Endovascular management of acute and chronic arterial mesenteric ischaemia: A narrative review of evidence informing interventional radiology treatment

Table 1 Imaging modalities in acute arterial mesenteric ischaemia

Modality	Principal role	Strengths	Limitations and practical considerations	Ref.
DUS	Unsuitable as the initial investigation in suspected AMI	May identify proximal mesenteric arterial stenosis or occlusion when technically feasible	Operator dependent; limited by bowel gas, ileus and body habitus. Distal occlusions may be missed. Should not delay CTA	[3]
CTA	First-line investigation for urgent diagnosis and treatment planning	Rapidly assesses arterial occlusion, atherosclerosis, collaterals, bowel enhancement and alternative abdominal pathology	Iodinated contrast and radiation exposure. Early bowel changes may be subtle; no individual CT sign definitively establishes bowel viability	[3,36,37,40,41]
MRA	Limited role in emergency diagnosis	Vascular imaging without ionising radiation	Longer acquisition, motion sensitivity and limited emergency availability. Should not delay diagnosis or reperfusion	[37]
DSA	Primarily used during endovascular treatment	Selective assessment of occlusion, distal perfusion and collateral flow; enables immediate treatment and assessment of reperfusion	Invasive; contrast, radiation and access-site risks. Does not directly establish bowel viability or comprehensively assess alternative abdominal pathology	[3,4]

AMI: Acute mesenteric ischaemia; CT: Computed tomography; CTA: Computed tomography angiography; DSA: Digital subtraction angiography; DUS: Duplex ultrasound; MRA: Magnetic resonance angiography.

Table 2 Imaging modalities in chronic arterial mesenteric ischaemia

Modality	Principal role	Strengths	Limitations and practical considerations	Ref.
DUS	Initial screening in experienced centres	Non-invasive assessment of proximal CA and SMA anatomy and flow velocities without radiation or intravenous contrast	Requires fasting and expertise; affected by bowel gas, body habitus and respiration. Positive or inconclusive results require CTA or MRA confirmation	[3,81,82,85]
CTA	Preferred examination for anatomical confirmation and treatment planning	Defines stenosis, lesion length, calcification, vessel origins and collaterals; evaluates alternative causes of symptoms	Iodinated contrast and radiation exposure. Anatomical stenosis alone does not establish symptomatic CMI	[3,84,85,87]
MRA	Alternative when CTA is contraindicated	Contrast-enhanced assessment of proximal mesenteric stenoses without radiation; specialised techniques permit flow assessment	Longer acquisition and motion artefact; smaller vessels less reliably assessed and stenosis may be overestimated. Gadolinium suitability requires individual assessment	[3,85,87,90,91]
DSA	Generally reserved for endovascular intervention	Detailed vascular and collateral assessment with concurrent treatment; selective pressure measurements may help assess uncertain lesions	Invasive; contrast, radiation and access-site risks. Pressure measurements are adjunctive and do not independently establish CMI	[3,85,92,93]

CA: Coeliac artery; CMI: Chronic mesenteric ischaemia; CTA: Computed tomography angiography; DSA: Digital subtraction angiography; DUS: Duplex ultrasound; MRA: Magnetic resonance angiography; SMA: Superior mesenteric artery.