Early Identification of Chronic Mesenteric Ischemia with Endoscopic Duplex Ultrasound

Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition's variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed.

PURPOSE

Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia.

METHODS

A narrative review of all relevant studies from January 2022 through September 2023.

RESULTS

A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review.

CONCLUSIONS

Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.

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.

Plasma α-Glutathione S-Transferase in Patients with Chronic Mesenteric Ischemia and Median Arcuate Ligament Syndrome

Background

Chronic mesenteric ischemia (CMI) due to either atherosclerosis of the mesenteric arteries or median arcuate ligament syndrome (MALS) is an underdiagnosed entity. The etiology of MALS and its existence have been debated and questioned. We aimed to identify plasma biomarkers indicating mesenteric ischemia in patients with CMI and MALS.

Methods

Plasma α-glutathione S-transferase (α-GST), intestinal fatty acid-binding protein (I-FABP), citrulline, and ischemia modified albumin (IMA) were analyzed in fifty-eight patients with CMI (Group A, n=44) and MALS (Group B, n=14) before and after revascularization. The plasma levels of these potential biomarkers were compared with those of healthy individuals (Group C, n=16). Group comparison was performed with the Mann–Whitney U-test. Cross-tabulation and its derivatives were obtained. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were calculated.

Results

Plasma levels of α-GST were significantly raised in the patients with CMI (7.8 ng/mL, p<0.001) and MALS (8.4 ng/mL, p<0.001), as compared with the control Group C (3.3 ng/mL). The threshold for normal median plasma α-GST levels of 4 ng/mL yielded a sensitivity of 93% and 86%, specificity of 86% and 88%, respectively, for the diagnosis of CMI due to atherosclerosis and MALS. AUC of ROC curves was 0.96 (p<0.0001) for CMI and 0.85 (p<0.002) for MALS. The patient groups did not differ from the healthy controls in any other biomarkers.

Conclusion

Plasma α-GST levels are elevated in CMI and MALS patients. Elevated plasma levels of α-GST suggest ischemia as the etiology of MALS.