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Nana P, Koelemay MJW, Leone N, Brodis A, van den Berg JC, de Bruin JL, Geelkerken RH, Spanos K. A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2023; 66:632-643. [PMID: 37451604 DOI: 10.1016/j.ejvs.2023.07.011] [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: 03/16/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Mark J W Koelemay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Konstantinos Spanos
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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Safi N, Ånonsen KV, Berge ST, Medhus AW, Sundhagen JO, Hisdal J, Kazmi SSH. Early Identification of Chronic Mesenteric Ischemia with Endoscopic Duplex Ultrasound. Vasc Health Risk Manag 2022; 18:233-243. [PMID: 35431549 PMCID: PMC9005355 DOI: 10.2147/vhrm.s358570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/21/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Due to diagnostic delay, chronic mesenteric ischemia (CMI) is underdiagnosed. We assumed that the patients suspected of CMI of the atherosclerotic origin or median arcuate ligament syndrome (MALS) could be identified earlier with endoscopic duplex ultrasound (E-DUS). Patients and Methods Fifty CMI patients with CTA-verified stenosis of either ≥50% and ≥70% of celiac artery (CA) and superior mesenteric artery (SMA) were examined with E-DUS and transabdominal duplex ultrasound (TA-DUS). Peak systolic velocities (PSV) of ≥200cm/s and ≥275cm/s for CA and SMA, respectively, were compared with CTA. Subgroup analysis was performed for the patients with (n=21) and without (n=29) prior revascularization treatment of CMI. The diagnostic ability of E-DUS and TA-DUS was tested with crosstabulation analysis. Receiver operating characteristics (ROC) curve analysis was performed, and the area under the curve (AUC) was calculated to investigate the test accuracy. Results In the patients with ≥70% stenosis, E-DUS had higher sensitivity than TA-DUS (91% vs 81% for CA and 100% vs 92% for SMA). AUC for SMA ≥70% in E-DUS was 0.75 and with TA-DUS 0.68. The sensitivity of E-DUS for CTA-verified stenosis ≥70% for CA was 100% in the patients without prior treatment. E-DUS demonstrated higher sensitivity than TA-DUS for both arteries with stenosis ≥50% and ≥70% in the treatment-naive patients. Conclusion E-DUS is equally valid as TA-DUS for the investigation of CMI patients and should be used as an initial diagnostic tool for patients suspected of CMI.
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Affiliation(s)
- Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kim Vidar Ånonsen
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Simen Tveten Berge
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle Wilhelm Medhus
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Correspondence: Syed Sajid Hussain Kazmi, Tel +47 92468309, Email
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Lundin N, Lehti L, Ekberg O, Acosta S. Validation of computed tomography angiography using mean arterial pressure gradient as a reference in stented superior mesenteric artery. Abdom Radiol (NY) 2021; 46:792-798. [PMID: 32776200 PMCID: PMC7897190 DOI: 10.1007/s00261-020-02700-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/18/2020] [Accepted: 07/29/2020] [Indexed: 11/01/2022]
Abstract
PURPOSE The aim of this prospective study was to validate the diagnostic performance of computed tomography angiography (CTA) in endoprosthesis stenosis in the superior mesenteric artery (SMA) using mean arterial pressure (MAP) gradients during angiography as a reference method. METHODS Twenty-nine patients with mesenteric atherosclerotic disease underwent 45 paired measurements of endoprosthesis stenosis in the SMA with CTA and MAP gradients between March 2009 and July 2015. The grade of endoprosthesis stenosis in the SMA at CTA using the TeraRecon Aquarius workstation was correlated with MAP gradients. RESULTS Grade of endoprosthesis stenosis in the SMA (r = 0.37, p = 0.013) correlated with MAP gradients. The intraclass correlations between the first and second CTA rater was 0.76 (95% CI 0.56-0.87) for estimation of grade of endoprosthesis stenosis in the SMA. The area under the receiver operating characteristics curve was 0.79 for diagnosis of significant endoprosthesis stenosis in the SMA at CTA for different threshold values using MAP gradient of ≥ 10 mmHg as reference. Sensitivity, specificity and positive predictive value for endoprosthesis stenosis in the SMA ≥ 50% at CTA were 52.4% (95% CI 31.0-73.7), 87.5% (95% CI 74.3-100.0) and 78.6 (95% CI 57.1-1.00), respectively. CONCLUSION Grading endoprosthesis stenosis in the SMA with CTA performed fair when using trans-stenotic MAP gradient as reference. Software development towards reduction of endoprosthesis artefacts may result in more accurate CTA assessment of the narrowest part.
