Functional testing in the diagnosis of chronic mesenteric ischemia

Surgical and endovascular revascularization of chronic mesenteric ischemia

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.

Chronic mesenteric ischaemia: the importance of the individual mesenteric artery

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.

Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery Status

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.

[Clinical implications of chronic mesenteric ischemia in elderly and senile patients]

AIM

To evaluate the sensitivity and specificity of the clinical criteria for the diagnosis of chronic mesenteric ischemia in elderly and senile patients with mesenteric atherosclerosis.

MATERIALS AND METHODS

The study included 142 patients (82 men and 60 women). The median age of patients is 66.0 [62.0; 72.0] years.

RESULTS

According to MDCT atherosclerotic lesions of the abdominal aorta and its unpaired visceral branches were diagnosed in 105 (73.9%) patients. A combination of atherosclerosis of the celiac trunk and the superior mesenteric artery with the presence of hemodynamically insignificant stenosis was revealed. Hemodynamically significant atherosclerotic narrowing of at least one mesenteric artery was present in 15% of cases. Among them, a single vascular lesion was found in 6 patients (4.2%), a combination of hemodynamically significant lesions of two arteries in 15 (11%) patients. Depending on the clinical manifestations, all patients are divided into two groups: the first group 30 (21.1%) patients with the presence of symptoms characteristic of chronic mesenteric ischemia (CMI). The second group consisted of 112 (78.8%) patients without a characteristic triad of symptoms. The clinical symptom complex of СMI, including postprandial abdominal pain, intestinal dysfunction and progressive weight loss, as a diagnostic criterion showed low sensitivity 13.3% and specificity 77.9%. At the same time, the sensitivity of such a clinical combination as a combination of atherosclerosis of the arteries of the lower extremities, weight loss and abdominal pain syndrome with a severity of more than 5.5 points, with respect to the detection of hemodynamically significant stenoses of two or more mesenteric arteries was sensitivity 86.7%, specificity 74.0%.

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

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.

Review Article: Mesenteric Ischemia

PURPOSE OF REVIEW

Mesenteric ischemia (MI), both acute (AMI) and chronic (CMI), is a challenging diagnosis to make, and early diagnosis and treatment are vital to improve outcomes. This manuscript summarizes the most up to date information on diagnosis and treatment of these disorders.

RECENT FINDINGS

There have been several significant advancements in the computed tomography (CT) diagnostic imaging as well as medical and endovascular management of AMI and CMI. In appropriate populations, endovascular interventions appear superior to open surgical management with lower mortality, morbidity, and cost of care. Efficient clinical identification and targeted testing are essential to diagnose AMI and CMI. Aggressive resuscitation and early endovascular (or in select cases, surgical) intervention improve outcomes in those with AMI. In those with CMI, considering this on the differential diagnosis and imaging appropriately can identify those that might benefit from intervention and halt progression to acute episodes.

Gastroscopy assisted laser Doppler flowmetry and visible light spectroscopy in patients with chronic mesenteric ischemia

Mucosal pathology due to chronic mesenteric ischemia (CMI) is rarely seen during upper endoscopy. Combining Laser Doppler Flowmetry (LDF) and Visible Light Spectroscopy (VLS) may aid in detection of CMI at an early stage. We aimed to investigate the utility of LDF and VLS in detecting microcirculatory changes in patients with CMI during upper endoscopy. In a single center, prospective study, 104 patients were evaluated for mesenteric ischemia during a 24 months period. Patients with a consensus diagnosis of CMI (n = 40) were examined with LDF and VLS. Thirty-two were successfully treated and had a definitive diagnosis of CMI. Results were compared with controls (n = 38) with normal intestinal circulation evaluated with duplex ultrasonography (DUS). Treatment response was evaluated clinically and with DUS at 1 month and with VLS and LDF at 3 months. A significant reduction in mucosal capillary hemoglobin oxygen saturation (SO₂) was found in CMI patients compared to controls before treatment: mean ± SD: 67 ± 9%, 81 ± 4%, respectively (p < .001). A significant reduction was also seen for the relative hemoglobin (rHb) amount, flow and velocity (p < .001). The sensitivity of SO₂ measured by VLS for diagnosing CMI was 94% and the specificity 72% (cut-off 78%), calculated with ROC curve analysis. A combination of SO₂ and rHb increased the test sensitivity and specificity to 97% and 79%, respectively. Conclusion: CMI patients have significantly reduced microcirculation in the stomach and duodenum compared to controls. The results suggest that VLS should be included when performing an upper endoscopy in patients with suspected CMI.

