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Harish KB, Chervonski E, Rokosh R, Garg K, Berland TL, Sadek M, Teter KA, Rockman CB, Jacobowitz GR, Maldonado TS. Natural History of Asymptomatic Mesenteric Artery Occlusive Disease and Predictors of Symptomatic Progression. J Vasc Surg 2025:S0741-5214(25)00957-7. [PMID: 40254189 DOI: 10.1016/j.jvs.2025.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2024] [Revised: 04/07/2025] [Accepted: 04/13/2025] [Indexed: 04/22/2025]
Abstract
OBJECTIVE The objective of this study was to characterize the natural history of incidentally identified asymptomatic mesenteric artery stenosis and to identify clinical and radiographic predictors that differentiate patients with asymptomatic mesenteric artery occlusive disease (MAOD) and patients with symptomatic chronic mesenteric ischemia (CMI) diagnosed at index study. METHODS This single-institution retrospective analysis included patients diagnosed with >70% stenosis of the celiac or superior mesenteric artery (SMA) on axial imaging or duplex ultrasound in an institutional radiology database. Patients were grouped into asymptomatic MAOD and symptomatic CMI cohorts according to their clinical presentation at index study. The primary endpoint was progression of disease from asymptomatic stenosis to CMI. Demographic, clinical, and imaging features at index study were also compared between asymptomatic and symptomatic cohorts. RESULTS 79 patients met the inclusion criteria, with 43 in the asymptomatic group and 36 in the symptomatic group. Patients in the asymptomatic group were followed for mean 32.7 ± 30.2 months; 60.5% (n=26) were referred to and followed by a vascular surgeon for 21.5 ± 27.8 months. No asymptomatic patients developed symptoms during the follow-up period. All patients in the symptomatic group were evaluated by a vascular surgeon and underwent procedural intervention for CMI within six months of diagnosis. Patients with CMI were more likely to have a history of smoking (p=0.02) and less likely to be anticoagulated (p<0.01) than patients with asymptomatic MAOD. Symptomatic patients trended towards a higher prevalence of coronary artery disease (p=0.06) and a lower prevalence of arrhythmia (p=0.08). On imaging, the symptomatic cohort was more likely to have severe SMA stenosis (p<0.001), multivessel mesenteric disease (p=0.001), calcified aortic plaque (p=0.01), and severe stenosis in one or both internal iliac arteries (p<0.001). On multivariable analysis, a lack of anticoagulation use (p<0.01) and severe SMA stenosis (p<0.001) were independently associated with higher odds of symptomatic mesenteric stenosis. While statistically insignificant, calcified aortic plaque (p=0.08) and smoking history (p=0.06) trended toward higher odds of symptomatic index presentation. CONCLUSIONS The rate of progression from asymptomatic MAOD to CMI appears exceedingly low in the first two to three years after diagnosis, suggesting that prophylactic revascularization is mostly unnecessary. Surveillance of asymptomatic MAOD may be personalized based on clinical and radiographic features of disease. SMA stenosis severity, anticoagulation use, and possibly smoking history and the presence of aortic plaque calcification may be promising markers to stratify the risk of ischemic progression.
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Affiliation(s)
- Keerthi B Harish
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Ethan Chervonski
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Rae Rokosh
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Todd L Berland
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Katherine A Teter
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Caron B Rockman
- Department of Vascular Surgery, Hackensack Meridian Health, Hackensack, NJ
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, Northwell Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Alonso A, Maaneb de Macedo K, Siracuse JJ. Endovascular Management of Acute and Chronic Mesenteric Ischemia. Ann Vasc Surg 2025:S0890-5096(25)00288-2. [PMID: 40246279 DOI: 10.1016/j.avsg.2025.04.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2025] [Revised: 04/03/2025] [Accepted: 04/04/2025] [Indexed: 04/19/2025]
Abstract
BACKGROUND Mesenteric ischemia demands prompt and effective revascularization. Endovascular therapy (EVT) has become a well-established treatment modality with several benefits. This review examines current EVT options for managing acute and chronic mesenteric ischemia in contemporary practice. METHOD A comprehensive literature review was conducted to evaluate endovascular techniques for mesenteric ischemia, including angioplasty, stenting, thrombectomy, thrombolysis, pharmacological thrombectomy, local vasodilator infusion, and hybrid approaches. We also evaluated access sites and post-operative management. RESULTS EVT offers several advantages in the management of mesenteric ischemia, with various access sites and techniques available for single or combined use. EVT has largely replaced open revascularization for CMI and is increasing in use for AMI. The utility of each approach varies by disease chronicity, with different risk-benefit profiles. While short term outcomes are favorable, long-term patency rates and the need for re-interventions remain concerns. Further research is needed to compare open to endovascular revascularization. CONCLUSION EVT provides diverse revascularization options for mesenteric ischemia, particularly for high-risk patients. While it has favorable short-term outcomes, EVT may be associated with higher rates of restenosis and reintervention in the long term and the overall mortality rates for this disease process remain high, particularly for AMI. The choice between endovascular and open surgical approaches should be individualized on patient factors, lesion characteristics, and surgeon/interventionist expertise. Further prospective and randomized trials are needed to better elucidate outcomes from this approach and guide operative management.
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Affiliation(s)
- Andrea Alonso
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Khuaten Maaneb de Macedo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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Burysz M, Litwinowicz R, Kowalewski M, Walocha J, Batko J. Changes in Abdominal Artery Diameter in Patients Treated for Acute Aortic Dissection. J Cardiovasc Dev Dis 2025; 12:129. [PMID: 40278188 DOI: 10.3390/jcdd12040129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2025] [Revised: 03/24/2025] [Accepted: 03/31/2025] [Indexed: 04/26/2025] Open
Abstract
BACKGROUND Mesenteric ischemia significantly increases intraoperative mortality in patients with acute aortic dissection (AAD). The arterial diameter affects both blood flow and arterial resistance. There are no data in the literature on changes in arterial diameter in patients with AAD. It has already been demonstrated that changes in arterial diameter can be observed in patients with non-occlusive intestinal ischemia. The aim of this study was to compare the arterial branches of the abdominal aorta in patients with AAD preoperatively and postoperatively. METHODS Preoperative and postoperative contrast-enhanced computed tomography scans of 25 patients who had undergone the frozen elephant trunk procedure for the treatment of AAD were reconstructed and retrospectively analyzed with detailed medical data of the patients. RESULTS In patients without AAD at the level of the abdominal aorta, statistically significant differences were observed when comparing the diameter of the superior mesenteric artery (p < 0.001) and the renal arteries (p < 0.001) between preoperative and postoperative scans. Occlusion of the inferior mesenteric artery was more common in patients with AAD involving the abdominal aorta. Statistically significant differences in true and false lumen were observed at each level of the abdominal aorta after a successful frozen elephant trunk procedure. CONCLUSION Significant changes in visceral artery diameter were observed at the abdominal aortic level in patients both with and without aortic dissection. Chronic or non-occlusive mesenteric ischemia may be associated with a lack of adjustment in arterial diameter. Patients with AAD of the abdominal aorta are more susceptible to occlusion of the inferior mesenteric artery.
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Affiliation(s)
- Marian Burysz
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Kraków, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, 85-067 Bydgoszcz, Poland
- Faculty of Medicine, Bydgoszcz University of Science and Technology, 85-796 Bydgoszcz, Poland
| | - Radosław Litwinowicz
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Kraków, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, 85-067 Bydgoszcz, Poland
- Faculty of Medicine, Bydgoszcz University of Science and Technology, 85-796 Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, 85-067 Bydgoszcz, Poland
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, 02-507 Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Jakub Batko
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 31-008 Kraków, Poland
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Harmankaya D, Vree Egberts KJ, Metz FM, Vaassen HGM, Slagboom-van Eeden Petersman S, Brusse-Keizer M, le Haen P, Bruno MJ, Geelkerken BH, van Noord D. Mesenteric Artery Stenosis is a Risk Factor for Anastomotic Leakage in Colorectal Surgery. Eur J Vasc Endovasc Surg 2025; 69:628-637. [PMID: 39557379 DOI: 10.1016/j.ejvs.2024.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 10/02/2024] [Accepted: 11/11/2024] [Indexed: 11/20/2024]
Abstract
OBJECTIVE Anastomotic leakage (AL) after colorectal surgery leads to substantial morbidity and mortality rates. Theoretically, compromised blood flow caused by mesenteric artery (MA) stenosis may create suboptimal healing conditions at the anastomotic site, increasing susceptibility to AL. The association between MA stenosis on pre-operative computed tomography (CT) scan and AL in patients undergoing colorectal surgery was investigated. METHODS A multicentre, retrospective, frequency matched, nested 1:5 case control study was conducted in the Netherlands. For each patient with AL, five controls without AL were recruited from the same database matched for age and body mass index. Pre-operative CT scans were assessed blindly to identify MA stenosis ≥ 50% as the primary outcome and atherosclerotic burden and vascular pathology as secondary outcomes. RESULTS One hundred and thirty patients with AL and 627 matched controls without AL were included. The prevalence of stenosis ≥ 50% in the superior mesenteric artery (SMA) was higher in patients with AL compared with controls (13.8% vs. 2.2%; p < .001). A stenosis ≥ 50% in the inferior mesenteric artery (IMA) was also more common in patients with AL (24.6% vs. 12.1%; p < .001). Multivariable regression analysis showed a 5.9 times higher risk (95% confidence interval [CI] 2.78 - 12.60; p < .001) of AL in patients with SMA stenosis and 2.1 times higher risk for patients with IMA stenosis (95% CI 1.11 - 3.63; p = .007). Stenosis ≥ 50% of the coeliac artery was not associated with AL. CONCLUSION The presence of SMA or IMA stenosis ≥ 50% on pre-operative CT scans is associated with a six and two times higher odds of AL, respectively, when corrected for known risk factors for AL. Whether preventive stent placement reduces the risk of AL still needs to be investigated.