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Affiliation(s)
- Niklas Lundin
- Division of Medical Radiology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Leena Lehti
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Center, Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, S205 02, Malmö, Sweden
| | - Olle Ekberg
- Division of Medical Radiology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.
- Vascular Center, Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, S205 02, Malmö, Sweden.
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Endovascular Pressure Measurements to Assess the Functional Severity of Mesenteric Arterial Stenoses. J Vasc Interv Radiol 2020; 31:430-437. [PMID: 32007405 DOI: 10.1016/j.jvir.2019.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the ability of pressure measurements to discriminate clinically significant celiac artery (CA) or superior mesenteric artery (SMA) stenosis in patients with suspected chronic mesenteric ischemia (CMI). MATERIALS AND METHODS Single-center, retrospective cohort study of 41 intra-arterial pressure measurements during mesenteric angiography with intended revascularization, performed in 37 patients (mean age 67.7 ± 10.8 years, 62% female) between April 2015 and May 2017. Simultaneous prestenotic and poststenotic pressure measurements had been obtained before and after intra-arterial administration of nitroglycerin. Revascularization was performed in 38 of 41 procedures. Definitive diagnosis of CMI was defined as patient-reported symptom relief or improvement after successful revascularization. RESULTS Pressure gradients obtained after vasodilator administration were significantly higher in CAs and SMAs with ≥50% stenosis. Pressure ratios (pressure distal [Pd]/pressure aorta [Pa]) obtained after vasodilator administration were significantly higher in CAs with ≥50% stenosis. Subgroup analysis of 22 patients with a ≥50% stenosis of either CA or SMA showed significantly higher pressure gradients and Pd/Pa ratios after vasodilator administration in CMI patients (median pressure gradient: CMI [interquartile ratio] 36 [21-40] mm Hg versus no-CMI 20 [9-21] mm Hg, P = 0.041; Pd/Pa: CMI 0.703 [0.598-0.769] versus no-CMI 0.827 [0.818-0.906], P = .009). A ≤0.8 Pd/Pa cutoff value after administration of a vasodilator best identified a clinically relevant stenosis, with 86% sensitivity and 83% specificity. Complications related to the pressure measurements were not observed. CONCLUSIONS Intra-arterial pressure measurements are feasible and safe. Low Pd/Pa ratios were associated with clinically relevant CA or SMA stenosis.
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Acosta S, Björgell O, Ekberg O. Prospective Study on Diagnostic Performance of Color Doppler Ultrasound Using Trans-stenotic Mean Arterial Pressure Gradient as a Reference in Stented Superior Mesenteric Artery. Ann Vasc Surg 2019; 56:294-302. [DOI: 10.1016/j.avsg.2018.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/07/2018] [Accepted: 09/20/2018] [Indexed: 12/26/2022]
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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: 337] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Pharmacological secondary prevention in patients with mesenterial artery atherosclerosis and arterial embolism. Best Pract Res Clin Gastroenterol 2017; 31:105-109. [PMID: 28395781 DOI: 10.1016/j.bpg.2016.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/20/2016] [Indexed: 01/31/2023]
Abstract
Visceral arteries such as the coeliac (CA), superior mesenteric (SMA), and the inferior mesenteric artery (IMA) might be affected by atherosclerotic occlusive lesions with or without thrombosis or embolization causing ischaemic symptoms from the gastrointestinal tract. After treatment of an acute event, these patients should be offered both non-pharmacological and pharmacological secondary prevention to reduce risk for future ischaemic arterial manifestations. Patients with mesenteric ischaemia caused by atherosclerosis should be evaluated concerning platelet antiaggregation with low dose aspirin or clopidogrel, and those with cardioembolic disease should be recommended anticoagulant treatment with either warfarin or one of the direct oral anticoagulants (DOAC; apixaban, dabigatran, edoxaban, or rivaroxaban). In all patients, blood pressure should be lowered to <140/90 mmHg with ACE-inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, or thiazide diuretics, and LDL-cholesterol should be kept at <1.8 mmol/l, preferably with statins. If present, diabetes should be treated aiming at good metabolic control, and all smokers should be recommended cessation.
