Open and endovascular revascularization for chronic mesenteric ischemia: tabular review of the literature

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm

Background

Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR).

Objectives

To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition.

Methods

Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature.

Results

All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years.

Conclusions

Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Chronic mesenteric ischaemia presenting as possible large bowl malignancy: an easily overlooked differential diagnosis

An 80-year-old woman presented to a regional emergency department with postprandial pain, weight loss and diarrhoea for 2 months and a Computed Tomography (CT) report suggestive of descending colon malignancy. Subsequent investigations revealed the patient to have chronic mesenteric ischaemia (CMI) with associated bowel changes. She developed an acute-on-chronic ischaemia that required emergency transfer, damage control surgery and revascularisation. While the patient survived, this case highlights the importance of considering CMI in elderly patients with vague abdominal symptoms and early intervention to avoid potentially catastrophic outcomes.

Endovascular Treatment of Chronic and Acute on Chronic Mesenteric Ischaemia: Results From a National Cohort of 245 Cases

OBJECTIVE

Endovascular treatment of chronic mesenteric ischaemia (CMI) is linked to low early morbidity and mortality but a higher risk of recurrence than open repair. Mid and long term outcomes after endovascular treatment remain to be proven in larger series. The aim of this study was to assess short and mid term outcome after first line endovascular revascularisation of CMI and acute on chronic mesenteric ischaemia (AoCMI).

METHODS

This was a prospective population and registry based cohort study supplemented by a retrospective review of medical records and imaging files. A national cohort was created based on data extracted from the Danish National Registry for Vascular Surgery (Karbase) for all patients treated endovascularly for CMI or AoCMI between 2011 and 2015 in Denmark. Survival data, bowel resection, complications, re-intervention rate, and improvement of clinical symptoms were analysed, as were potential risk factors.

RESULTS

In total, 245 patients had an endovascular intervention for CMI (n = 178; 72.6%) and AoCMI (n = 67; 27.3%). One and three year survival estimates were 85% (95% confidence interval [CI] 79 - 90) and 74% (95% CI 67 - 80) in the CMI-group, and 67% (95% CI 54 - 77) and 54% (95% CI 41 - 65) in the AoCMI group. The hazard ratio for death was 1.89 (95% CI 1.23 - 2.9) for AoCMI, relative to patients with CMI. Superior mesenteric artery (SMA) stenosis, rather then occlusion, significantly increased the success of SMA recanalisation: OR 19.4 (95% CI 6.2 - 61.4) and 9.3 (95% CI 1.6 - 53.6) in the CMI and AoCMI groups, respectively. The proportion of patients reporting clinical improvement was 71% (n = 127) in the CMI group and 59% (n = 39) in the AoCMI group. Five patients (3%) in the CMI and 30 (45%) in the AoCMI groups underwent bowel resection (p < .001), and the overall length of hospital stay (LoS) was a median of two days (interquartile range [IQR] 1 - 3 days) in the CMI group and seven days (IQR 3 - 23 days) in the AoCMI group. Within the first year, re-intervention was performed in 14 patients (5.7%).

CONCLUSION

First line endovascular treatment of CMI carries a three year mortality rate of 25%, and low risk of re-occurrence of symptomatic ischaemia. Relative to CMI, patients suffering AoCMI have significantly higher morbidity and mortality, more bowel resections, and longer LoS.

Renal and Mesenteric Artery Intervention

Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.

Retrograde open superior mesenteric artery stenting: a novel approach to managing occluded ilio-superior mesenteric artery grafts

Acute mesenteric ischaemia (AMI) can be treated either by open bypass grafting or occasionally by antegrade endovascular stenting. We present a patient with symptoms of AMI, in the early postoperative period, following thrombosis of an iliac to superior mesenteric bypass to treat chronic mesenteric ischaemia. A hybrid technique combining open surgery with a retrograde endovascular approach was performed. This allowed for direct visualisation of the bowel and immediate revascularisation of the mesenteric circulation.