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Affiliation(s)
- Duygu Harmankaya
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands; Department of Radiology, Erasmus MC, Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Koen J Vree Egberts
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centrum, University Twente, Enschede, the Netherlands
| | - Flores M Metz
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centrum, University Twente, Enschede, the Netherlands.
| | - Harry G M Vaassen
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centrum, University Twente, Enschede, the Netherlands
| | | | - Marjolein Brusse-Keizer
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands; Health Technology and Services Research, University Twente, Enschede, the Netherlands
| | - Pum le Haen
- Department of Radiology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Bob H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Multi-Modality Medical Imaging Group, TechMed Centrum, University Twente, Enschede, the Netherlands
| | - Desiree van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
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Almatroud L, Billiar I, Chess B, Elrakhawy M. Axillary to Superior Mesenteric Artery Bypass as a Viable Solution for Chronic Mesenteric Ischemia. Cureus 2024; 16:e75524. [PMID: 39803027 PMCID: PMC11720271 DOI: 10.7759/cureus.75524] [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] [Accepted: 12/11/2024] [Indexed: 01/16/2025] Open
Abstract
Chronic mesenteric ischemia (CMI) is a progressive condition that primarily affects the elderly, causing chronic abdominal pain and malnutrition. Timely treatment is essential to prevent further deconditioning or bowel ischemia. Surgical repair options include both endovascular and open procedures. We present the case of a patient with CMI and diffuse atherosclerotic disease of the aorta, treated with a left axillary-to-superior mesenteric artery (SMA) bypass. This case highlights axillary-to-SMA bypass as a novel and effective solution for CMI in patients with complex vascular anatomy and diffuse vascular disease, providing a viable alternative when traditional methods are contraindicated. Following the procedure, the patient experienced resolution of abdominal symptoms, and a six-month abdominal CT scan confirmed a widely patent bypass.
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Affiliation(s)
- Lanah Almatroud
- College of Human Medicine, Michigan State University, East Lansing, USA
| | - Isabel Billiar
- Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Division of Vascular Surgery, Allegheny Health Network, Pittsburgh, USA
| | - Bart Chess
- Vascular Surgery, McGinnis Thoracic & Cardiovascular Associates, Pittsburgh, USA
- Division of Vascular Surgery, Allegheny Health Network, Pittsburgh, USA
| | - Mahmoud Elrakhawy
- Vascular Surgery, Carle Foundation Hospital, Urbana, USA
- Division of Vascular Surgery, Allegheny Health Network, Pittsburgh, USA
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Karino M, Nishizawa T, Arioka H. Intestinal angina due to coeliac artery occlusion. BMJ Case Rep 2024; 17:e260916. [PMID: 39510611 DOI: 10.1136/bcr-2024-260916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2024] Open
Affiliation(s)
- Mayuko Karino
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
| | - Toshinori Nishizawa
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
| | - Hiroko Arioka
- Department of General Internal Medicine, St. Luke's International Hospital, Chuo-ku, Japan
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Audu CO, Schechtman DW, Davis FM. Mesenteric Ischemia. Clin Colon Rectal Surg 2024; 37:417-423. [PMID: 39399138 PMCID: PMC11466515 DOI: 10.1055/s-0043-1777667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
Mesenteric ischemia occurs when perfusion of the visceral organs fails to meet normal metabolic requirements and subsequently results in abdominal symptoms such as diffuse postprandial pain, peritonitis, food fear, and weight loss. While generally divided into acute and chronic manifestations, mesenteric ischemia is commonly misdiagnosed at initial presentation due to the significant overlap with symptoms of other abdominal pathologies. Prompt recognition and diagnosis, mesenteric revascularization, and critical care management remain the mainstay of treatment in these patients for optimal outcomes. This review will highlight acute versus chronic mesenteric ischemia, their etiology, diagnostic criteria, treatment options, and will emphasize the joint role of the gastrointestinal and vascular surgeon in the timely management of this condition to prevent devastating outcomes.
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Affiliation(s)
- Christopher O. Audu
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - David W. Schechtman
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Frank M. Davis
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Zafarghandi MR, Samimiat A, Nikraftar P, Sadeghi A, Pourazari P, Shokri A. Aortic reimplantation of the superior mesenteric artery (SMA) for SMA stenosis in a previously stented patient: New technique and a case report. Int J Surg Case Rep 2024; 115:109170. [PMID: 38181654 PMCID: PMC10809098 DOI: 10.1016/j.ijscr.2023.109170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/07/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Mesenteric artery stenosis leads to inadequate blood flow toward various parts of the gastrointestinal tract. Revascularization is the primary aim of treatment regardless of its approach. During the last decades, open revascularization has been replaced by endovascular-first approach. Mesenteric artery in-stent restenosis occurs in a considerable number of patients that need reintervention in up to half of them using redo endovascular revascularization or open surgery. Here, we reported a case of SMA and celiac artery stenoses treated by aortic reimplantation of the SMA. CASE PRESENTATION A 62-year-old man with history of previous stenting of CA and SMA was referred due to chronic intermittent abdominal. CT angiography of the abdomen showed restenosis of both arteries. A transection distal part of the occlusions SMA and reimplantation of it into the SMA on the anterolateral face of the infrarenal aorta as the end-to-side anastomosis were performed resulting in resolving the patient problem. CLINICAL DISCUSSION Chronic mesenteric ischemia can result from various medical conditions. Mesenteric vascular surgical revascularization through open laparotomy had been considered the standard of care. However, minimally invasive surgery such as endovascular therapy has attracted attention in the recent decades. There are some concerns about the difficulties of further surgery in case of re-occlusion. The end-to-side anastomosis and aortic reimplantation can be considered in patients with appropriate runoff in the remaining parts of corresponding vessels. CONCLUSION Aortic reimplantation of the superior mesenteric artery in patients with restenosis of stents is a viable option especially in case of inappropriate iliac artery to perform retrograde mesenteric bypass.
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Affiliation(s)
- Mohammad Reza Zafarghandi
- Vascular Surgery, Department of Vascular Surgery, Sina Hospital, Tehran University of Medical Science, Tehran, Iran.
| | - Alireza Samimiat
- Department of General Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Nikraftar
- Department of Vascular Surgery, Sina Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Afrooz Sadeghi
- Department of Vascular Surgery, Sina Hospital, Tehran University of Medical Science, Tehran, Iran.
| | - Pejman Pourazari
- Surgery Department of Surgery, School of Medicine Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Shokri
- Vascular & Trauma Surgery, Department of General Surgery, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Xhepa G, Vanzulli A, Sciacqua LV, Inzerillo A, Faerber P, Ierardi AM, Carrafiello G, Del Grande F, Ricoeur A. Advancements in Treatment Strategies for Chronic Mesenteric Ischemia: A Comprehensive Review. J Clin Med 2023; 12:7112. [PMID: 38002726 PMCID: PMC10672107 DOI: 10.3390/jcm12227112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Chronic mesenteric ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability in patient symptoms and the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduction of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate efficacy, patency rates, and long-term outcomes in CMI patients.
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Affiliation(s)
- Genti Xhepa
- Istituto Di Imaging ella Svizzera Italiana (IIMSI), Clinica Di Radiologia, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland;
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Andrea Vanzulli
- Residency Program in Diagnostic and Interventional Radiology, Università degli Studi di Milano, 20126 Milan, Italy; (A.V.); (L.V.S.)
| | - Lucilla Violetta Sciacqua
- Residency Program in Diagnostic and Interventional Radiology, Università degli Studi di Milano, 20126 Milan, Italy; (A.V.); (L.V.S.)
| | - Agostino Inzerillo
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Pierre Faerber
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
| | - Anna Maria Ierardi
- Department of Radiology, Foundation IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy;
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, IRCCS Ca’ Granda Fondazione Ospedale Maggiore Policlinico, Università degli Studi di Milano, 20126 Milan, Italy;
| | - Filippo Del Grande
- Istituto Di Imaging ella Svizzera Italiana (IIMSI), Clinica Di Radiologia, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland;
- Facoltà Di Scienze Biomediche, Campus Est, Università Della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Alexis Ricoeur
- Interventional Radiology Unit, University Hospital of Geneva (HUG), 1205 Geneva, Switzerland; (A.I.); (P.F.); (A.R.)