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Asciutto G, Sonesson B, Björses K, Kristmundsson T, Resch T, Dias N. Retrograde Totally Endovascular Recanalization of Occluded Mesenteric Arteries Through the Pancreaticoduodenal Arcade. EJVES Short Rep 2015. [DOI: 10.1016/j.ejvssr.2015.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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AbuRahma AF, Campbell JE, Stone PA, Hass SM, Mousa AY, Srivastava M, Nanjundappa A, Dean LS, Keiffer T. Perioperative and late clinical outcomes of percutaneous transluminal stentings of the celiac and superior mesenteric arteries over the past decade. J Vasc Surg 2013; 57:1052-61. [DOI: 10.1016/j.jvs.2012.10.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 11/15/2022]
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Jain G, Pandit BN, Goyal M, Trehan VK. Percutaneous retrograde revascularization of the occluded celiac artery for chronic mesenteric ischemia using intravascular ultrasound guidance. Cardiovasc Interv Ther 2013; 28:307-12. [DOI: 10.1007/s12928-013-0167-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 02/10/2013] [Indexed: 11/24/2022]
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Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia. J Vasc Surg 2013; 57:747-55; discussion 754-5. [PMID: 23332245 DOI: 10.1016/j.jvs.2012.09.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/11/2012] [Accepted: 09/18/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate long-term patient survival and causes of death after open (OR) or endovascular (ER) mesenteric revascularization for atherosclerotic chronic mesenteric ischemia using propensity score-matched comparison and clinical risk stratification. METHODS The clinical data of 343 patients treated with mesenteric revascularization for chronic mesenteric ischemia between 1991 and 2010 were retrospectively reviewed. Clinical, anatomical, and procedure-related variables were analyzed using a multivariate model to identify independent predictors of any-cause early and late (>30 days) mortality. Cause of death was retrieved from review of the National Death Index. Patient survival was analyzed using Society for Vascular Surgery (SVS) comorbidity scores and propensity score-matched comparison based on independent predictors of any-cause mortality. RESULTS There were 187 patients treated by OR and 156 patients treated by ER. Early procedure-related mortality was 2.6% (9/343), including five OR (2.7%) and four ER (2.6%) patients. Median follow-up was 96 ± 54 months (range, 1-168 months). There were 144 late deaths, most commonly from cardiac causes in 35% (51/144), followed by cancer in 15% (21/144), pulmonary complications in 13% (19/144), and mesenteric ischemia in 11% (16/144). A further 21 patients died from various identifiable causes, and 14 patients (10%) died of unknown causes. Overall, 25 patients (7.3%) died of mesenteric-related causes, including nine early and 16 late deaths (OR, 10/187; 8.0%, and ER, 6/156; 6.4%). Multivariate analysis identified age >80, diabetes, chronic kidney disease (CKD) stage IV or V, and home oxygen therapy as independent predictors (P < .05) of any cause of death. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death (P < .05). Late patient survival at 5 years in the OR and ER groups was 75% ± 4% and 60% ± 9% for low SVS risk (<9), 52% ± 8% and 43% ± 9% for intermediate SVS risk (9-16), and 67% ± 15% and 30% ± 8% for high SVS risk (>16). Using propensity matched scores, 5-year survival was nearly identical for patients treated by OR (60%) or ER (57%; P = .7). CONCLUSIONS Long-term patient survival after mesenteric revascularization was not influenced by type of arterial reconstruction. Age >80 years, diabetes, CKD stage IV or V, and home oxygen were independent predictors of any-cause mortality. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death.
