesenteric arteries was successfully achieved using techniques tailored to each lesion. Complete clinical recovery was observed at the six-month post-procedure follow-up.