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Høyer C, Zacho HD, Stefanov V, Abrahamsen J. Improvement of the splanchnic blood flow and hepatic vein oxygenation following revascularization in patients with chronic mesenteric ischaemia. Clin Physiol Funct Imaging 2023; 43:33-39. [PMID: 36178112 PMCID: PMC10092538 DOI: 10.1111/cpf.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/16/2022] [Accepted: 09/27/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Chronic mesenteric ischaemia (CMI) is an underdiagnosed but severe condition. Access to functional testing is often limited and the diagnosis is usually based primarily on symptoms and imaging. One of the functional tests available is measurement of the splanchnic blood flow (SBF). The purpose of the present investigation was to evaluate if changes in the splanchnic perfusion after revascularization can be detected by measuring the SBF and hepatic vein oxygenation. MATERIALS AND METHODS The SBF was measured in 10 patients before and after revascularization of the mesenteric arteries by either percutaneous transluminal angioplasty (n = 9) or open revascularization (n = 1). The SBF was measured indirectly using Fick's principle and using the tracer Tc-99m Mebrofenin along with assessment of hepatic blood oxygenation, before and after a standard meal, following catheterization of a hepatic vein and the femoral artery. RESULTS Nine of 10 patients (90%) achieved a profound increase in SBF after revascularization (mean increase in postprandial response to meal stimulation from 71 ± 95 to 531 ± 295 ml/min, p = 0.001), and an increase in postprandial hepatic vein oxygen saturation (from 52 ± 14% to 59 ± 13%, p = 0.006). The symptoms of the patients diminished accordingly. One patient had no symptom relief, and no increase in postprandial SBF, but an angiographic result with no significant stenosis postrevascularization. CONCLUSIONS Revascularization increased the SBF and hepatic vein oxygen saturation significantly concurrent with symptom relief and according with the angiographic successful result in the vast majority of patients. A satisfying angiographic result post vascular intervention does not rule out CMI.
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Affiliation(s)
- Christian Høyer
- Department of Clinical PhysiologyViborg Regional HospitalViborgDenmark
| | - Helle D. Zacho
- Department of Nuclear MedicineAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborg OestDenmark
| | - Viktor Stefanov
- Department of RadiologyViborg Regional HospitalViborgDenmark
| | - Jan Abrahamsen
- Department of Clinical PhysiologyViborg Regional HospitalViborgDenmark
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Development of a Novel Scoring Model to Estimate the Severity Grade of Mesenteric Artery Stenosis. J Clin Med 2022; 11:jcm11247420. [PMID: 36556035 PMCID: PMC9785168 DOI: 10.3390/jcm11247420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/19/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Objective: This study aimed to derive a new scoring model from estimating the severity grade of mesenteric artery stenosis. We sought to analyze the relationship between the new scoring model and the development, treatment, and mortality of chronic mesenteric ischemia (CMI). Methods: This retrospective study included 242 patients (128 (53%) women and 114 (47%) men) with suspected CMI from January 2011 to December 2020. A weighted sum six-point score (CSI-score; the celiac artery is abbreviated by “C”, superior mesenteric artery by “S”, and inferior mesenteric artery by “I”) based on the number of affected vessels and the extent and grade of the stenosis or occlusion of the involved visceral arteries was derived by maximizing the area under the ROC curve. The calculated CSI-score ranged from 0 to 22. The patients were divided according to the best cut-off point into low-score (CSI-score < 8) and high-score (CSI-score ≥ 8) groups. Results: The area under the receiver operating characteristic curve (AUC) of the CSI-score was 0.86 (95% CI, 0.82−0.91). The best cut-off point of “8” represented the highest value of Youden’s index (0.58) with a sensitivity of 87% and specificity of 72%. The cohort was divided according to the cut-off point into a low-score group (n = 100 patients, 41%) and high-score group (n = 142 patients, 59%) and according to the clinical presentation into a CMI group (n = 109 patients, 45%) and non-CMI group (n = 133 patients, 55%). The median CSI-score for all patients was 10 (range: 0 -22). High-scoring patients showed statistically significant higher rates of coronary artery disease (54% vs. 36%, p = 0.007), chronic renal insufficiency (50% vs. 30%, p = 0.002), and peripheral arterial disease (57% vs. 16%, p < 0.001). A total of 109 (45%) patients underwent invasive treatment of the visceral arteries and were more often in the high-score group (69% vs. 11%, p < 0.001). Of those, 79 (72%) patients underwent primary endovascular treatment, and 44 (40%) patients underwent primary open surgery or open conversion after endovascular treatment. Sixteen (7%) patients died during the follow-up, with a statistically significant difference between high- and low-scoring patients (9% vs. 0%, p = 0.008). The score stratification showed that the percentage of patients treated with endovascular and open surgical methods, the recurrence of the stenosis or failure of the endovascular treatment, the need for a bypass procedure, and the mortality rates significantly increased in the subgroups. The CSI-score demonstrated an excellent ability to discriminate between patients who needed treatment and those who did not, with an AUC of 0.87 (95% CI, 0.82−0.91). Additionally, the CSI-score’s ability to predict the patients’ mortality was moderate, with an AUC of 0.73 (95% CI, 0.62−0.83). Conclusions: The new scoring model can estimate the severity grade of the stenosis of the mesenteric arteries. Our study showed a strong association of the score with the presence of chronic mesenteric ischemia, the need for treatment, the need for open surgery, and mortality.
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Conway AM, Carroccio A, Rosen RJ. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Surgical and endovascular revascularization of chronic mesenteric ischemia. Langenbecks Arch Surg 2022; 407:2085-2094. [PMID: 35182180 PMCID: PMC9399053 DOI: 10.1007/s00423-022-02462-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2022] [Indexed: 11/05/2022]
Abstract
Purpose Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study reviewed outcomes in patients treated surgically for CMI by open treatment (OT) and endovascular treatment (ET), analyzing risk factors for endovascular failure. Methods Clinical data for 36 patients treated for CMI from 2007 to 2017 were retrospectively analyzed. The study’s primary endpoint was symptom-free survival. The secondary endpoint was the primary technical success for endovascular and open surgical treatments. Risk factors for endovascular failure were identified by using univariate analysis. Results Patients were analyzed as treated: 21 patients (58.3%) in the ET and 15 (41.6%) in the OT group. Overall, 20 patients (56%) presented with abdominal angina, 9 (25%) with rest pain, and 7 (19%) without symptoms. An ET was initially attempted in 31 patients (86.1%). The conversion rate from ET to OT was 32.3%, which resulted in a primary technical success of 67.6% in ET and 100% in OT. Six patients from the ET group (19.3%) required surgical revision due to restenosis. One-year (OT 91.6% vs. ET 96.8%; n.s.) and three-year primary patency (OT 91.6% vs. ET 80.6%; n.s.) as well as 3-year symptom-free survival did not differ between the groups (OT 62.5% vs. ET 69.4%; n.s). Overall, in-hospital mortality was 2.8% (n = 1), which was not statistically different between the groups (OT 6% vs. ET 0%; n.s.). High-grade stenosis of the superior mesenteric artery tended to be associated with higher technical failure (P = 0.06). Conclusions ET showed a comparable perioperative outcome with higher technical failure. OT was distinguished by excellent early and late technical success.
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Høyer C, Christensen MH, Sandermann J, Leusink R, Abrahamsen J. Chronic mesenteric ischaemia: the importance of the individual mesenteric artery. Clin Physiol Funct Imaging 2021; 42:15-22. [PMID: 34608740 DOI: 10.1111/cpf.12730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/31/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic mesenteric ischaemia (CMI) is a vastly underdiagnosed condition that typically leads to postprandial abdominal pain and weight loss. The aim of the study was to explore the involvement of various mesenteric vessels in total splanchnic blood flow (SBF) and hepatic vein oxygenation. METHODS Single-blinded comparative trial of 476 patients clinically suspected of CMI. Routine investigation included measurement of hepatic vein oxygen saturation, indirect measurement of the total splanchnic blood flow (SBF), using Fick's principle and the tracer [99m Tc]Mebrofenin, before and after a meal, and digital subtraction angiography. RESULTS A total of 176 of the 476 patients (36%) had at least one angiographically significant stenosis (lumen reduction ≥70%). In patients with a significant one-vessel disease, the percentage having CMI according to SBF was 10% for a celiac trunk stenosis (n = 60), 50% for a superior mesenteric stenosis (n = 24) and 6% for an inferior mesenteric artery stenosis (n = 34). In patients with a significant two-vessel disease, the percentage with CMI according to SBF response was 92%, 18% and 79%, for no significant stenosis of the celiac trunk (n = 13), superior mesenteric artery (n = 17) and inferior mesenteric artery (n = 19), respectively. CONCLUSION Patients with significant one- or two-vessel stenosis involving the superior mesenteric artery have a higher likelihood of CMI according to flow criteria and a greater postprandial decrease in hepatic vein saturation on average than patients with no involvement of the superior mesenteric artery.
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Affiliation(s)
- Christian Høyer
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | | | - Jes Sandermann
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Robert Leusink
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark
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Mitchell EL. The Society for Vascular Surgery clinical practice guidelines define the optimal care of patients with chronic mesenteric ischemia. J Vasc Surg 2021; 73:84S-86S. [PMID: 33349350 DOI: 10.1016/j.jvs.2020.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Erica L Mitchell
- Department of Surgery, University of Tennessee, and the Division of Vascular and Endovascular Surgery, Regional One Health, Memphis, Tenn.
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Sardar P, White CJ. Chronic mesenteric ischemia: Diagnosis and management. Prog Cardiovasc Dis 2021; 65:71-75. [PMID: 33901516 DOI: 10.1016/j.pcad.2021.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 03/13/2021] [Indexed: 01/13/2023]
Abstract
Chronic mesenteric ischemia (CMI) is an uncommon, potentially underdiagnosed clinical condition. Although there is a high prevalence of mesenteric artery stenoses (MAS), an abundant collateral network in the mesenteric circulation mitigates occurrence of ischemia. The most common etiology of CMI is atherosclerosis. CMI is a clinical diagnosis, based upon typical and atypical symptoms and consistent anatomic findings. Typical symptoms of CMI are postprandial abdominal pain, unintended weight loss and food avoidance. The main modalities to diagnose MAS are duplex ultrasound, CT angiography or MR angiography, although high resolution CTA is preferred. Endovascular therapy with balloon expandable stents has become the preferred treatment for MAS.