Air within surgical arterial graft on computed tomography-An alarming finding of a rare complication

We present a case of a 61 years old lady operated 2 years back for severe superior mesenteric artery stenosis with a surgical vascular graft and presenting as acute severe abdominal pain and vomiting. Her CT angiography showed occlusion of the surgical vascular graft with graft migration into small bowel. Both the findings of graft occlusion and bowel perforation were optimally demonstrated on the CT angiography study. The alarm of bowel perforation in addition to graft infection was raised by the presence of air pockets within the graft and its communication with bowel lumen. Coexistent graft infection was evident on graft culture.

[Endovascular treatment of chronic mesenteric ischemia]

INTRODUCTION

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries.

METHODS

We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018.

RESULTS

Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day.

CONCLUSION

Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

Mesenteric vascular treatment 2016: from open surgical repair to endovascular revascularization

The rise of endovascular techniques has improved the outcome of mesenteric ischemia. Key principle in reduction of morbidity and mortality is "revascularization first, resection later". We believe that mesenteric ischemia is a clinical challenge demanding 24/7 multidisciplinary team availability. This article describes the current insights into treatment of mesenteric ischemia.

Abdominal Angina Treated by Urgent Percutaneous Angioplasty: An Excellent Alternative to Surgical Revascularisation

Chronic Mesenteric Ischemia (CMI) presenting as acute abdomen can be treated percutaneously. An endovascular intervention has surpassed surgical revascularization over the past decade due to its lesser perioperative complication rate. Trans-femoral approach of revascularising is limited by its difficulty in coaxial alignment of the guiding catheter and hence, brachial artery and recently the radial approach have been utilized for mesenteric artery revascularisation for over a decade. Here by we report a case of chronic mesenteric ischemia having total occlusion of two and 70% occlusion of one of the three mesenteric vessels. The patient had presented with acute abdomen which in turn was percutaneously revascularised via the left brachial artery for the two major abdominal visceral vessels being superior mesenteric artery and inferior mesenteric artery.

Anatomic and radiologic review of chronic mesenteric ischemia and its treatment

Chronic mesenteric ischemia (CMI) is a vascular occlusive disease process that generally affects the elderly population. Clinical presentation occurs when two of the three mesenteric arteries are affected and includes non-specific abdominal pain and weight loss. The most common cause of CMI is atherosclerotic arterial occlusion. The aim of this review is to present the vascular anatomy of the mesenteric arterial circulation including the different collateral pathways. The imaging findings and the different treatment options with a brief review of the literature is presented.

Acute acalculous cholecystitis as a rare manifestation of chronic mesenteric ischemia. A case report

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Acute acalculous cholecystitis can present de novo in an outpatient setting without any major illness or associated trauma and aortic occlusive disease may represent the most relevant etiological factor in these patients.

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In the settings of chronic mesenteric ischemia, acute acalculous cholecystitis may be interpreted as a herald sign of critical ischemia and mesenteric infarction as a consequence of an acute-on-chronic mesenteric ischemia.

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In our patient, the decision was taken to proceed with immediate mesenteric revascularization simultaneously with the cholecystectomy in order to minimize the risk and extension of a possible bowel infarct.

Introduction

Symptomatic chronic mesenteric ischemia (CMI) is an uncommon condition that usually presents with intestinal angina, sitophobia and unintentional weight loss. Acute acalculous cholecystitis (AAC) has very rarely been described in the settings of CMI.

Presentation of case

We describe a case of a 73 year old man that developed an AAC as a complication of CMI. The patient underwent a simultaneous cholecystectomy and open aortic revascularization which was successful. At 24 months of follow-up the patient is clinically well and regained weight.

Discussion

Ischemia has been considered an important etiology for the development of AAC. In the settings of CMI, an AAC might develop has a herald sign of progression to acute mesenteric ischemia and infarction, as the cystic artery is a terminal artery with no collateral network. Performing the aortic revascularization simultaneously with the cholecystectomy might prevent this possible fatal outcome.

Conclusion

This case reinforces aortic and visceral occlusive disease as a possible risk factor for the development of AAC, and discusses the treatment controversies when managing both conditions simultaneously.

