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Dreksler H, Nagpal SK, Hajjar G, Roberts DJ. Successful surgical management of a suspected high-flow inferior mesenteric artery aneurysm in a patient with chronic celiac and superior mesenteric artery occlusions. J Vasc Surg Cases Innov Tech 2024; 10:101438. [PMID: 38445064 PMCID: PMC10912906 DOI: 10.1016/j.jvscit.2024.101438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/11/2024] [Indexed: 03/07/2024] Open
Abstract
Inferior mesenteric artery (IMA) aneurysms account for approximately 1% of visceral artery aneurysms and can occur secondary to high flow because of occlusive disease in other mesenteric arteries. We describe the case of a 79-year-old man who presented with a 3.3-cm IMA aneurysm and chronic total occlusions of the celiac artery and superior mesenteric artery (SMA). After an unsuccessful attempt at endovascular SMA recanalization, he underwent an uncomplicated retrograde aorta to SMA bypass and antegrade aorta to IMA bypass. We propose that an aorta to IMA bypass after SMA revascularization is safe and effective to treat suspected high-flow IMA aneurysms.
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Affiliation(s)
- Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Sudhir K. Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - George Hajjar
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Sorour AA, Dehaini H, Alnahhal KI, Khalifeh A, Rowse JW, Quatromoni JG, Caputo FJ, Lyden SP, Kirksey L. Natural history of superior mesenteric artery in-stent restenosis. J Vasc Surg 2024; 79:818-825.e2. [PMID: 38128845 DOI: 10.1016/j.jvs.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence. METHODS Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350. RESULTS The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups. CONCLUSIONS The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.
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Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
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Jacobs CR, Scali ST, Jacobs BN, Filiberto AC, Anderson EM, Fazzone B, Back MR, Upchurch GR, Giles KA, Huber TS. Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia. J Vasc Surg 2024:S0741-5214(24)00515-9. [PMID: 38552885 DOI: 10.1016/j.jvs.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Clinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI. METHODS All patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death. RESULTS A total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death. CONCLUSIONS The perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.
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Affiliation(s)
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
| | - Benjamin N Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Amanda C Filiberto
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Kristina A Giles
- Division of Vascular Surgery, Maine Medical Center, Portland, PE
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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Lehane D, Geiger J, Kedwai B, Zottola Z, Newhall K, Mix D, Doyle A, Stoner M. Long-term value in open and endovascular repair of chronic mesenteric ischemia. J Vasc Surg 2024; 79:55-61. [PMID: 37709177 DOI: 10.1016/j.jvs.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. METHODS Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. RESULTS From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively. CONCLUSIONS Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.
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Affiliation(s)
- Daniel Lehane
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Joshua Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Baqir Kedwai
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Zachary Zottola
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karina Newhall
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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Savlania A, Vaddavalli VV, Abuji K, Ravi A, Maheshwari N, Kaman L, Behera A, Gorsi U. Outcomes of open revascularization for chronic mesenteric ischemia at a tertiary care center in India. Indian J Gastroenterol 2023; 42:833-838. [PMID: 37768446 DOI: 10.1007/s12664-023-01447-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/09/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Chronic mesenteric ischemia (CMI) is a rare, debilitating disease associated with higher morbidity and mortality if not treated on time. In the past two decades, there has been a paradigm shift in its management with endovascular modality due to reduced perioperative morbidity and mortality. In the endovascular era, only a few patients require surgical therapy. We conducted this study to report our experience with open surgical revascularization at our hospital. METHODS We have conducted a retrospective study after obtaining approval from Institutional Ethics Committee. Data regarding patients who underwent open revascularization for CMI with long-segment occlusion from 2016 to 2021 has been retrieved from the institutional database. The demographic data, clinical presentation, type of surgery and graft used, perioperative mortality and morbidity and length of hospital stay were evaluated. Overall survival and disease-free survival were assessed using Kaplan-Meier analysis. RESULTS Twenty-one patients underwent open surgical revascularization; 16 were males and five females. The median age was 43 years. Fourteen (66.7%) were smokers. The mean duration of follow-up was 28.4 ± 13.6 months. Thirty-day postoperative mortality was 0% and morbidity was 28%. The average duration of hospital stay and postoperative weight gain were 6.9 ± 3.7 days and 11 ± 4.9 kgs, respectively. One patient died at two years of follow-up due to myocardial infarction and one had a recurrence. Long-term survival at 60 months of follow-up was 91.6% and the primary-patency rate was 95.2%. CONCLUSION Owing to better long-term and reintervention-free patency, open revascularization should be considered in patients who are fit for surgery, particularly in patients with long-segment mesenteric artery occlusion.