Weight Loss: A Significant Cue To The Diagnosis of Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is a condition defined by a state of attenuated blood circulation in the mesenteric vasculature affecting one or more abdominal viscera, and is more common in the female and elderly populations. Amongst the many causes, it occurs most frequently in connection with diffuse atherosclerosis. Its presentation is variable with symptoms such as weight loss, nausea, vomiting, diarrhea and/or constipation, with postprandial pain classically present in the majority of the cases; this, in addition to the chronic course of the disease, makes timely diagnosis a challenge. Physical examination may reveal signs of malnutrition and other findings usually linked with the underlying medical condition. It can have grave consequences if not managed promptly. In our case, an 81-year-old woman came in with loss of appetite, nausea, vomiting, diarrhea and/or constipation, and weight loss. Computed tomography angiography (CTA) of the abdomen/pelvis confirmed chronic occlusion of the mesenteric vessels. She was treated surgically. This discussion is based on chronic mesenteric ischemia and its nonspecific symptomatology, particularly its association with weight loss.

Serological biomarkers for acute mesenteric ischemia

Acute mesenteric ischemia (AMI) defines a complex of conditions characterized by an interruption of the splanchnic circulation, leading to insufficient oxygen delivery or utilization to fill the metabolic needs of the visceral organs. Early diagnosis and immediate therapy are the cornerstones of early ischemia to reach a successful outcome and are necessary to reduce the high mortality. Although there is still lack of specific biomarkers to assist the diagnosis of AMI in clinical practice, there are several biomarkers with high specificity, may become a potential tools in early diagnosis of AMI, including intestinal fatty acid binding protein (I-FABP), a-glutathione S-transferase (a-GST), D-dimer, L- and D-lactate, citrulline, ischemia modified albumin, procalcitonin (PCT). However, they use in clinical limited duo to the many studies about these makers finished with small patient populations, and heterogeneous among these populations. This review describes the etiology of AMI, the current most studied promising biomarkers, the current research situation and future of biomarker research.

Intraobserver and interobserver reliability of visible light spectroscopy during upper gastrointestinal endoscopy

BACKGROUND

Visible light spectroscopy (VLS) performed during upper gastrointestinal endoscopy allows measuring mucosal oxygen saturation levels to determine gastrointestinal ischemia. We aimed to determine the observer variability of VLS.

METHODS

This is a single-center prospective study of 24 patients planned for usual care upper endoscopy. To test intraobserver variability, VLS measurements were performed in duplicate by a single endoscopist in 12 patients. For interobserver variability analysis, in another 12 patients VLS measurements were repeatedly and independently performed by two endoscopists in the same patient during the same endoscopy session. Observer variability was assessed with intraclass correlation coefficient (ICC) and clinical disagreement defined as >5% difference between first and second set of VLS measurements.

RESULTS

The intraobserver reliability was excellent (ICC antrum 0.77, duodenal bulb 0.81 and duodenum 0.84) with clinical disagreement only in antrum (3% of all intraobserver measurements). The interobserver reliability was good for the duodenal bulb (ICC 0.70) without clinical disagreement; however, interobserver reliability was fair for duodenum (ICC 0.49) and antrum (ICC 0.56) with clinical disagreement occurring in 11% of all interobserver measurements.

CONCLUSIONS

The observer reliability of VLS is fair to good with intraobserver reliability being better than interobserver reliability. This supports the use of VLS for detection of gastrointestinal ischemia.

Exertional Abdominal Pain as a Rare Presenting Manifestation of Chronic Mesenteric Ischemia from a Single Mesenteric Vessel Stenosis

We present an atypical manifestation of chronic mesenteric ischemia in a patient with progressively worsening exertional abdominal pain. Imaging modalities revealed significant isolated stenosis of superior mesenteric artery (SMA). Successful angioplasty and stenting of SMA relieved patient's symptoms, thereby confirming the diagnosis of chronic mesenteric ischemia. Exertional abdominal pain may be a unique manifestation of this disease, but when it presents, clinicians should have acute clinical awareness of this diagnosis.