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Affiliation(s)
- Partha Sardar
- Department of Cardiovascular Diseases, The John Ochsner Heart and Vascular Institute, The Ochsner Clinical School, University of Queensland, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, United States of America
| | - Christopher J White
- Department of Cardiovascular Diseases, The John Ochsner Heart and Vascular Institute, The Ochsner Clinical School, University of Queensland, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, United States of America.
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Bordet M, Tresson P, Huvelle U, Long A, Passot G, Bergoin C, Lermusiaux P, Millon A, Della Schiava N. Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery Status. Eur J Vasc Endovasc Surg 2021; 61:810-818. [PMID: 33810975 DOI: 10.1016/j.ejvs.2021.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 02/09/2021] [Accepted: 03/01/2021] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. METHODS This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI). RESULTS Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups. CONCLUSION Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.
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Affiliation(s)
- Marine Bordet
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France.
| | - Philippe Tresson
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Ugo Huvelle
- Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Anne Long
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Internal Medicine and Vascular Medicine, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Team Vascular biology and Red Blood Cell, Villeurbanne, France
| | - Guillaume Passot
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Digestive Surgery, Hospices Civils de Lyon, Lyon Sud University Hospital, Lyon, France; Université de Lyon, University Claude Bernard Lyon 1, France
| | - Charlotte Bergoin
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Nutrition Intensive Care Unit, Hospices Civils de Lyon, Lyon Sud University Hospital, Pierre Bénite, France
| | - Patrick Lermusiaux
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France; Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Antoine Millon
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
| | - Nellie Della Schiava
- Intestinal Stroke Centre, Centre rHodANien d'isChemie intEStinale (CHANCES Network), Lyon, France; Department of Vascular and Endovascular Surgery, Hospices Civils de Lyon, Louis Pradel University Hospital, Bron, France
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Idil Soylu A, Avcıoglu U, Uzunkaya F, Soylu K. Evaluation of mesenteric artery disease in patients with severe aortic valve stenosis. J Investig Med 2021; 69:719-723. [PMID: 33452127 DOI: 10.1136/jim-2020-001549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 02/04/2023]
Abstract
The aim of this study is to evaluate the mesenteric artery stenosis (MAS) in routinely performed CT angiography (CTA) of patients with severe aortic stenosis (AS) planned for transcatheter aortic valve implantation (TAVI) before the procedure. Patients with AS (AS group) who routinely underwent CTA before the TAVI procedure due to severe AS and patients who had CTA for other indications (control group) were retrospectively and sequentially scanned. The demographic characteristics of the patients in both groups were similar. Calcification and stenosis in the mesenteric arteries were recorded according to the localization of celiac truncus, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Class 0-3 classification was used for calcification score. Stenoses with a stenosis degree ≥50% were considered as significant. A total of 184 patients, 73 patients with severe AS and 111 control groups, were included in the study. SMA and IMA calcification scores of patients with AS were significantly higher than the control group (p=0.035 for SMA and p=0.020 for IMA). In addition, the rate of patients with significant MAS in at least 1 artery (45.2% vs 22.5%, p=0.001) and the rate of patients with significant stenosis in multiple arteries were also significantly higher in the AS group (8.2% vs 1.8%, p=0.037). According to the study results, patients with AS are at a higher risk for MAS. Chronic mesenteric ischemia should be kept in mind in patients with AS who have symptoms such as non-specific abdominal pain and weight loss.
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Affiliation(s)
- Aysegul Idil Soylu
- Department of Radiology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey
| | - Ufuk Avcıoglu
- Department of Gastroenterology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey
| | - Fatih Uzunkaya
- Department of Radiology, Ondokuz Mayis University, Faculty of Medicine, Samsun, Turkey
| | - Korhan Soylu
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Affiliation(s)
- G Jay Bishop
- Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth V Ratchford
- Johns Hopkins Center for Vascular Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Terlouw LG, van Noord D, van Walsum T, Bruno MJ, Moelker A. Mesenteric artery calcium scoring: a potential screening method for chronic mesenteric ischemia. Eur Radiol 2020; 31:4212-4220. [PMID: 33263162 PMCID: PMC8128738 DOI: 10.1007/s00330-020-07530-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/29/2020] [Accepted: 11/17/2020] [Indexed: 01/09/2023]
Abstract
Objective A practical screening tool for chronic mesenteric ischemia (CMI) could facilitate early recognition and reduce undertreatment and diagnostic delay. This study explored the ability to discriminate CMI from non-CMI patients with a mesenteric artery calcium score (MACS). Methods This retrospective study included CTAs of consecutive patients with suspected CMI in a tertiary referral center between April 2016 and October 2019. A custom-built software module, using the Agatston definition, was developed and used to calculate the MACS for the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery. Scoring was performed by two blinded observers. Interobserver agreement was determined using 39 CTAs scored independently by both observers. CMI was defined as sustained symptom improvement after treatment. Non-CMI patients were patients not diagnosed with CMI after a diagnostic workup and patients not responding to treatment. Results The MACS was obtained in 184 patients, 49 CMI and 135 non-CMI. Interobserver agreement was excellent (intraclass correlation coefficient 0.910). The MACS of all mesenteric arteries was significantly higher in CMI patients than in non-CMI patients. ROC analysis of the combined MACS of CA + SMA showed an acceptable AUC (0.767), high sensitivity (87.8%), and high NPV (92.1%), when using a ≥ 29.7 CA + SMA MACS cutoff. Comparison of two CTAs, obtained in the same patient at different points in time with different scan and reconstruction parameters, was performed in 29 patients and revealed significant differences in MACSs. Conclusion MACS seems a promising screening method for CMI, but correction for scan and reconstruction parameters is warranted. Key Points • A mesenteric artery calcium score obtained in celiac artery and superior mesenteric artery has a high negative predictive value for chronic mesenteric ischemia and could serve as a screening tool. • Interobserver agreement of the mesenteric artery calcium score is excellent. • Scan and reconstruction parameters influence the mesenteric artery calcium score and warrant the development of a method to correct for these parameters.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands. .,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Theo van Walsum
- Biomedical Imaging Group Rotterdam, Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Rotterdam, 3015 GD, The Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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Revzin MV, Pellerito JS, Nezami N, Moshiri M. The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia. Abdom Radiol (NY) 2020; 45:2960-2979. [PMID: 31410506 DOI: 10.1007/s00261-019-02165-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Brasoveanu V, Romanescu D, Diaconu C, Iliescu L, Bratu O, Savu C, Savu C, Neacsu A, Socea B, Balescu I, Bacalbasa N. Reconstruction of superior mesenteric artery by prostheses placement in a case of chronic mesenteric ischemia: A case report and literature review. Exp Ther Med 2020; 20:3504-3507. [PMID: 32905147 PMCID: PMC7464867 DOI: 10.3892/etm.2020.9119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/03/2020] [Indexed: 11/06/2022] Open
Abstract
Although superior mesenteric artery stenosis is a relatively common situation, it is rarely symptomatic due to the fact that in a significant number of cases an adequate collateral circulation exists. The aim of this study is to report a case in which arterial reconstruction was needed due to the absence of such a patent collateral circulation. The 47-year-old patient was investigated for chronic postprandial pain and was diagnosed with superior mesenteric artery stenosis. Percutaneous treatment was the initial option of choice but the patient rapidly became symptomatic again. Therefore surgery was performed, the segment of arterial stenosis was resected and the arterial continuity was re-established by using a synthetic prosthesis. The postoperative outcome was uneventful, the patient was discharged in the seventh postoperative day under anticoagulant therapy. In conclusion, superior mesenteric artery reconstruction by using a synthetic prosthesis can be useful in cases presenting chronic mesenteric ischemia and failure of percutaneous treatment.
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Affiliation(s)
- Vladislav Brasoveanu
- Department of Surgery, ‘Dan Setlacec’ Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Surgery, ‘Titu Maiorescu’ University of Medicine and Pharmacy, 040441 Bucharest, Romania
| | - Dragos Romanescu
- Department of Surgery, Sanador Medical Center, 011038 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine, Clinical Emergency Hospital Bucharest, 105402 Bucharest, Romania
| | - Laura Iliescu
- Department of Internal Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Ovidiu Bratu
- Department of Urology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Urology, ‘Carol Davila’ Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Cornel Savu
- Department of Thoracic Surgery, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Thoracic Surgery, ‘Marius Nasta’ Institute of Pneumonology, 050159 Bucharest, Romania
| | - Carmen Savu
- Department of Anesthesiology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Adrian Neacsu
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Obstetrics and Gynecology, ‘Sf. Ioan’ Clinical Emergency Hospital, 042122 Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, ‘Sf. Pantelimon’ Clinical Hospital, 021659 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, ‘Ponderas’ Academic Hospital, 021188 Bucharest, Romania
| | - Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Visceral Surgery, Center of Excellence in Translational Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Obstetrics and Gynecology, ‘I. Cantacuzino’ Clinical Hospital, 030167 Bucharest, Romania
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Memon S, Janzer S, Kalra S, George JC. Recanalization of superior mesenteric artery chronic total occlusion using hybrid algorithm and dissection reentry device. Catheter Cardiovasc Interv 2020; 95:1314-1319. [PMID: 31925989 DOI: 10.1002/ccd.28704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/04/2019] [Accepted: 12/28/2019] [Indexed: 11/07/2022]
Abstract
Chronic total occlusion (CTO) of mesenteric arteries with associated chronic mesenteric ischemia (CMI) is associated with high morbidity and mortality. Endovascular intervention has been associated with high technical success with high rates of freedom from symptoms and long-term patency. However, to achieve high procedural success, use of optimal vascular access and expertise in CTO hybrid algorithm including advanced dissection reentry strategies are essential. We present a case of CMI from severe celiac artery (CA) stenosis and CTO of superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). After treatment of CA stenosis, we were unsuccessful in our first attempt at recanalization of SMA CTO. On second attempt, left brachial artery (BA) access was obtained and the hybrid algorithm along with use of Stingray Reentry balloon (Boston Scientific) for dissection reentry into true lumen was successful in recanalizing the SMA CTO with placement of balloon expandable covered stents (CS). To the best of our knowledge, this is the first case report utilizing Sting-ray Reentry balloon in the mesenteric arteries.