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Affiliation(s)
- Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Venkata Vineeth Vaddavalli
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kishore Abuji
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ashwitha Ravi
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Naveen Maheshwari
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Arunanshu Behera
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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Alnahhal KI, Sorour AA, Lyden SP, Caputo FJ, Park WM, Rowse JW, Quatromoni JG, Khalifeh A, Dehaini H, Bena JF, Kirksey L. Management of patients with chronic mesenteric ischemia across three consecutive eras. J Vasc Surg 2023; 78:1228-1238.e1. [PMID: 37399971 DOI: 10.1016/j.jvs.2023.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. METHODS A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. RESULTS A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). CONCLUSIONS Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Woosup M Park
- Division of Vascular Surgery, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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Cirillo-Penn NC, Lima GB, Colglazier JJ, Mendes BC. Open repair of symptomatic superior mesenteric artery dissection. J Vasc Surg Cases Innov Tech 2023; 9:101255. [PMID: 37635739 PMCID: PMC10448315 DOI: 10.1016/j.jvscit.2023.101255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/01/2023] [Indexed: 08/29/2023] Open
Affiliation(s)
- Nolan C. Cirillo-Penn
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Guilherme B.B. Lima
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Jill J. Colglazier
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
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Ratner M, Muqri F, Garg K. Intravascular lithotripsy for the treatment of inferior mesenteric artery in-stent restenosis. J Vasc Surg Cases Innov Tech 2023; 9:101254. [PMID: 37539441 PMCID: PMC10393793 DOI: 10.1016/j.jvscit.2023.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/30/2023] [Indexed: 08/05/2023] Open
Abstract
Endovascular revascularization with intraluminal stenting is the recommended first-line therapy for chronic mesenteric ischemia. However, early recurrence and in-stent thrombosis remain significant challenges. We present the case of a patient with recurrent chronic mesenteric ischemia secondary to in-stent restenosis that was successfully treated with intravascular lithotripsy, a novel, safe approach to stent salvage.
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Affiliation(s)
| | | | - Karan Garg
- Correspondence: Karan Garg, MD, Division of Vascular Surgery, Department of Surgery, New York University Langone Hospital, 550 First Ave 11th Floor, New York, NY 10016
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Lam A, Kim YJ, Fidelman N, Higgins M, Cash BD, Charalel RA, Guimaraes MS, Kwan SW, Patel PJ, Plett S, Scali ST, Stadtlander KS, Stoner M, Tong R, Kapoor BS. ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia: 2022 Update. J Am Coll Radiol 2022; 19:S433-S444. [PMID: 36436968 DOI: 10.1016/j.jacr.2022.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Mesenteric ischemia is a serious medical condition characterized by insufficient vascular supply to the small bowel. In the acute setting, endovascular interventions, including embolectomy, transcatheter thrombolysis, and angioplasty with or without stent placement, are recommended as initial therapeutic options. For nonocclusive mesenteric ischemia, transarterial infusion of vasodilators, such as papaverine or prostaglandin E1, is the recommended initial treatment. In the chronic setting, endovascular means of revascularization, including angioplasty and stent placement, are generally recommend, with surgical options, such as bypass or endarterectomy, considered alternative options. Although the diagnosis of median arcuate ligament syndrome remains controversial, diagnostic angiography can be helpful in rendering a diagnosis, with the preferred treatment option being a surgical release. Systemic anticoagulation is recommended as initial therapy for venous mesenteric ischemia with acceptable rates of recanalization. If anticoagulation fails, transcatheter thrombolytic infusion can be considered with possible adjunctive placement of a transjugular intrahepatic portosystemic shunt to augment antegrade flow. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alexander Lam
- University of California, San Francisco, San Francisco, California.
