Endovascular Treatment of Chronic Splanchnic Syndrome

Celiac Trunk Stenosis Treated by Resection and Splenic Patch Reconstruction - A Case Report and Literature Review

Celiac trunk stenosis is a relatively common finding; the most common causes of this obstruction are median arcuate ligament syndrome, pancreatitis, local invasion of various malignancies originating from the pancreatic body, atherosclerosis or it can be idiopathic. However, most such cases remain asymptomatic for a long period of time, especially due to the presence of a patent collateral circulation originating from the superior mesenteric artery. In certain cases, the patient might become symptomatic, diffuse post-prandial pain being reported. We present the case of a 51-year-old patient diagnosed with celiac axis stenosis who was initially submitted to surgery with the preoperative suspicion of median arcuate ligament syndrome; however, the patient reported the persistence of the abdominal symptoms, leading to suspicion of idiopathic celiac axis stenosis. The patient underwent reoperation, the celiac trunk stenosis being resected, and the continuity of the vascular axis being established using a splenic artery patch. The postoperative course was uneventful, the patient presenting an adequate hepatic blood flow in the first day postoperatively.

Percutaneous transluminal angioplasty and stenting in the management of chronic mesenteric angina: A single center experience

INTRODUCTION

The objective of our study was to review the results of percutaneous angioplasty (PTA)/stenting in the treatment of patients who presented with symptoms and angiographic findings of chronic mesenteric ischemia (CMI).

MATERIALS AND METHODS

We performed a retrospective analysis of 13 consecutive patients from a single institution who underwent PTA/stenting for the treatment of symptoms suggestive of CMI.

RESULTS

All 13 patients in our study were men, and most common presenting symptoms were weight loss and postprandial pain. Atherosclerosis was the most common cause. PTA and stenting was performed in 9 patients and PTA alone was done in 4 patients. Primary technical success rate was 92% with complete resolution of symptoms within 2 weeks in all patients. No statistical difference was noted in primary clinical success rate based on the number of vessels treated or the method of treatment. However, in patients whom SMA was treated had longer duration of symptom-free survival as compared to other vessels.

CONCLUSION

PTA and stenting are very effective therapeutic options for patients presenting with CMI symptoms. It should be considered as the first-line of management in such patients.

Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes

OBJECTIVE

Outcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification.

METHODS

The data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting.

RESULTS

The ER patients were significantly older (71 +/- 15 vs 65 +/- 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 +/- 0.5 vs 1.8 +/- 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group (P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 +/- 8 vs 3 +/- 5 days; P < .001). At 5 years, OR had improved (P < .05) recurrence-free survival (89% +/- 4% vs 51% +/- 9%), and primary (88% +/- 3% vs 41% +/- 9%) and secondary patency rates (97% +/- 2% vs 88% +/- 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved (P < .05) recurrence-free survival (91% +/- 3% vs 56% +/- 8% at 5 years) and better primary and secondary patency rates (93% +/- 2% and 98% +/- 1% vs 52% +/- 8% and 93% +/- 4% at 3 years).

CONCLUSION

OR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.

Chronic mesenteric ischemia: critical review and guidelines for management

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.

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.

Role for endovascular therapy in chronic mesenteric ischemia

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.

Clinical Approach to Chronic Gastrointestinal Ischaemia: From 'Intestinal Angina' to the Spectrum of Chronic Splanchnic Disease

Stenotic disorders of the splanchnic arteries are not rare, and it is generally assumed that symptoms are rare in patients with a single splanchnic stenosis, and even in patients with multiple-vessel stenoses. Currently, only gastric exercise tonometry aids the diagnostic evaluation, as it indicates actual ischaemia. Patients with stenotic disorders without complaints are referred to as having chronic splanchnic disease (CSD) and those with ischaemic complaints as having chronic splanchnic syndrome (CSS). The classical presentation of CSS, including the triad postprandial pain, weight loss and upper abdominal bruit, is also known as 'intestinal angina'. From the experience of our multidisciplinary working team on gastrointestinal ischaemia in 110 patients with stenoses of at least one splanchnic artery, two different clinical patterns were observed. In our series approximately 60% of patients with single-vessel stenoses, including the coeliac artery compression syndrome, have CSS. They have fewer complications, very low mortality, but most can be successfully treated by stenting or surgical treatment. Patients with multivessel splanchnic stenoses have more classical ischaemic complaints. Progression to a bowel infarction was seen in 34%, and mortality was 21%, mostly from bowel or myocardial infarction. Treatment should be tailored based upon perioperative risk assessment and local vascular anatomy. This may consist of autologous arterial bypass of one or two vessels, preferably antegrade. stenting or a combination of both. This differentiation between single- and multivessel splanchnic disease has considerable consequences for optimal work-up and treatment.

