Chronic mesenteric ischemia: diagnosis and management

Advancements in Treatment Strategies for Chronic Mesenteric Ischemia: A Comprehensive Review

Chronic mesenteric ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability in patient symptoms and the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduction of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate efficacy, patency rates, and long-term outcomes in CMI patients.

High risk and low prevalence diseases: Mesenteric ischemia

INTRODUCTION

Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment.

CONCLUSIONS

An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.

Chronic mesenteric ischemia: causes, methods of diagnosis and treatment

Chronic mesenteric ischemia (CMI) is an urgent public health problem. The long asymptomatic course of the disease, sudden onset and an unfavorable prognosis in the absence of treatment make it necessary to pay closer attention to this pathology. There are currently two competitive treatments for CMI: surgical and endovascular revascularization. Despite numerous studies comparing these methods, the question of which one is more effective and reliable remains open. The review includes current data from clinical trials and meta-analyses demonstrating the advantages and disadvantages of both methods.

Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT

Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ^©RSNA, 2020.

Early and Midterm Outcomes of Open and Endovascular Revascularization of Chronic Mesenteric Ischemia

Background

Revascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center.

Patients and methods

From 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years.

Results

In total, 63 patients (33% male; mean age 71, range 60–76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10–71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p < 0.001). Freedom from reintervention rate after 2 years was 82% after OR and 73% after ER (p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11–15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05–1.08; p = 0.06).

Conclusion

Due to a lower invasiveness, despite the higher reintervention rate, an “endovascular first” strategy is justified and recommended.

Recanalization of superior mesenteric artery chronic total occlusion using hybrid algorithm and dissection reentry device

Chronic total occlusion (CTO) of mesenteric arteries with associated chronic mesenteric ischemia (CMI) is associated with high morbidity and mortality. Endovascular intervention has been associated with high technical success with high rates of freedom from symptoms and long-term patency. However, to achieve high procedural success, use of optimal vascular access and expertise in CTO hybrid algorithm including advanced dissection reentry strategies are essential. We present a case of CMI from severe celiac artery (CA) stenosis and CTO of superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). After treatment of CA stenosis, we were unsuccessful in our first attempt at recanalization of SMA CTO. On second attempt, left brachial artery (BA) access was obtained and the hybrid algorithm along with use of Stingray Reentry balloon (Boston Scientific) for dissection reentry into true lumen was successful in recanalizing the SMA CTO with placement of balloon expandable covered stents (CS). To the best of our knowledge, this is the first case report utilizing Sting-ray Reentry balloon in the mesenteric arteries.

Naturally shrunk visceral artery aneurysms by stenting for the superior mesenteric artery occlusion

A 77-year-old woman who had experienced postprandial abdominal pain for four years was admitted to our institution presenting sudden and severe abdominal pain. Contrast-enhanced computed tomography (CECT) demonstrated complete short-segmented occlusion in the orifice of the superior mesenteric artery (SMA), and saccular aneurysms in the right hepatic artery and the anterior superior pancreaticoduodenal artery. She was diagnosed with abdominal angina due to occlusion of the SMA. The SMA was recanalized by stenting, and a CECT scan confirmed naturally shrunk aneurysms after eight months. The patency of the SMA was maintained at five years after endovascular treatment.

Superior mesenteric artery endarterectomy for chronic mesenteric ischemia: A viable alternative in poor candidates for endovascular interventions

Background

Chronic mesenteric ischemia can be treated with either endovascular approaches or surgical revascularization. Recent data suggest that surgery leads to more durable symptom relief with similar long-term survival compared to transcatheter angioplasty. Splanchnic vessel endarterectomy has been shown to lead to longer freedom from recurrence compared to the more commonly used surgical bypass procedure.

Methods

We retrospectively reviewed the medical records of patients with chronic mesenteric ischemia who were considered poor candidates for endovascular repair and therefore underwent superior mesenteric artery endarterectomy in our institution. Study period was April 2016 to April 2018.

Results

A 73-year-old female and a 69-year-old male patient fulfilled our inclusion criteria. Extensive stenosis of the celiac axis and the superior mesenteric artery was found in both patients. superior mesenteric artery endarterectomy was performed in both cases. Endarterectomy was closed using a polytetrafluoroethylene patch. Both patients are alive and symptom-free at one year postoperatively with no signs of restenosis.