| | - Yoon-Jin Kim
- Research Author, University of California, San Francisco, San Francisco, California
| | - Nicholas Fidelman
- Panel Chair, University of California, San Francisco, San Francisco, California
| | - Mikhail Higgins
- Panel Vice-Chair, Boston University School of Medicine, Boston, Massachusetts
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Marcelo S Guimaraes
- Division Chief Pediatric Radiology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Parag J Patel
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sara Plett
- Department of Radiology Chair, Sonoran Crossing Medical Center, Southwest Medical Imaging, Scottsdale, Arizona
| | - Salvatore T Scali
- University of Florida, Gainesville, Florida; Society for Vascular Surgery; SVS PSO VQI EVAR Registry Chair
| | | | - Michael Stoner
- Chief, Division of Vascular Surgery, Vice-Chair, Clinical Operations, University of Rochester Medical Center, Rochester, New York; Society for Vascular Surgery
| | - Ricky Tong
- Main Line Health, Bryn Mawr, Pennsylvania; Peer Review Committee
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Thurner A, Augustin AM, Bley TA, Kickuth R. 2D-perfusion angiography for intra-procedural endovascular treatment response assessment in chronic mesenteric ischemia: a feasibility study. BMC Med Imaging 2022; 22:90. [PMID: 35578260 PMCID: PMC9109376 DOI: 10.1186/s12880-022-00820-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endovascular revascularization has become the first-line treatment of chronic mesenteric ischemia (CMI). The qualitative visual analysis of digital subtraction angiography (DSA) is dependent on observer experience and prone to interpretation errors. We evaluate the feasibility of 2D-Perfusion Angiography (2D-PA) for objective, quantitative treatment response assessment in CMI. METHODS 49 revascularizations in 39 patients with imaging based evidence of mesenteric vascular occlusive disease and clinical signs of CMI were included in this retrospective study. To assess perfusion changes by 2D-PA, DSA-series were post-processed using a dedicated, commercially available software. Regions of interest (ROI) were placed in the pre- and post-stenotic artery segment. In aorto-ostial disease, the inflow ROI was positioned at the mesenteric artery orifice. The ratios outflow to inflow ROI for peak density (PD), time to peak and area-under-the-curve (AUC) were computed and compared pre- and post-interventionally. We graded motion artifacts by means of a four-point scale. Feasibility of 2D-PA and changes of flow parameters were evaluated. RESULTS Motion artifacts due to a mobile vessel location beneath the diaphragm or within the mesenteric root, branch vessel superimposition and inadequate contrast enhancement at the inflow ROI during manually conducted DSA-series via selective catheters owing to steep vessel angulation, necessitated exclusion of 26 measurements from quantitative flow evaluation. The feasibility rate was 47%. In 23 technically feasible assessments, PDoutflow/PDinflow increased by 65% (p < 0.001) and AUCoutflow/AUCinflow increased by 85% (p < 0.001). The time to peak density values in the outflow ROI accelerated only minimally without reaching statistical significance. Age, BMI, target vessel (celiac trunk, SMA or IMA), stenosis location (ostial or truncal), calcification severity, plaque composition or the presence of a complex stenosis did not reach statistical significance in their distribution among the feasible and non-feasible group (p > 0.05). CONCLUSIONS Compared to other vascular territories and indications, the feasibility of 2D-PA in mesenteric revascularization for CMI was limited. Unfavorable anatomic conditions contributed to a high rate of inconclusive 2D-PA results.