Endovascular Versus Surgical Revascularization for the Management of Chronic Mesenteric Ischemia

Background:

Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization (SR) or endovascular revascularization (ER).

Materials and Methods:

Systematic review of 12 studies comparing ER and SR in CMI. Primary end point was perioperative (30 days) survival. A secondary composite end point consisted of perioperative mortality, nonfatal cardiac events, nonfatal stroke, and nonfatal bowel ischemia. Further end points included late survival, primary patency, and symptom improvement.

Results:

The cumulative odds ratio (OR) for perioperative mortality was 0.78 (95% confidence interval [CI]: 0.40-1.50, P = .45) and 0.56 (95% CI: 0.28-1.11, P = .10) for the composite end point. The cumulative OR for survival after the 30th day was 0.83 (95% CI: 0.47-1.46), P = .51. Late primary patency was reported in 8 studies, with a cumulative OR of 3.57 (95% CI: 1.83-6.97, P = .0002)—favoring SR.

Conclusion:

In the first meta-analysis to compare ER and SR in CMI, there were no differences in mortality and morbidity. Patency rates were better following SR.

Management of Mesenteric Ischemia

Acute mesenteric ischemia is associated with a high mortality rate and requires emergent evaluation and surgical management. However, patients with chronic mesenteric ischemia can undergo either surgical or endovascular revascularization. Review of recent medical literature suggests lower rates of mortality and complications after endovascular revascularization, but higher rates of primary patency after surgical revascularization. The decision regarding method of revascularization in patients with chronic mesenteric ischemia should be based on the patient's vascular anatomy, comorbidities, and life expectancy.

Ileocolic to right iliac arterial transposition for the treatment of chronic mesenteric ischemia

The treatment of chronic mesenteric ischemia remains challenging and controversy exists over the best interventional option. Endovascular treatment has emerged as first-line management due to its associated lower morbidity and mortality than surgical reconstruction. However, open mesenteric reconstructions continue to play an important role in patients with lesions that are unsuitable for an endovascular option. Mesenteric operations utilize the aorta or iliac artery as the inflow source for a vein or prosthetic bypass to the celiac artery or superior mesenteric artery. We describe an exceptional case of chronic mesenteric ischemia due to atherosclerosis that was treated successfully with a novel ileocolic to right iliac arterial transposition.

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

Background

Endovascular revascularization has recently been established as a less invasive treatment method for chronic mesenteric ischemia. However, intestinal necrosis caused by distal embolization following this procedure has not been emphasized.

Case presentation

The present report describes a 59-year-old man who was treated with endovascular revascularization for chronic mesenteric ischemia. After the procedure, he was diagnosed with intestinal necrosis caused by distal embolization. Despite emergent bowel resection, he died on postoperative day 109.

Conclusion

Although endovascular revascularization for chronic mesenteric ischemia is less invasive and may be suitable for high-risk patients, attention should be paid to avoid embolic complications that can cause intestinal infarction possibly leading to a fatal condition.

Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia

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.

Endovascular recanalization of the superior mesenteric artery in the context of mesenteric bypass graft infection

Mesenteric prosthetic graft infection is a rare and challenging clinical scenario. A patient is described who developed recurrent abdominal pain after occlusion of an iliomesenteric prosthetic bypass. Endovascular recanalization of the native superior mesenteric artery, which had been occluded for more than 10 years, was accomplished using axillofemoral through-wire access and a steerable guiding catheter. The infected prosthetic was then explanted and his graft-enteric fistula repaired. Technical and strategic considerations are discussed.

Endovascular treatment of mesenteric ischemia

OBJECTIVES

Our goal was to describe a single-center's experience in managing acute and chronic mesenteric ischemia with endovascular therapies.

BACKGROUND

Open surgical revascularization has been considered the historical gold standard treatment for mesenteric ischemia though it poses considerable morbidity and mortality risk. An aging population with increased comorbidities makes endovascular treatment a more attractive treatment option.

METHODS

Consecutive subjects receiving percutaneous mesenteric interventions for acute and chronic mesenteric ischemia from 2004 to 2010 were identified retrospectively. Information on comorbidities, symptoms, screening tests, procedural outcomes, and follow up was obtained.