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Affiliation(s)
- Sehrish Memon
- Division of Interventional Cardiology and Endovascular Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sean Janzer
- Division of Interventional Cardiology and Endovascular Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sanjog Kalra
- Division of Interventional Cardiology and Endovascular Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Jon C George
- Division of Interventional Cardiology and Endovascular Medicine, Einstein Medical Center, Philadelphia, Pennsylvania
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Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, Boyer L, Corcos O, van Dijk LJD, Duran M, Geelkerken RH, Illuminati G, Jackson RW, Kärkkäinen JM, Kolkman JJ, Lönn L, Mazzei MA, Nuzzo A, Pecoraro F, Raupach J, Verhagen HJM, Zech CJ, van Noord D, Bruno MJ. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J 2020; 8:371-395. [PMID: 32297566 PMCID: PMC7226699 DOI: 10.1177/2050640620916681] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/08/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center,
Rotterdam, the Netherlands
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital,
Viborg, Denmark
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Lund,
Sweden
- Department of Cardio‐Thoracic and Vascular Surgery, Skane
University Hospital, Malmö, Sweden
| | - Olaf J Bakker
- Department of Vascular Surgery, Sint Antonius hospital,
Nieuwegein, the Netherlands
- Department of Vascular Surgery, University Hospital Leipzig,
Leipzig, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital,
Bern University Hospital, University of Bern, Bern, Switzerland
| | - Louis Boyer
- Department of Diagnostic and Interventional Radiology, Montpied
University Hospital, Clermont‐Ferrand, France
| | - Olivier Corcos
- Department of Gastroenterology, Intestinal Stroke Center,
Hopital Beaujon APHP, Clichy, France
| | - Louisa JD van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital
Gelsenkirchen, Gelsenkirchen, Germany
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente,
Enschede, the Netherlands
- Multi-modality Medical Imaging (M3I) group, Faculty of Science
and Technology, Technical Medical Centre, University of Twente, Enschede, the
Netherlands
| | - Giulio Illuminati
- Department of Surgical Sciences, University of Rome La
Sapienza, Rome, Italy
| | - Ralph W Jackson
- Department of Interventional Radiology, Newcastle upon Tyne
Hospitals NHS Foundation Trust, UK
| | - Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland
- Department of Vascular Surgery, Mayo Clinic, Rochester, MN,
USA
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum
Twente, Enschede, the Netherlands
- Department of Gastroenterology and Hepatology, University
Medical Center Groningen, Groningen, the Netherlands
| | - Lars Lönn
- Department of Radiology, University of Copenhagen, Copenhagen,
Denmark
| | - Maria A Mazzei
- Department of Medical, Surgical and Neuro Sciences, Diagnostic
Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena,
Italy
| | - Alexandre Nuzzo
- Department of Gastroenterology, Hopital Beaujon APHP, Clichy,
France
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences,
University of Palermo, Vascular Surgery Unit, AOUP ‘P. Giaccone’ Palermo,
Palermo, Italy
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove,
Hradec Kralove, Czech Republic
| | - Hence JM Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical
Center, Rotterdam, the Netherlands
| | - Christoph J Zech
- Radiology and Nuclear Medicine, University of Basel, Basel,
Switzerland
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus
Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC
University Medical Center, Rotterdam, the Netherlands
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Van Damme H, Boesmans E, Creemers E, Defraigne JO. How to manage chronic mesenteric ischemia? A deliberated strategy. Acta Chir Belg 2020; 120:1-5. [PMID: 31580204 DOI: 10.1080/00015458.2019.1675971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.
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Affiliation(s)
- Hendrik Van Damme
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Evelyne Boesmans
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Etienne Creemers
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Jean-Olivier Defraigne
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
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Chiu YW, Wu CS, Chen PC, Wei YC, Hsu LY, Wang SH. Risk of acute mesenteric ischemia in patients with diabetes: A population-based cohort study in Taiwan. Atherosclerosis 2020; 296:18-24. [PMID: 32005001 DOI: 10.1016/j.atherosclerosis.2020.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 12/13/2019] [Accepted: 01/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Diabetes is a common and complex endocrine disorder that often results in hyperglycemia, which has been strongly implicated in several cardiovascular and cerebrovascular events that cause disability. Acute mesenteric ischemia (AMI) is a vascular emergency with high mortality rates. We conducted a population-based cohort study that utilizes data from medical claims databases to investigate whether diabetes increases the risk of AMI. METHODS Using claims data from Taiwan's National Health Insurance program, 66,624 diabetic patients were enrolled from 1998 to 2009, and a comparison group of 266,496 individually matched subjects without diabetes was selected. The two groups were followed up until diagnosis of AMI, death, or the end of 2011. Incidence rates of AMI were assessed in both groups. Cox proportional hazards models were used to estimate the hazard ratios of diabetes for AMI. RESULTS The diabetes cohort had a higher incidence rate than the comparison cohort for AMI (0.56 vs. 0.29 per 1,000 person-years). After adjusting for sex, age, comorbidity, and health system utilization, the adjusted hazard ratio of diabetes was 1.32 (95% confidence interval 1.11-1.56) for AMI. The risk of AMI associated with diabetes was greater in men (adjusted hazard ratio = 1.48, 95% confidence interval 1.17-1.87) than in women (adjusted hazard ratio = 1.17, 95% confidence interval 0.92-1.49). CONCLUSIONS There was an increased risk of AMI in patients with diabetes. However, further research is required to understand whether this association is causal or due to a common set of risk factors.
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Affiliation(s)
- Yen-Wei Chiu
- Department of Public Health, China Medical University, Taichung, Taiwan; Department of Emergency Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chi-Shin Wu
- Department of Psychiatry, College of Medicine and National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan
| | - Pei-Chun Chen
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Yu-Chung Wei
- Institute of Statistics and Information Science, College of Science, National Changhua University of Education, Changhua, Taiwan
| | - Le-Yin Hsu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shi-Heng Wang
- Department of Public Health, China Medical University, Taichung, Taiwan; Department of Occupational Safety and Health, China Medical University, Taichung, Taiwan.
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 2199] [Impact Index Per Article: 366.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Ohtsuka R, Amano H, Hashimoto M, Iwao T. Pancreaticoduodenectomy following total occlusion of the superior mesenteric artery: a case report and literature review. Surg Case Rep 2019; 5:168. [PMID: 31686292 PMCID: PMC6828884 DOI: 10.1186/s40792-019-0718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Patients with chronic occlusion of the celiac artery and superior mesenteric artery (SMA) are often asymptomatic, and occlusion may be caused by arteriosclerosis or median arcuate ligament compression. Pancreaticoduodenectomy (PD) is occasionally performed for patients with celiac artery occlusion; however, reports on patients with SMA occlusion are rare. We report a patient with cholangiocarcinoma and total atherosclerotic occlusion of the SMA without preoperative stenting or bypass. Case presentation A 73-year-old man suspected to have lower bile duct carcinoma was admitted to our hospital for further treatment. Three-dimensional computed tomography (3DCT) showed a common bile duct tumor and total occlusion of the SMA with collateral circulation of the gastroduodenal artery (GDA) and inferior mesenteric artery (IMA). We performed a PD. During the operation, we used test clamping of the GDA, which revealed no bowel ischemia. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 30. 3DCT on POD 98 and POD 307 showed development of collateral circulation between the IMA and SMA. Conclusion Here, we report the case of a patient with total occlusion of the SMA who subsequently underwent PD. 3DCT was instrumental in gathering vascular collateral information and thus we conclude that the assessment of collateral circulation before surgery is important.