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Affiliation(s)
- Annette Thurner
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Anne Marie Augustin
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Ralph Kickuth
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Roberts GS, François CJ, Starekova J, Roldán-Alzate A, Wieben O. Non-invasive assessment of mesenteric hemodynamics in patients with suspected chronic mesenteric ischemia using 4D flow MRI. Abdom Radiol (NY) 2022; 47:1684-98. [PMID: 33547918 DOI: 10.1007/s00261-020-02900-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Chronic mesenteric ischemia (CMI) is a rare disease with a particularly difficult diagnosis. In this study, 4D flow MRI is used to quantitatively evaluate mesenteric hemodynamics before and after a meal in patients suspected of having CMI and healthy individuals. METHODS Nineteen patients suspected of CMI and twenty control subjects were analyzed. Subjects were scanned using a radially undersampled 4D flow MR sequence (PC-VIPR). Flow rates were assessed in the supraceliac (SCAo) and infrarenal aorta, celiac artery, superior mesenteric artery (SMA), left and right renal arteries, superior mesenteric vein (SMV), splenic vein, and portal vein (PV) in a fasting state (preprandial) and 20 min after a 700-kcal meal (postprandial). Patients were subcategorized into positive diagnosis (CMI+, N = 6) and negative diagnosis (CMI-, N = 13) groups based on imaging and clinical findings. Preprandial, postprandial, and percent change in flow rates were compared between subgroups using a Welch t test. RESULTS In controls and CMI- patients, SCAo, SMA, SMV, and PV flow increased significantly after meal ingestion. No significant flow increases were observed in CMI+ patients. Percent changes in SMA, SMV, and PV flow were significantly greater in controls compared to CMI+ patients. Additionally, percent changes in flow in the SMV and PV were significantly greater in CMI- patients compared to CMI+ patients. CONCLUSIONS 4D flow MRI with large volumetric coverage demonstrated significant differences in the redistribution of blood flow in SMA, SMV, and PV in CMI+ patients after a meal challenge. This approach may assist in the challenging diagnosis of CMI.
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Wolk S, Kapalla M, Ludwig S, Radosa C, Hoffmann RT, Weitz J, Reeps C. Surgical and endovascular revascularization of chronic mesenteric ischemia. Langenbecks Arch Surg 2022. [PMID: 35182180 DOI: 10.1007/s00423-022-02462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2022] [Indexed: 11/05/2022]
Abstract
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.
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Olson KA, Teixeira PG. Mesenteric Ischemia: When and How to Revascularize. Adv Surg 2021; 55:75-87. [PMID: 34389101 DOI: 10.1016/j.yasu.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kristofor A Olson
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, 1500 Red River Street, Annex, Austin, TX 78701, USA
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, 1500 Red River Street, Annex, Austin, TX 78701, USA.
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Abstract
Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.
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Affiliation(s)
- Monjur Ahmed
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA 19107, United States
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Balboa Arregui O, Seoane Pose C, Balboa Alonso M, Bolaño Pampín T. Use of Shockwave intravascular lithotripsy for the treatment of symptomatic and severely calcified superior mesenteric artery stenosis. CVIR Endovasc 2021; 4:53. [PMID: 34128127 PMCID: PMC8203768 DOI: 10.1186/s42155-021-00243-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We present the use of intravascular lithotripsy as a treatment for highly calcified superior mesenteric artery stenosis. CASE PRESENTATION A 67-year-old diabetic man had chronic postprandial abdominal pain and weight loss. Computed tomography angiography revealed highly calcified stenosis of the superior mesenteric artery. Selective angiography confirmed severe stenosis. A Shockwave lithotripsy balloon catheter was successfully used via brachial access to modify calcified plaque and increase vascular lumen. After 12 months of follow-up the patient had gained weight and had no abdominal postprandial pain. CONCLUSION Intravascular lithotripsy could be considered a new treatment modality to modify calcified lesions in the visceral arteries. More controlled studies are needed to demonstrate the efficacy, safety and feasibility of this new technology. LEVEL OF EVIDENCE 4, Case Report.