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Pecoraro F, Rancic Z, Lachat M, Mayer D, Amann-Vesti B, Pfammatter T, Bajardi G, Veith FJ. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg 2012; 27:113-22. [PMID: 23088809 DOI: 10.1016/j.avsg.2012.05.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 07/06/2011] [Accepted: 05/06/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist. METHODS A systematic literature review of the last 25-years was conducted through MEDLINE, Embase, and Cochrane Review/Trials register to identify studies reporting on CMI treatment with more than 10 patients. Primary outcomes were perioperative mortality and morbidity rates. Secondary outcomes were survival rates, primary and secondary patency rates, vessels treated, CMI recurrence, follow-up (FU), technical success (TS), and in-hospital length of stay (InH-LOS). Patients were divided into endovascular treatment (ET) or open treatment (OT) groups. Subsequently, primary and secondary outcomes were analyzed by study publication year for the interval periods 1986-2000 ("A") and 2001-2010 ("B"). Differences were assessed using the t-test and the χ(2) test. RESULTS Forty-three articles with 1,795 patients were included. Perioperative mortality and morbidity rates were lower in the ET group. No difference in survival rate was observed. Primary and secondary patencies were superior in the OT group. A greater number of vessels were revascularized in the OT group. CMI recurrence was more frequent in the ET group. FU was longer in the OT group. TS was superior in the OT group and InH-LOS was shorter in the ET group. A higher number of patients were treated by ET in the period "A." No differences in mortality and morbidity were observed between period "A" and "B" in ET and OT groups. CONCLUSIONS Considering the lower periprocedural mortality and morbidity after ET, this approach should be considered as the first treatment option in most CMI patients, especially in those with severe malnutrition. Primary OT should be restricted to cases that do not qualify for ET or good surgical risk patients with long life expectancy. Considering better long-term results of OT, ET treatment should be considered as a bridge therapy to OT in some patients requiring retreatment if ET does not preclude subsequent OT.
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Affiliation(s)
- Felice Pecoraro
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; Vascluar Surgery Unit, University Hospital P. Giaccone, Via L.Giuffrè 5, Palermo, Italy.
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Abstract
Chronic mesenteric ischemia (CMI) is the most common vascular disorder involving the intestines, however it is unusual in clinical practice. The redundancy of the visceral circulation with multiple interconnections between the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA) is the most likely explanation for the infrequent occurrence of CMI in clinical practice. Atherosclerosis is by the far the most common etiology of CMI. The increased utilization of diagnostic abdominal cross-sectional imaging has increased the recognition of atherosclerotic mesenteric stenoses. CMI is a clinical diagnosis, based upon symptoms and consistent anatomic findings. The classic setting for CMI is a female patient presenting with post-prandial abdominal discomfort that results in significant weight loss. Endovascular therapy with stenting has become the most common method chosen for revascularization having replaced open surgery with its associated morbidity and mortality.
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Affiliation(s)
- Christopher J White
- Department of Cardiovascular Diseases, The John Ochsner Heart & Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA 70121, USA.