Conclusions

Our institutional outcomes are in line with recent literature supporting superior mesenteric artery endarterectomy as a viable alternative to surgical bypass in patients with chronic mesenteric ischemia who are suboptimal candidates for endovascular angioplasty and stenting.

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.

Aorto-mesenteric Bypass for the Treatment of Chronic Mesenteric Ischemia

Chronic mesenteric artery disease has a much lower incidence than the acute one, but it raises the same problems in terms of patient survival. The long-term outcomes for open surgery are crucial for the right choice of a particular technique. We present the case of a 39-year-old female patient with a history of total nephrectomy, chronic kidney failure, and hypertension, who presented in the Emergency Department with abdominal pain with high intensity, for which she was admitted to the General Surgery Department. Abdominal computed tomography angiography was performed, which indicated the diagnosis of partial upper mesenteric artery stenosis. The patient underwent surgery, during which a retrograde aorto-mesenteric bypass with a Gore-Tex 5 mm diameter prosthesis was performed. In situations where the endovascular approach fails or has no indication (multiple incidence lesions from the origin of the superior mesenteric artery), open surgery is the indication in chronic mesenteric ischemia.

Neutrophil-to-lymphocyte ratio and mesenteric ischemia: can it predict the etiology of mesenteric ischemic at computed tomography?

OBJECTIVES

To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain.

METHODS

This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated.

RESULTS

A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA.

CONCLUSIONS

The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment.

An Approach to the Patient With Chronic Undiagnosed Abdominal Pain

Abdominal pain is a common reason for referral to a gastroenterologist. The workup of patients with chronic abdominal pain can be extremely challenging as clinicians are responsible for determining whether the patient can be observed or treated symptomatically or this abdominal pain heralds a more systemic disease. The differential is typically wide and given the innervation of the abdomen, localization of abdominal pain does not always provide clear insight into the etiology. This review attempts to help the gastroenterologist narrow down that broad differential and focus on key elements of the patient visit. We emphasize the importance of a detailed history from the patient, along with review-specific details of their history and physical examination that can clue one in about the etiology of the abdominal pain. We review the causes of diffuse abdominal pain that may not first be considered along with uncommon causes of localized abdominal pain. We also review the functional causes of abdominal pain and the importance of identifying these disorders, to avoid unnecessary testing that commonly occurs with these patients.

Arterial thrombosis in unusual sites: A practical review

While cardiovascular disease is common, occasionally hematologists and other practitioners will encounter patients with arterial thrombosis/infarction in unusual sites, without clear cause or obvious diagnostic and treatment paradigms. Contrary to the more commonly encountered cerebrovascular accident and cardiovascular disorders, the various infarctions outlined in this review have unique presentations, pathophysiology, workup, and treatments that all hematologists should be aware of. This review outlines the current literature on arterial thrombosis, with consideration given to anatomic sources and hypercoagulable associations, while focusing on the epidemiology, pathophysiology, provoking factors, and current recommended treatments for intracardiac thrombus, primary aortic mural thrombus, visceral infarctions, and cryptogenic limb ischemia to provide a useful and practical review for the practitioner.

MI: Not a Heart Attack but a Gut Attack

Mesenteric ischemia and infarction are infrequent but often deadly conditions in acute and critically ill patients. Mesenteric ischemia may be a primary admission diagnosis or may develop secondary to another diagnosis. Having a high index of suspicion for patients at risk of mesenteric ischemia and mesenteric infarction can alter a poor outcome. This article reviews the pathophysiology, risk factors, assessment, medical and nursing diagnoses, as well as collaborative management for mesenteric ischemia. Early identification of patients at risk and the appropriate diagnostic testing are stressed. Nurses armed with the knowledge of this condition are better able to provide safe care to their patients.

A case of extreme weight loss due to mesenteric ischemia and antiphospholipid syndrome

Mesenteric ischemia and antiphospholipid syndrome is a rare combination but should be suspected as a differential diagnosis. This may be presented as diffuse abdominal pain typically after food intake, diarrhea, and weight loss. Early recognition is warranted, and nutrition, stenting, and anticoagulant treatments are indicated.