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Affiliation(s)
- Oscar Balboa Arregui
- Division of Vascular and Interventional Radiology, Department of Radiology, Hospital Universitario de León, León, Spain.
| | - Carmen Seoane Pose
- Division of Vascular and Interventional Radiology, Department of Radiology, Hospital Clínico Universitario de Santiago de Compostela, A Coruña, Spain
| | | | - Teresa Bolaño Pampín
- Division of Vascular and Interventional Radiology, Department of Radiology, Hospital Clínico Universitario de Santiago de Compostela, A Coruña, Spain
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Abstract
Chronic mesenteric ischemia (CMI) is an uncommon, potentially underdiagnosed clinical condition. Although there is a high prevalence of mesenteric artery stenoses (MAS), an abundant collateral network in the mesenteric circulation mitigates occurrence of ischemia. The most common etiology of CMI is atherosclerosis. CMI is a clinical diagnosis, based upon typical and atypical symptoms and consistent anatomic findings. Typical symptoms of CMI are postprandial abdominal pain, unintended weight loss and food avoidance. The main modalities to diagnose MAS are duplex ultrasound, CT angiography or MR angiography, although high resolution CTA is preferred. Endovascular therapy with balloon expandable stents has become the preferred treatment for MAS.
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Affiliation(s)
- Partha Sardar
- Department of Cardiovascular Diseases, The John Ochsner Heart and Vascular Institute, The Ochsner Clinical School, University of Queensland, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, United States of America
| | - Christopher J White
- Department of Cardiovascular Diseases, The John Ochsner Heart and Vascular Institute, The Ochsner Clinical School, University of Queensland, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, United States of America.
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Mokhtari S, Abualtayef T, El Arabi S, Ben Chaib R, Benzirar A, El Mahi O. Acute Abdominal Compartment Syndrome complicating a chronic mesenteric ischemia revascularization. Int J Surg Case Rep 2021; 81:105801. [PMID: 33770634 PMCID: PMC8024655 DOI: 10.1016/j.ijscr.2021.105801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Abdominal Compartment Syndrome (ACS) is a pathological condition that results from an increase in pressure within the abdomen associated with organ failure. It can be acute or chronic, primary or secondary. ACS poses a serious diagnostic challenge for physicians as the clinical presentation is varied and can mimic other medical pathologies. To prevent a multi-organ failure and ultimately death due to this disease, the World Society of Abdominal Compartment Syndrome (WSACS) suggested clinical criteria and biology tests to facilitate an early diagnosis of acute ACS. CASE PRESENTATION We report a case of 61 year-old man diagnosed with chronic mesenteric ischemia that has been successfully treated by prosthetic bypass. The postoperative period was eventual, the patient presented complications corresponding essentially to a manifest acute ACS. The treatment consisted on abdominal decompression and resuscitation measures. CONCLUSIONS An early diagnosis of ACS disease for an appropriate therapeutic initiation is mandatory to prevent its complications and save the patient's life prognosis.
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Affiliation(s)
- Sara Mokhtari
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Morocco; Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco.
| | - Taha Abualtayef
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Morocco; Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco.
| | - Soumia El Arabi
- Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco; Radiology Department, Mohammed VI University Hospital Center, Oujda, Morocco.
| | - Rajae Ben Chaib
- Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco; Emergency and Anesthesiology Department, Mohammed VI University Hospital Center, Oujda, Morocco.
| | - Adnane Benzirar
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Morocco; Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco.
| | - Omar El Mahi
- Vascular Surgery Department, Mohammed VI University Hospital Center, Oujda, Morocco; Mohammed 1st University, Faculty of Medicine and Pharmacy of Oujda, Morocco.
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18
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Girault A, Pellenc Q, Roussel A, Senemaud J, Cerceau P, Maggiori L, Huguet A, Corcos O, Ben Abdallah I, Castier Y. Midterm results after covered stenting of the superior mesenteric artery. J Vasc Surg 2021; 74:902-909.e3. [PMID: 33684478 DOI: 10.1016/j.jvs.2021.02.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. METHODS Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. RESULTS During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. CONCLUSIONS Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.