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Affiliation(s)
- Reo Ohtsuka
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan
| | - Hodaka Amano
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Michiyo Hashimoto
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Toshiyasu Iwao
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
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Krishnamurthy G, Menon A, Kannan K, Prakash S, Rajendran A, Philips D. Coronary artery disease and mesenteric artery stenosis - Two sides of the same coin? - Long term prospective analysis. Intractable Rare Dis Res 2019; 8:245-251. [PMID: 31890451 PMCID: PMC6929593 DOI: 10.5582/irdr.2019.01087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Coronary artery disease (CAD) patients might have concomitant mesenteric artery stenosis (MAS). Identification of risk factors predicting mesenteric artery involvement might guide screening high risk individuals. A dilemma of intervention in radiologically severe MAS exists. This prospective study included CAD patients undergoing a coronary angiogram. A concomitant mesenteric angiogram was performed to diagnose MAS. Clinically relevant MAS (CR-MAS) was defined as i) presence of classical mesenteric angina with any degree of MAS or ii) severe stenosis (> 70%) involving two or more vessels. Risk factors for CR-MAS were studied and followed up prospectively. One hundred and three patients were included in the study. Left anterior descending artery was the most common involved coronary artery and was affected in 73% (n = 76). Mesenteric angiogram revealed 42.7% (n = 44) to have MAS. CR-MAS was present in 21 patients (20.4%). Involvement of celiac axis, superior mesenteric artery and inferior mesenteric artery was 22, 39 and 15 respectively. Multivariate analysis showed mesenteric angina (p < 0.01), diabetes mellitus (p < 0.01) and peripheral artery disease (p < 0.01) to be independent predictors of CR-MAS. At a median follow-up of 36 months (range 29-48 months), there was no acute mesenteric ischemia. In patients with CR-MAS, 16 (76.2%) had symptomatic improvement and 5 (23.8%) had stable symptoms. Three patients underwent angioplasty of superior mesenteric artery for persistent symptoms. Chronic CAD patients had a high prevalence of MAS. Mesenteric angina, diabetes mellitus and peripheral artery disease are independent predictors of CR-MAS. Intervention for MAS should be dictated by symptoms and not radiological severity. Lifestyle modification and medication for atherosclerotic ischemic heart disease probably prevents acute mesenteric ischemia in CAD patients.
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Affiliation(s)
- Gautham Krishnamurthy
- Department of General Surgery, Stanley Medical College, Chennai, India
- Address correspondence to:Dr. Gautham Krishnamurthy, Department of General Surgery, Stanley Medical College, No. 1, Old Jail Road, Old Washermanpet, Chennai 600001, India. E-mail:
| | - Aravind Menon
- Department of General Surgery, Stanley Medical College, Chennai, India
| | - Kumaresan Kannan
- Department of Cardiology, Stanley Medical College, Chennai, India
| | - Suhasini Prakash
- Department of Radio-diagnosis, Stanley Medical College, Chennai, India
| | - A Rajendran
- Department of General Surgery, Stanley Medical College, Chennai, India
| | - Darwin Philips
- Department of General Surgery, Stanley Medical College, Chennai, India
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Bisdas T, Stavroulakis K. Endovascular-First Approach for Chronic Mesenteric Ischemia: The Critical Need for Reporting Standards and High-Grade Evidence. JACC Cardiovasc Interv 2019; 10:2448-2450. [PMID: 29217009 DOI: 10.1016/j.jcin.2017.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Theodosios Bisdas
- Clinic for Vascular Surgery, St. Franziskus Hospital and University Clinic of Muenster, Muenster, Germany.
| | - Konstantinos Stavroulakis
- Clinic for Vascular Surgery, St. Franziskus Hospital and University Clinic of Muenster, Muenster, Germany
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Tagkalos E, Jungmann F, Lang H, Heinrich S. One visceral artery may be enough; successful pancreatectomy in a patient with total occlusion of the celiac and superior mesenteric arteries. BMC Surg 2018; 18:26. [PMID: 29769055 PMCID: PMC5956858 DOI: 10.1186/s12893-018-0352-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/28/2018] [Indexed: 12/16/2022] Open
Abstract
Background The anatomic variations of the visceral arteries are not uncommon. The liver arterial blood supply shows 50% variability between humans, with the most common anatomy being one hepatic artery arising from the celiac trunk and one pancreatico-duodenal arcade between the celiac trunk and the superior mesenteric artery. Occlusion of one artery are mostly asymptomatic but may become clinically relevant when surgery of the liver, bile duct or the pancreas is required. If these pathologies are not reversible, an oncologic pancreatic head resection cannot be performed. Case presentation We report the case of a 64-year-old Caucasian female patient with a locally advanced, resectable adenocarcinoma of the pancreas with complete atherosclerotic occlusion of the celiac trunk and the superior mesenteric artery. This vascular anomaly was missed on the preoperative imaging and became known postoperatively. A collateral circulation from a hypertrophic inferior mesenteric artery to the celiac trunk and the superior mesenteric artery compensated the blood supply to the visceral organs. The postoperative course was complicated by an elevation of the transaminases AST/ALT, which normalized under conservative treatment with alprostadil (prostavasin™) and anticoagulation, since angiographic recanalization failed. The patient recovered fully and was discharged at the 14th postoperative day. Two years later, she required endovascular repair of an aortic rupture during which the inferior mesenteric artery was preserved. Conclusion This case underlines the natural potential of the human body to adapt to chronic arterial malperfusion by creating a collateral circulation and supports the need for adequate preoperative imaging, including a proper arterial phase before upper abdominal surgery.
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Affiliation(s)
- Evangelos Tagkalos
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Florian Jungmann
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg University Hospital, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Stefan Heinrich
- Department of General, Visceral and Transplantation Surgery, Johannes Gutenberg University Hospital, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Pillai AK, Kalva SP, Hsu SL, Walker TG, Silberzweig JE, Annamalai G, Baerlocher MO, Mitchell JW, Midia M, Nikolic B, Dariushnia SR. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol 2018; 29:642-647. [PMID: 29574024 DOI: 10.1016/j.jvir.2017.11.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 11/19/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anil K Pillai
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Texas
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven L Hsu
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - T Gregory Walker
- Division of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ganesan Annamalai
- Department of Medical Imaging, University of Toronto, Mt. Sinai Hospital & University Health Network, Toronto, Ontario, Canada
| | - Mark O Baerlocher
- Department of Radiology, Royal Victoria Hospital, Barrie, Ontario, Canada
| | - Jason W Mitchell
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Mehran Midia
- Department of Diagnostic Imaging, McMaster University, Hamilton, Ontario, Canada
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, New York
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia.
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Erben Y, Jean RA, Protack CD, Chiu AS, Liu S, Sumpio BJ, Miller SM, Sumpio BE. Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia. J Vasc Surg 2018; 67:1805-1812. [PMID: 29395425 DOI: 10.1016/j.jvs.2017.10.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Chronic mesenteric ischemia (CMI) continues to be a devastating diagnosis. There is a national trend toward increased use of endovascular procedures with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed CMI patients' length of hospitalization and health care cost. METHODS We identified all patients admitted for CMI from the National Inpatient Sample (NIS) from 2000 to 2014. Our primary end points included length of hospital stay (LOS) and cost of hospitalization (COH). Our secondary end points included mortality assessment of the CMI hospitalization. RESULTS There were 15,475 patients admitted for CMI. The mean age of patients was 71 years, and 4022 (26.0%) were male. There were 10,920 (70.6%) patients treated endovascularly (ENDO) and 4555 (29.4%) patients treated in an open fashion (OPEN). Although a higher proportion of patients in the ENDO (43.3%) group vs OPEN (33.1%) had a Charlson Comorbidity Index score of ≥2 (P < .0001), they had a lower mortality rate (2.4% vs 8.7%; P < .0001), lower mean LOS (6.3 vs 14.0 days; P < .0001), and lower COH ($21,686 vs $42,974; P < .0001). After adjusting for clinical and hospital factors, OPEN continued to demonstrate higher mortality than ENDO (odds ratio, 7.2; 95% confidence interval, 4.9-10.6; P < .0001), longer LOS (mean, +9.7 days; P < .0001), and higher COH (mean, +$25,834; P < .0001). CONCLUSIONS The rate of ENDO continues to rise nationally in the treatment of CMI patients. After adjusting for clinical and hospital factors, patients in the ENDO group tend to have lower in-hospital mortality of 2.4% and lower LOS by 10 days, and they incur a cost saving of >$25,000 compared with patients in the OPEN group. ENDO should be considered first line of therapy for patients with CMI.
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Affiliation(s)
- Young Erben
- Section of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, Conn; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | | | - Alex S Chiu
- Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Shirley Liu
- Department of Surgery, Yale School of Medicine, New Haven, Conn
| | | | - Samuel M Miller
- Warren Alpert Medical School, Brown University, Providence, RI
| | - Bauer E Sumpio
- Section of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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Large-diameter inferior mesenteric artery in a case involving a ruptured common iliac artery aneurysm. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 3:197. [PMID: 29349421 PMCID: PMC5764910 DOI: 10.1016/j.jvscit.2016.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 11/23/2022]
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Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Sanddal Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Geelkerken B, Gloviczki P, Huber T, Naylor R. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 53:460-510. [PMID: 28359440 DOI: 10.1016/j.ejvs.2017.01.010] [Citation(s) in RCA: 403] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Paliogiannis P, Ginesu GC, Fancellu A, Pischedda A, Maiore M, Maiore E, Pinna A, Barmina M, Porcu A. Surgical and Endovascular Management of Patients with Chronic Mesenteric Ischemia: A Single Center Experience. Am Surg 2017; 83:1453-1457. [DOI: 10.1177/000313481708301235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Chronic mesenteric ischemia is a rare intestinal disorder, with a potential evolution toward intestinal infraction. The choice of the appropriate treatment is currently the most crucial issue in the management of patients with chronic mesenteric ischemia. We describe our experience with 16 cases, and we discuss the current diagnostic and therapeutic approaches. A retrospective review of the clinical records was performed, and demographic, clinical, therapeutic, and prognostic data were collected. Six patients were females (37%), and the mean age was 62 years. Postprandial pain was present in all the cases, whereas sitophobia and weight loss were detected in 87 per cent of them. Eight patients were treated with open surgery; no perioperative deaths or relevant complications occurred. One patient had a restenosis of the celiac trunk and superior mesenteric artery 10 months after surgery. No deaths or relevant complications occurred in the remaining patients, who underwent an endovascular procedure. One patient presented a restenosis distal to the vascular stent, whereas two patients died due to comorbidities. The low rates of postoperative morbidity, mortality, and restenosis obtained suggest that surgical or endovascular correction of chronic mesenteric ischemia is satisfactory when performed by experienced surgeons, with an adequate selection of the patients.