Fractured Superior Mesenteric Artery Stent With Stent Displacement Leading to Recurrent Symptoms of Superior Mesenteric Ischemia

We report a case of a patient with recurrent symptoms of superior mesenteric ischemia 7 months after successful percutaneous angioplasty and implantation of a stent in the superior mesenteric artery (SMA). Stent fracture and stent displacement were observed. To the best of our knowledge, this is the first report of SMA stent fracture with stent displacement.

Influence of splanchnic artery stenosis on the in-hospital clinical course of elderly patients

BACKGROUND

Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition.

AIMS

The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery.

METHODS

For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission.

RESULTS

Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46).

CONCLUSIONS

In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.

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.

Bowel Movement Frequency, Laxative Use, and Mortality From Coronary Heart Disease and Stroke Among Japanese Men and Women: The Japan Collaborative Cohort (JACC) Study

Background

The associations of bowel movement frequency and laxative use with cardiovascular disease (CVD) are unclear.

Methods

A total of 72 014 subjects (29 668 men and 42 346 women) aged 40 to 79 years, without a history of CVD or cancer, completed a lifestyle questionnaire at baseline between 1988 and 1990 that included information on bowel movement frequency (daily, every 2–3 days, or once every 4 or more days) and laxative use (yes or no), and were followed-up until 2009.

Results

During the subjects’ 1 165 569 person-years of follow-up, we documented 977 deaths from coronary heart disease (561 men and 416 women), 2024 from total stroke (1028 men and 996 women), 1127 from ischemic stroke (606 men and 521 women), and 828 from hemorrhagic stroke (388 men and 440 women). The prevalence of CVD risk factors, such as diabetes, stress, depression, and physical inactivity, was higher in laxative users and in those with a lower frequency of bowel movements. The multivariable HRs (95% confidence intervals [CIs]) of laxative users were as follows: 1.56 (95% CI, 1.21–2.03) for coronary heart disease and 1.37 (95% CI, 1.07–1.76) for ischemic stroke in men, and 1.27 (95% CI, 1.08–1.49) for total stroke, and 1.45 (95% CI, 1.17–1.79) for ischemic stroke in women. Similar results were observed even after the exclusion of deaths that occurred early in the follow-up period. A significant association between bowel movement frequency and mortality from CVD was not observed.

Conclusions

Constipation could be a marker of exposure to CVD risk factors, and laxative use could be a risk factor for mortality from coronary heart disease and ischemic stroke.

Endovascular Therapy as a Primary Revascularization Modality in Acute Mesenteric Ischemia

PURPOSE

To evaluate endovascular therapy (EVT) as the primary revascularization method for acute mesenteric ischemia (AMI).

METHODS

A retrospective review was performed on all consecutive patients treated for AMI during a 5-year period (January 2009 to December 2013). EVT was attempted in all patients referred for emergent revascularization. Surgical revascularization was performed selectively after failure of EVT. Patient characteristics, clinical presentation, and outcomes were studied. Failures and complications of EVT were recorded.

RESULTS

Fifty patients, aged 79 ± 9 years (mean ± SD), out of 66 consecutive patients with AMI secondary to embolic or thrombotic obstruction of the superior mesenteric artery were referred for revascularization. The etiology of AMI was embolism in 18 (36 %) and thrombosis in 32 (64 %) patients. EVT was technically successful in 44 (88 %) patients. Mortality after successful or failed EVT was 32 %. The rates of emergency laparotomy, bowel resection, and EVT-related complication were 40, 34, and 10 %, respectively. Three out of six patients with failure of EVT were treated with surgical bypass. EVT failure did not significantly affect survival.

CONCLUSIONS

EVT is feasible in most cases of AMI, with favorable patient outcome and acceptable complication rate.

Chronic mesenteric ischemia: Time to remember open revascularization

Chronic mesenteric ischemia is caused by stenosis or occlusion of one or more visceral arteries. It represents a therapeutic challenge and diagnosis and treatment require close interdisciplinary cooperation between gastroenterologist, vascular surgeon and radiologist. Although endovascular treatment modalities have been developed, the number of restenoses ultimately resulting in treatment failure is high. In patients fit for open surgery, the visceral arteries should be revascularized conventionally. These patients will then experience long term relief from the symptoms, a better quality of life and a better overall survival.