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Debus E, Larena-Avellaneda A, Carpenter W, Diener H, Kölbel T. Operative Therapie der chronischen mesenterialen Ischämie. Chirurg 2011; 82:871-4, 876-9. [DOI: 10.1007/s00104-011-2099-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Renner P, Kienle K, Dahlke MH, Heiss P, Pfister K, Stroszczynski C, Piso P, Schlitt HJ. Intestinal ischemia: current treatment concepts. Langenbecks Arch Surg 2010; 396:3-11. [PMID: 21072535 DOI: 10.1007/s00423-010-0726-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Accepted: 11/03/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Mesenteric ischemia is a condition well-known among physicians treating patients with abdominal symptoms. Even so, mortality rates have not decreased significantly over the last decades. The purpose of this article is to review current treatment concepts of acute and chronic mesenteric ischemia. RESULTS Early diagnosis is one of the most important features that determine a patient's prognosis. Conventional angiography and multidetector computed tomography are therefore appropriate to quickly diagnose mesenteric ischemia, the latter being commonly more available. Once a patient presents with signs of peritonitis, instant laparotomy is indicated, and infarcted bowel segments need to be resected, followed by a second-look operation if necessary. If bowel necrosis is clinically not suspected, different approaches should be applied according to source and nature of mesenteric ischemia. Besides established surgical treatment concepts, more and more interventional procedures are developed and evaluated. However, superiority of these new techniques could only be shown for selected patient groups so far. In chronic mesenteric ischemia, interventional approaches seem to be an attractive alternative in patients who are in a condition too bad to undergo surgery. Patients with colonic ischemia are treated best in a conservative manner and by resolving the underlying cause, if identified. CONCLUSION Patients with acute mesenteric ischemia are still at highest risk for a fatal course of disease. New diagnostic and therapeutic developments have not been tested in larger studies yet, neither has any of these methods led to an increased survival in studies published so far. Taken together, mesenteric ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons.
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Affiliation(s)
- Philipp Renner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
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Rodríguez-Perálvarez ML, Jurado-García J, Benítez-Cantero JM, Vignote-Alguacil M, González-Galilea A, Pleguezuelo-Navarro M, González-Menchen A, Gómez-Morá A, De Dios Vega JF. [Fulminant ischemic gastropathy: the final stage of a difficult-to-diagnose disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:700-3. [PMID: 21051112 DOI: 10.1016/j.gastrohep.2010.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 07/26/2010] [Accepted: 08/03/2010] [Indexed: 12/23/2022]
Abstract
Ischemic gastropathy is highly infrequent in daily medical practice. In the last few years, the number of reported cases has increased. Although the guiding symptom is usually abdominal pain, the clinical spectrum of the disease is highly variable. Early diagnosis and treatment are essential to change the natural history of the disease. We present the case of a 75-year-old man with chronic abdominal pain who developed a fulminant form of necrotizing gastric ischemia and died within less than 24h.
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Outcomes of planned celiac artery coverage during TEVAR. J Vasc Surg 2010; 52:1153-8. [DOI: 10.1016/j.jvs.2010.06.105] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/14/2010] [Accepted: 06/17/2010] [Indexed: 11/18/2022]
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Abstract
The overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö, Sweden was estimated at 12.9/100,000 person-years. Autopsy rate was 87%. Acute superior mesenteric artery (SMA) occlusion (embolus/thrombus ratio = 1.4), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI) were found in approximately 68%, 16%, and 16%, respectively. Acute SMA occlusion was found to be more common than ruptured abdominal aortic aneurysms. The incidence increased exponentially with age, equally distributed among men and women after adjusting for age and gender in the population. Thrombotic occlusions were located more proximally than embolic occlusions and intestinal infarction was more extensive, whereas patients with embolus had a higher frequency of acute myocardial infarction, and had cardiac thrombi in 48% and synchronous emboli in 68% of the patients. The proportion of patients with symptoms inherent with chronic mesenteric ischemia prior to onset of acute thrombotic occlusion has been reported to occur in 73%. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal NOMI. MVT is either caused by thrombophilia, direct injury, or local venous congestion or stasis. Multidetector row computed tomography with intravenous contrast enhancement and imaging in the arterial phase for suspicion of acute SMA occlusion and imaging in the venous phase for MVT has become the diagnostic method of choice. In-hospital mortality is highest for NOMI, lower for acute SMA occlusion, and lowest, around 20%, for MVT.
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Affiliation(s)
- Stefan Acosta
- Vascular Center, University Hospital, Malmö, Sweden.
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Oderich GS. Current Concepts in the Management of Chronic Mesenteric Ischemia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 12:117-30. [DOI: 10.1007/s11936-010-0061-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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