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Affiliation(s)
- Panagiotis Paliogiannis
- Experimental Pathology and Oncology, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giorgio C. Ginesu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Alessandro Fancellu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Aldo Pischedda
- Unit of Radiology, Azienda Ospedaliera Universitaria Di Sassari, Sassari, Italy
| | - Mario Maiore
- Unit of Radiology, Azienda Ospedaliera Universitaria Di Sassari, Sassari, Italy
| | - Eleonora Maiore
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Antonio Pinna
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Michele Barmina
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
| | - Alberto Porcu
- Surgical Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy; and
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Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 55:305-368. [PMID: 28851596 DOI: 10.1016/j.ejvs.2017.07.018] [Citation(s) in RCA: 713] [Impact Index Per Article: 89.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Guo B, Guo D, Xu X, Chen B, Jiang J, Yang J, Shi Z, Fu W. Endovascular Management for Symptomatic Chronic Mesenteric Ischemia: A Single-Center Experience. Vasc Endovascular Surg 2017; 51:453-459. [PMID: 28764609 DOI: 10.1177/1538574417720364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to classical intestinal ischemia, although a clear pathophysiology has yet to be elucidated. Here, we have presented our institution's experience in the management of symptomatic CMI. METHODS From February 2007 to February 2016, a retrospective study was performed of all consecutive patients with symptomatic CMI managed by endovascular treatment (ET). We reviewed these patients' demographics, comorbidities, clinical presentations, and treatment modalities. Perioperative and midterm outcomes included technical success, clinical symptom relief, complications, symptomatic recurrence, mortality, restenosis, and reintervention. RESULTS Thirty-five mesenteric arteries (74.3% stenotic/25.7% occluded) identified in 32 patients (12 females, 20 males) were treated with endovascular procedures. There were no 30-day deaths; the perioperative complication rate was 12.5%. Overall, the median postprocedural time to symptom relief was 7.6 days (range: 1-30 days). Twenty-two (68.8%) had complete remission of symptom, whereas 7 (21.9%) had partial improvement in symptom after ET. After a mean follow-up of 35.4 (25.9) months, 5 (15.6%) patients developed recurrent symptoms, with 4 requiring reinterventions. The primary patency was 93.7%, 82.6%, and 73.1% at 12, 24, and 36 months, respectively, and the freedom from symptomatic recurrence was 90.6%, 84.0%, 84.0%, and 84.0% at 6, 12, 24, and 36 months, respectively. CONCLUSIONS Endovascular treatment for patients with CMI had a high technical success rate and satisfactory clinical outcomes. Symptomatic recurrence was not frequent but found mainly within 12 months following the initial procedure.
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Affiliation(s)
- Baolei Guo
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Daqiao Guo
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Xin Xu
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Bin Chen
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Junhao Jiang
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Jue Yang
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Zhenyu Shi
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
| | - Weiguo Fu
- 1 Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, People Republic of China
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Diagnostic Accuracy of the Combination of Clinical Symptoms and CT or MR Angiography in Patients With Chronic Gastrointestinal Ischemia. J Clin Gastroenterol 2017; 51:e39-e47. [PMID: 27466167 DOI: 10.1097/mcg.0000000000000605] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND No golden diagnostic standard is available to diagnose chronic gastrointestinal ischemia (CGI). GOALS We aimed to establish an accurate prediction model for CGI, based on clinical symptoms and radiologic evaluation of the amount of stenosis in the celiac artery (CA) and superior mesenteric artery (SMA) by means of computed tomography-angiography or magnetic resonance (MR)-angiography. STUDY We prospectively included 436 consecutive patients with clinical suspicion of CGI in a tertiary referral center. Predictors for CGI were obtained by comparing clinical parameters to the diagnosis of CGI. Multivariable logistic regression was used to combine the strongest predictors in a model. A score chart based on the prediction model was provided to calculate the risk of CGI. RESULTS CGI was present in 171/436 (39%) patients (67 y; range, 54 to 74 y; 27% male). Strongest predictors for CGI were female gender [odds ratio (OR)=1.44; 95% confidence interval (CI), 0.85-2.43], weight loss (OR=1.63, 95% CI, 0.98-2.72), concomitant cardiovascular disease (OR=1.70, 95% CI, 1.04-2.78), duration of symptoms (OR=0.88, 95% CI, 0.79-0.99), and stenosis of CA and SMA (50% to 70% stenosis CA: OR=1.33, 95% CI, 0.56-3.19; >70% stenosis CA: OR=5.79, 95% CI, 3.42-9.81; 50% to 70% stenosis SMA: OR=3.21, 95% CI, 0.81-12.74; >70% stenosis SMA: OR=4.39, 95% CI, 2.30-8.41). A model based on clinical symptoms alone showed limited discriminative ability for diagnosing CGI (c-statistic 0.62). Adding radiologic imaging of the mesenteric arteries improved the discriminative ability (c-statistic 0.79). CONCLUSIONS Clinical symptoms alone are insufficient to predict the risk of CGI. Radiologic evaluation of the mesenteric arteries is essential. This tool may be useful for clinicians to assess the risk of CGI and to decide whether further diagnostic work-up for CGI is needed.
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Kolkman JJ, Geelkerken RH. Diagnosis and treatment of chronic mesenteric ischemia: An update. Best Pract Res Clin Gastroenterol 2017; 31:49-57. [PMID: 28395788 DOI: 10.1016/j.bpg.2017.01.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 01/17/2017] [Accepted: 01/30/2017] [Indexed: 02/06/2023]
Abstract
Although the prevalence of mesenteric artery stenoses (MAS) is high, symptomatic chronic mesenteric ischemia (CMI) is rare. The collateral network in the mesenteric circulation, a remnant of the extensive embryonal vascular network, serves to prevent most cases of ischemia. This explains the high incidence of MAS and relative rarity of cases of CMI. The number of affected vessels is the major determinant in CMI development. Most subjects with single vessel mesenteric stenosis do not develop ischemic complaints. Our experience is that most subjects with CA and SMA stenoses with abdominal complaints have CMI. A special mention should be made on patients with median arcuate ligament compression (MALS). There is ongoing debate whether the intermittent compression, caused by respiration movement, can cause ischemic complaints. The arguments pro and con treatment of MALS will be discussed. The clinical presentation of CMI consists of postprandial pain, weight loss, and an adapted eating pattern caused by fear of eating. In end-stage disease more continuous pain, diarrhea or a dyspepsia-like presentation can be observed. Workup of patients suspected for CMI consists of three elements: the anamnesis, the vascular anatomy and proof of ischemia. The main modalities to establish mesenteric vessel patency are duplex ultrasound, CT angiography or MR angiography. Assessing actual ischemia is still challenging, with only tonometry and visual light spectroscopy as tested candidates. Treatment consists of limiting metabolic demand, treatment of the atherosclerotic process and endovascular or operative revascularisation. Metabolic demand can be reduced by using smaller and more frequent meals, proton pump inhibition. Treatment of the atherosclerotic process consists of cessation of smoking, treatment of dyslipidemia, hypertension, hyperglycaemia, and medication with trombocyte aggregation inhibitors.
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Affiliation(s)
- Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology, Enschede, The Netherlands; University Medical Center Groningen, Department of Gastroenterology, Groningen, The Netherlands.
| | - Robert H Geelkerken
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, The Netherlands; University of Twente, Faculty of Science and Technology, Enschede, The Netherlands.
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Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (part I) - Incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol 2017; 31:15-25. [PMID: 28395784 DOI: 10.1016/j.bpg.2016.10.018] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
Acute mesenteric ischemia (AMI) is generally thought to be a rare disease, but in fact, it is more common cause of acute abdomen than appendicitis or ruptured abdominal aortic aneurysm in patients over 75 years of age. In occlusive AMI, surgical treatment without revascularization is associated with as high as 80% overall mortality. It has been shown that early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI by up to 50%. However, only a minority of patients with AMI are being treated actively with revascularization in the United States, and the situation is very likely similar in Europe as well. What can we do to improve diagnostic performance, so that more patients get proper treatment? The diagnosis is a collaborative effort of emergency department surgeons, gastrointestinal and vascular surgeons, and radiologists. The etiological categorization of AMI should be practical and guide the therapy. Furthermore, the limitations of the diagnostic examinations need to be understood with special emphasis on computed tomography findings on patients with slowly progressing "acute-on-chronic" mesenteric ischemia.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, P.O. Box 100, 70029 Kuopio, Finland.
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Sweden.
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Cardin F, Fratta S, Perissinotto E, Militello C, Martella B. Influence of splanchnic artery stenosis on the in-hospital clinical course of elderly patients. Aging Clin Exp Res 2017; 29:131-137. [PMID: 27830518 DOI: 10.1007/s40520-016-0646-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/12/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition. AIMS The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery. METHODS For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission. RESULTS Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46). CONCLUSIONS In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.