RESULTS

Thirty-one patients received percutaneous mesenteric interventions during this period. The mean age of the population was 65.0 years with roughly equal proportions of males (48.4%) and females (51.6%). Traditional cardiovascular risk factors were highly prevalent (hypertension 45.2%, diabetes 25.8%, dyslipidemia 38.7%, nicotine use 45.2%). Procedural success was 93.5%; no periprocedural complications were reported. During a mean follow up of 13 months, 16.1% required repeat revascularization and 22.6% died. Endovascular treatment of acute mesenteric ischemia was successful (n = 8) and no patient required open surgical revascularization acutely or during follow-up.

CONCLUSIONS

Endovascular treatment of mesenteric ischemia is a safe and effective therapy with acceptable long-term results. Our experience with acute mesenteric ischemia suggests that percutaneous treatment may be an effective alternative to surgical revascularization in appropriately selected patients.

Chronic mesenteric ischemia: diagnosis and management

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.

Chronic atherosclerotic mesenteric ischemia (CMI)

Chronic mesenteric ischemia (CMI) is most likely caused by atherosclerosis and less frequently by external compression and vasculitis. Symptomatic CMI is an uncommon, potentially under-diagnosed condition caused by fixed stenoses or occlusion of, in most conditions, at least two visceral arteries. If only one of the three major bowel-providing arteries — the celiac trunk, and the superior and inferior mesenteric arteries — is affected, the patient is usually asymptomatic due to a tight collateral network. The only exception is the celiac artery compression syndrome which represents primarily a compression syndrome of celiac plexus nerves by the arcuate ligament in conjunction with a compression of the celiac trunk. CMI of atherosclerotic origin is associated with a high morbidity and mortality. During the last decade, endovascular revascularization has replaced surgical revascularization as the therapy of choice in most centers. This article reviews the most relevant clinical aspects of the disease and the current practice of diagnosis and treatment of CMI.

Open surgical treatment for chronic mesenteric ischemia in the endovascular era: when it is necessary and what is the preferred technique?

Treatment of chronic mesenteric ischemia has evolved during the last 2 decades. Endovascular treatment has first emerged as an alternative to bypass in the elderly or higher-risk patient, but has become the primary modality of treatment in most patients with suitable lesions, independent of their surgical risk. Open mesenteric revascularization with bypass or (rarely) endarterectomy still has an important role in the treatment of patients with more extensive disease, including long-segment or flush occlusions, small vessel size, multiple tandem lesions, and severe calcification. Our preference for open reconstruction in good-risk patients with multivessel disease is a supraceliac aorta to celiac and superior mesenteric artery (SMA) bypass, whereas an iliac artery to SMA bypass or, occasionally, an infrarenal aortic to SMA bypass is used in the higher-risk group. In this article, we summarize the selection criteria, techniques, and outcomes of open mesenteric reconstruction in the endovascular era.

Open or percutaneous revascularization for chronic splanchnic syndrome

BACKGROUND

Treatment of chronic splanchnic syndrome remains controversial. In the past 10 years, endovascular repair (ER) has replaced open repair (OR) to some extent. This evidence summary reviews the available evidence for ER or OR of chronic splanchnic syndrome.

METHODS

A systematic literature search of MEDLINE database was performed to identify all studies that evaluated treatment of chronic splanchnic syndrome between 1988 and 2009.

RESULTS

The best available evidence consists of prospectively accumulated but retrospectively analyzed data with a high risk for confounding. Only a few of these studies incorporated functional tests to assess splanchnic ischemia before or after treatment. ER has the advantage of low short-term morbidity but the disadvantage of decreased long-term primary patency compared with OR. ER and OR have similar rates of secondary patency, although the reintervention rate after ER is higher.

CONCLUSION

ER appears to be preferential in the treatment of elderly patients and in patients with comorbidity, severe cachexia, or hostile abdomen. Long-term results after OR are excellent. OR can still be proposed as the preferred option for relatively young and fit patients.