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Affiliation(s)
- Antoine Girault
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France.
| | - Quentin Pellenc
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Arnaud Roussel
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Jean Senemaud
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Pierre Cerceau
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Léon Maggiori
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de chirurgie viscérale, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Audrey Huguet
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Olivier Corcos
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Iannis Ben Abdallah
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Yves Castier
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
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Kersjes WH, Hesse A. Percutaneous retrograde revascularization of chronic occlusions of the superior mesenteric artery via collaterals of the celiac artery. CVIR Endovasc 2020; 3:81. [PMID: 33188614 PMCID: PMC7666649 DOI: 10.1186/s42155-020-00170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/06/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose To evaluate the technical success of percutaneous retrograde revascularization of the superior mesenteric artery (SMA) via the celiac artery (CA) in patients with chronic mesenteric ischemia (CMI). Methods We performed a retrospective review of three patients with chronic total occlusions (CTOs) of the origin of SMA which were recanalized retrograde via collaterals of the CA after frustrating attempt of antegrade revascularization from the abdominal aorta in our institute between May 2019 and June 2020. Results All technical procedures of retrograde revascularization of CTOs of SMA via collaterals of the CA were successful. The clinical outcome resulted in a sustained resolution of abdominal pain in all cases. Conclusion Retrograde recanalization of SMA via collaterals from the CA seems to be a successful endovascular option for patients with CMI and a chronically occluded superior mesenteric artery when antegrade recanalization fails as far as it can be concluded from the small number of presented cases.
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Affiliation(s)
- Wilhelm H Kersjes
- Institute of Diagnostic and Interventional Radiology, Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany.
| | - Alexander Hesse
- Institute of Diagnostic and Interventional Radiology, Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
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Abstract
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.
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Affiliation(s)
| | - Paul Feuerstadt
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA. .,Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, CT, USA.
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21
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Abstract
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.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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22
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Van Damme H, Boesmans E, Creemers E, Defraigne JO. How to manage chronic mesenteric ischemia? A deliberated strategy. Acta Chir Belg 2020; 120:1-5. [PMID: 31580204 DOI: 10.1080/00015458.2019.1675971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.
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Affiliation(s)
- Hendrik Van Damme
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Evelyne Boesmans
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Etienne Creemers
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
| | - Jean-Olivier Defraigne
- CHU Liège, Department of Cardiovascular and Thoracic Surgery, University Hospital Sart-Tilman, Liège, Belgium
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Bakoyiannis C, Mylonas KS, Davakis S, Tsaples G, Karaolanis G, Liakakos T. Superior mesenteric artery endarterectomy for chronic mesenteric ischemia: A viable alternative in poor candidates for endovascular interventions. Vascular 2019; 28:126-131. [PMID: 31699006 DOI: 10.1177/1708538119887567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Christos Bakoyiannis
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Davakis
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsaples
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Georgios Karaolanis
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Liakakos
- First Department of Surgery, Division of Vascular Surgery, Laiko General Hospital, National Kapodistrian University of Athens, Athens, Greece
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Farooq M, Greben C, Frankini L, Gandras E. The use of an upper extremity hemodialysis access site for stenting of the superior mesenteric artery for chronic mesenteric ischemia. J Vasc Surg Cases Innov Tech 2019; 5:406-409. [PMID: 31660460 PMCID: PMC6806649 DOI: 10.1016/j.jvscit.2019.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/05/2019] [Indexed: 11/25/2022]
Abstract
We report the use of an upper extremity hemodialysis access site to facilitate endovascular treatment of the superior mesenteric artery in the setting of chronic mesenteric ischemia. A 64-year-old woman with end-stage renal disease on hemodialysis presented with worsening symptoms associated with chronic mesenteric ischemia. Her left upper extremity interposition graft within the fistula access site was selected to avoid a hostile aortoiliac system and in consideration of the potential benefits it provided over transfemoral, transbrachial, and transradial sites. The procedure was technically successful without complication. Hemodialysis access sites, such as the interposition graft within the fistula of this patient, are a potential route of upper extremity access for mesenteric interventions in patients with end-stage renal disease on hemodialysis.