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Affiliation(s)
- Fabrizio Cardin
- Simple Operational Unit of Surgical Endoscopy, Department of Surgical and Gastroenterological Sciences, General and University Hospital of Padua, Via Giustiniani, 2, 35100, Padua, Italy.
| | - Stefania Fratta
- Clinical Geriatrics Unit, Department of Internal Medicine, University of Padua, Padua, Italy
| | - Egle Perissinotto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | - Bruno Martella
- Complex Operational Unit of General Surgery, General and University Hospital of Padua, Padua, Italy
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Rosen RJ, Jain A, Drury J. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Amit Jain
- Lenox Hill Heart and Vascular Institute; New York NY USA
| | - Jennifer Drury
- Lenox Hill Heart and Vascular Institute; New York NY USA
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45
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Arazińska A, Polguj M, Wojciechowski A, Trębiński Ł, Stefańczyk L. Median arcuate ligament syndrome: Predictor of ischemic complications? Clin Anat 2016; 29:1025-1030. [DOI: 10.1002/ca.22773] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Agata Arazińska
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Michał Polguj
- Department of Angiology; Medical University of Łódź; Narutowicza 60 Łódź 90-136 Poland
| | - Andrzej Wojciechowski
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Łukasz Trębiński
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
| | - Ludomir Stefańczyk
- Department of Radiology; Medical University of Łódź; Kopcińskiego 22 Łódź 90-153 Poland
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Yeoh SW. A Delayed Diagnosis of Chronic Mesenteric Ischaemia: The Role of Clinicians' Cognitive Errors. Case Rep Gastroenterol 2016; 10:68-74. [PMID: 27403105 PMCID: PMC4929383 DOI: 10.1159/000444276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Chronic diarrhoeal illnesses with nausea and weight loss are a common indication for gastroenterology review. While many such cases have intra-luminal aetiologies, such as inflammatory bowel disease, coeliac disease or other malabsorptive conditions, with many other cases due to functional gut disorders or systemic malignancy, clinicians must also keep vascular disorders in mind. Here we report a patient with a delayed diagnosis of chronic mesenteric ischaemia after 6 months of gastrointestinal symptoms strongly mimicking an alternative diagnosis such as inflammatory bowel disease due an atypical predominance of nausea and diarrhoea rather than pain. We briefly review the literature on treatment of this condition but also discuss with particular attention the sequence of cognitive errors made by clinicians that led to a diagnostic delay, inviting readers to thus reflect on how such errors can be minimised in their practice.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology and Hepatology, Eastern Health, Melbourne, Vic., Australia
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47
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Fawzy M, Edrees A, Okasha H, El Ashmaui A, Ragab G. Gastrointestinal manifestations in systemic lupus erythematosus. Lupus 2016; 25:1456-1462. [PMID: 27055518 DOI: 10.1177/0961203316642308] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by multisystem involvement, including the gastrointestinal (GI) tract. There is a significant variation in the clinical presentation and severity of GI disorders. When GI symptoms present as the initial manifestation of SLE, there is likely to be a delay in the diagnosis. The cause of these GI manifestations in SLE may be the disease, or the side effects of medications, or infections. In this study we investigated the GI manifestations in a group of SLE patients. Our study was conducted on 40 SLE patients and 30 healthy controls to assess the prevalence of GI symptoms in SLE patients. The prevalence of gastrointestinal manifestations in our study was 42.5%. GI manifestations in our SLE patients were: acute abdominal pain (due to pleurisy and peritonitis), 6%; diffuse abdominal pain, 23.5%; epigastric pain, 29%; epigastric pain with vomiting, 23.5%; epigastric pain with chronic constipation, 6%; chronic constipation, 6%; and diffuse abdominal pain with bleeding per rectum, 6%. In our study, we found a higher incidence of Giardia infestation in SLE patients than in healthy controls, and 10% of these patients were asymptomatic. There was more Giardia infestation in patients with GI symptoms as compared with patients with no GI symptoms, with a P value of 0.009. In our study SLE patients with GI symptoms had a peak systolic velocity (cm/s) with a mean of 108.4 ± 32.1 standard deviation (SD) in the celiac Doppler study. Patients without GI symptoms had a peak systolic velocity with a mean of 111.9 ± 37.7 SD, meaning that our patients mostly had no evidence of celiac trunk stenosis, but there was significant difference between SLE patients without GI symptoms and controls, as the mean was higher in SLE patients than in the controls. Also, the celiac end diastolic velocity was higher in both groups of SLE patients with GI symptoms and those without GI symptoms, compared to controls.
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Affiliation(s)
- M Fawzy
- 1 Cairo University, Internal Medicine, Kasr Al Ainy Medical School, Cairo, Egypt
| | - A Edrees
- 2 Department of Internal Medicine University of Missouri-Kansas City, Kansas City, USA
| | - H Okasha
- 1 Cairo University, Internal Medicine, Kasr Al Ainy Medical School, Cairo, Egypt
| | - A El Ashmaui
- 1 Cairo University, Internal Medicine, Kasr Al Ainy Medical School, Cairo, Egypt
| | - G Ragab
- 1 Cairo University, Internal Medicine, Kasr Al Ainy Medical School, Cairo, Egypt
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48
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Foley TR, Rogers RK. Endovascular Therapy for Chronic Mesenteric Ischemia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:39. [DOI: 10.1007/s11936-016-0463-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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49
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Kärkkäinen JM, Saari P, Kettunen HP, Lehtimäki TT, Vanninen R, Paajanen H, Manninen H. Interpretation of Abdominal CT Findings in Patients Who Develop Acute on Chronic Mesenteric Ischemia. J Gastrointest Surg 2016; 20:791-802. [PMID: 26553268 DOI: 10.1007/s11605-015-3013-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND We studied whether ischemia-specific computed tomography (CT) findings are consistently detectable in patients who develop acute on chronic mesenteric ischemia (AOCMI), whereas absent in chronic mesenteric ischemia (CMI). METHODS Consecutive patients with symptomatic angiography-verified atherosclerotic obstruction of the superior mesenteric artery (SMA) were categorized as AOCMI (n = 27) or CMI (n = 20). Three experienced radiologists blindly evaluated the contrast-enhanced CTs for vascular and intestinal findings. Kappa statistics was used to test interobserver agreement. RESULTS Two observers had substantial agreement (k = 0.66) that two thirds of AOCMI patients showed ischemia-specific CT findings (decreased bowel wall enhancement, pneumatosis, or thrombotic SMA clot); the third observer agreed only fairly regarding pneumatosis and thrombosis (k = 0.3-0.4). All observers had substantial agreement (k = 0.65-0.71) that most patients with AOCMI had unspecific intestinal findings such as mesenteric fat stranding in up to 96%, bowel lumen dilatation in 93%, and bowel wall thickening in 70%, while only few patients with CMI had such findings (due to chronic ischemic colitis) (P < 0.001). CONCLUSION One third of AOCMI patients presented without any ischemia-specific CT signs. However, any intestinal abnormality in CT together with SMA obstruction should raise suspicion of intestinal ischemia. Furthermore, clinicians need to be aware of the interobserver variability in the CT interpretation.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland. .,Department of Gastrointestinal Surgery, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
| | - Petri Saari
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Hannu-Pekka Kettunen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Tiina T Lehtimäki
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Hannu Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
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50
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Barret M, Martineau C, Rahmi G, Pellerin O, Sapoval M, Alsac JM, Fabiani JN, Malamut G, Samaha E, Cellier C. Chronic Mesenteric Ischemia: A Rare Cause of Chronic Abdominal Pain. Am J Med 2015; 128:1363.e1-8. [PMID: 26291907 DOI: 10.1016/j.amjmed.2015.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia is a rare disease with nonspecific clinical symptoms, such as chronic postprandial abdominal pain and weight loss. Diagnostic modalities and revascularization techniques have evolved during the past 20 years. The significance of stenosis in a single splanchnic vessel remains unclear. Our aims were to assess the outcomes of 2 revascularization techniques and report on the diagnostic modalities of splanchnic vessel stenoses. METHODS The demographic data, medical history, technical characteristics, and outcomes of the revascularization procedures were recorded for all of the patients admitted for endovascular revascularization or open surgical revascularization of the splanchnic vessels as treatment for chronic mesenteric ischemia in our tertiary referral center since 2000. RESULTS Fifty-four patients were included in this study: 43 received endovascular revascularization, and 11 had open surgical revascularization. The symptoms were abdominal pain, weight loss, and diarrhea in 98%, 53%, and 25% of the cases, respectively. Computed tomography angiography was the key diagnostic tool for 60% of the patients. A single-vessel stenosis was found in one-third of the patients. Endovascular and open revascularization had similar early and late outcomes, and no 30-day mortality was observed. However, we did observe higher morbidity in the open revascularization group (73% vs 19%, P <.03). CONCLUSIONS Chronic mesenteric ischemia may be diagnosed in the presence of a splanchnic syndrome and stenosis of a single splanchnic vessel, typically assessed using computed tomography angiography. In selected patients, endovascular revascularization had similar efficacy as, and lower complication rates than open revascularization.
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Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France.
| | - Chloé Martineau
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Gabriel Rahmi
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Olivier Pellerin
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Marc Sapoval
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Jean-Marc Alsac
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Jean-Noël Fabiani
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Georgia Malamut
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Elia Samaha
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France
| | - Christophe Cellier
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
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