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

Chronic mesenteric ischemia is an uncommon disease in vascular surgery practice worldwide. Open revascularization remains the best treatment for low-risk patients due to durability and efficacy. Endovascular revascularization for chronic mesenteric ischemia was primarily indicated for elderly and higher-risk patients, but this has changed over the past 10 years due to development of more precise devices and lower morbidity and mortality rates despite the higher recurrence and restenosis rates. Our purpose was to summarize the data on endovascular and open revascularization for chronic mesenteric ischemia in a schematic tabular presentation.

Management of chronic mesenteric ischemia. The role of endovascular therapy

Chronic mesenteric ischemia is an uncommon disorder manifested most commonly as abdominal pain. Surgical revascularization has traditionally been the treatment of choice. Endovascular management of this entity was originally attempted as an alternative for high-risk patients. Improvements in stent technology, refinement in technique, and increased efficiency of antiplatelet regimens have, over time, increased the popularity of this minimally invasive approach. We present a review of the available series on endovascular treatment of chronic mesenteric ischemia, with emphasis on short- and long-term outcome and morbidity and mortality results. Principles of operative technique and controversial issues and topics of interest are also discussed.

Clinical significance of splanchnic artery stenosis

BACKGROUND

The clinical relevance of splanchnic artery stenosis is often unclear. Gastric exercise tonometry enables the identification of patients with actual gastrointestinal ischaemia. A large group of patients with splanchnic artery stenosis was studied using standard investigations, including tonometry.

METHODS

Patients referred with possible intestinal ischaemia were analysed prospectively, using duplex imaging, conventional abdominal angiography and tonometry. All results were discussed within a multidisciplinary team.

RESULTS

Splanchnic stenoses were found in 157 (49.7 percent) of 316 patients; 95 patients (60.5 percent) had one-vessel, 54 (34.4 percent) two-vessel and eight (5.1 percent) had three-vessel disease. Chronic splanchnic syndrome was diagnosed in 107 patients (68.2 percent), 54 (57 percent) with single-vessel, 45 (83 percent) with two-vessel and all eight with three-vessel stenoses. Treatment was undertaken in 95 patients, 62 by surgery and 33 by endovascular techniques. After a median follow-up of 43 months, 84 percent of patients were symptom free.

CONCLUSION

Gastric exercise tonometry proved crucial in the evaluation of possible intestinal ischaemia. Comparing patients with single- and multiple-vessel stenoses, there were significant differences in clinical presentation and mortality rates.

Stent Placement with the Monorail Technique for Treatment of Mesenteric Artery Stenosis

PURPOSE

To analyze the immediate and midterm success of stenting of mesenteric arteries by a monorail technique in patients with chronic mesenteric ischemia.

MATERIALS AND METHODS

In this prospective case series, 19 patients (11 male, 8 female; mean age, 62.9 +/- 10.4 y; range, 36-82 y) with 23 symptomatic stenoses of mesenteric arteries were treated with stent placement by a monorail technique in a radiologic intervention center over a period of 4.5 years. Clinical examinations and duplex sonography were used to evaluate the stents' patency and clinical success. Kaplan-Meier graphs were calculated to analyze the patency and freedom-from-symptom rate.

RESULTS

Initial technical success rate was 22/23 (96%). Mean follow-up was 17 months (range, 1-58 mo). Primary patency and primary clinical success rates were 82% and 78%, respectively. According to Kaplan-Meier tables, the patency rates were 96%, 87%, 76%, and 61% at 0, 1, 15, and 24 months, respectively, and the freedom-from-symptom rates were 95%, 90%, 72%, and 54% at 0, 1, 24, and 30 months, respectively. No peri-interventional complications occurred. Two patients died of cardiac failure in the hospital within 30 days after intervention; deaths were not related to the intervention.

CONCLUSIONS

Stent placement by a monorail technique in mesenteric arteries is an effective and safe treatment for symptomatic stenoses in patients with chronic mesenteric ischemia after a mean follow-up of 17 months.