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Affiliation(s)
- Mobeen Farooq
- Division of Vascular and Interventional Radiology, Department of Radiology, North Shore University Hospital, Manhasset, NY
| | - Craig Greben
- Division of Vascular and Interventional Radiology, Department of Radiology, North Shore University Hospital, Manhasset, NY
| | - Larry Frankini
- Division of Vascular Surgery, Department of Surgery, North Shore University Hospital, Manhasset, NY
| | - Eric Gandras
- Division of Vascular and Interventional Radiology, Department of Radiology, North Shore University Hospital, Manhasset, NY
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Berge ST, Safi N, Medhus AW, Ånonsen K, Sundhagen JO, Hisdal J, Kazmi SSH. Gastroscopy assisted laser Doppler flowmetry and visible light spectroscopy in patients with chronic mesenteric ischemia. Scand J Clin Lab Invest 2019; 79:541-549. [PMID: 31560225 DOI: 10.1080/00365513.2019.1672084] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Simen T Berge
- Department of Vascular Surgery, Oslo University Hospital HF , Oslo , Norway
| | - Nathkai Safi
- Faculty of Medicine, University in Oslo , Oslo , Norway
| | - Asle W Medhus
- Department of Gastroenterology, Oslo University Hospital HF , Oslo , Norway
| | - Kim Ånonsen
- Department of Gastroenterology, Oslo University Hospital HF , Oslo , Norway
| | - Jon O Sundhagen
- Department of Vascular Surgery, Oslo University Hospital HF , Oslo , Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Oslo University Hospital HF , Oslo , Norway.,Faculty of Medicine, University in Oslo , Oslo , Norway
| | - Syed S H Kazmi
- Department of Vascular Surgery, Oslo University Hospital HF , Oslo , Norway
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26
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Ben Hammamia M, Ben Mrad M, Hadhri S, Tarzi M, Miri R, Ghedira F, Derbel B, Ben Omrane S, Kalfat T, Ziadi J, Denguir R. [Endovascular treatment of chronic mesenteric ischemia]. J Med Vasc 2019; 44:318-323. [PMID: 31474341 DOI: 10.1016/j.jdmv.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/11/2019] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- M Ben Hammamia
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie.
| | - M Ben Mrad
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - S Hadhri
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - M Tarzi
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - R Miri
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - F Ghedira
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - B Derbel
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - S Ben Omrane
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - T Kalfat
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - J Ziadi
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
| | - R Denguir
- Service de chirurgie cardiovasculaire La Rabta, université de Tunis El Manar, Tunis, Tunisie
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van Dijk LJD, Harki J, van Noord D, Verhagen HJM, Kolkman JJ, Geelkerken RH, Bruno MJ, Moelker A. Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): study protocol for a randomized controlled trial. Trials 2019; 20:519. [PMID: 31429792 PMCID: PMC6700968 DOI: 10.1186/s13063-019-3609-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
Background Chronic mesenteric ischemia (CMI) is the result of insufficient blood supply to the gastrointestinal tract and is caused by atherosclerotic stenosis of one or more mesenteric arteries in > 90% of cases. Revascularization therapy is indicated in patients with a diagnosis of atherosclerotic CMI to relieve symptoms and to prevent acute-on-chronic mesenteric ischemia, which is associated with high morbidity and mortality. Endovascular therapy has rapidly evolved and has replaced surgery as the first choice of treatment in CMI. Bare-metal stents (BMS) are standard care currently, although retrospective studies suggested significantly higher patency rates for covered stents (CS). The Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI) trial is designed to prospectively assess the patency of CS versus BMS in patients with atherosclerotic CMI. Methods/design The CoBaGI trial is a randomized controlled, parallel-group, patient- and investigator-blinded, superiority, multicenter trial conducted in six centers of the Dutch Mesenteric Ischemia Study group (DMIS). Eighty-four patients with a consensus diagnosis of atherosclerotic CMI are 1:1 randomized to either a balloon-expandable BMS (Palmaz Blue with rapid-exchange delivery system, Cordis Corporation, Bridgewater, NJ, USA) or a balloon-expandable CS (Advanta V12 over-the-wire, Atrium Maquet Getinge Group, Hudson, NH, USA). The primary endpoint is the primary stent-patency rate at 24 months assessed with CT angiography. Secondary endpoints are primary stent patency at 6 and 12 months and secondary patency rates, freedom from restenosis, freedom from symptom recurrence, freedom from re-intervention, quality of life according the EQ-5D-5 L and SF-36 and cost-effectiveness at 6, 12 and 24 months. Discussion The CoBaGI trial is designed to assess the patency rates of CS versus BMS in patients treated for CMI caused by atherosclerotic mesenteric stenosis. Furthermore, the CoBaGI trial should provide insights in the quality of life of these patients before and after stenting and its cost-effectiveness. The CoBaGI trial is the first randomized controlled trial performed in CMI caused by atherosclerotic mesenteric artery stenosis. Trial registration ClinicalTrials.gov, ID: NCT02428582. Registered on 29 April 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3609-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louisa J D van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands. .,Department of Radiology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Jihan Harki
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands.,TechMed Centre, Faculty Science and Technology, University Twente, Postbus 50 000, 7500 KA, Enschede, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Ischemic disorders of the small bowel represent a rare but highly morbid disease process which is often difficult to diagnose and has a complex management course involving multidisciplinary care. Given recent advances in radiologic modalities and surgical/endovascular techniques, this review seeks to provide a disease overview as well as a summary of emerging management strategies. RECENT FINDINGS In cases of acute mesenteric ischemia without evidence of frank bowel necrosis, an endovascular-first strategy employing thrombolysis, pharmacomechanical thrombectomy, and/or adjunctive angioplasty/stenting has been shown to have positive outcomes. In cases requiring open laparotomy, retrograde open mesenteric stenting may facilitate less dissection and more straightforward revascularization. While endovascular intervention for chronic mesenteric ischemia was historically limited by high rates of restenosis, use of covered stents in these vascular beds has been shown to have excellent patency rates. Ischemia of the small bowel can be acute or chronic in nature-endovascular treatment modalities have been shown to have excellent results given appropriate patient selection and should be an important tool in the armamentarium of management options for this complex disease process.
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Affiliation(s)
- Vivek S Prakash
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Michael Marin
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY, USA.
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29
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Ubbink R, van Dijk LJD, van Noord D, Johannes T, Specht PAC, Bruno MJ, Mik EG. Evaluation of endoscopic visible light spectroscopy: comparison with microvascular oxygen tension measurements in a porcine model. J Transl Med 2019; 17:65. [PMID: 30819196 DOI: 10.1186/s12967-019-1802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/17/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Visible light spectroscopy (VLS) is a technique used to measure the mucosal oxygen saturation during upper gastrointestinal endoscopy to evaluate mucosal ischemia, however in vivo validation is lacking. We aimed to compare VLS measurements with a validated quantitative microvascular oxygen tension (μPO2) measurement technique. METHODS Simultaneous VLS measurements and μPO2 measurements were performed on the small intestine of five pigs. First, simultaneous measurements were performed at different FiO2 values (18%-100%). Thereafter, the influence of bile was assessed by comparing VLS measurements in the presence of bile and without bile. Finally, simultaneous VLS and μPO2 measurements were performed from the moment a lethal dose potassium chloride intravenously was injected. RESULTS In contrast to μPO2 values that increased with increasing FiO2, VLS values decreased. Both measurements correlated poorly with R2 = 0.39, intercept 18.5, slope 0.41 and a bias of - 16%. Furthermore, the presence of bile influenced VLS values significantly (median (IQR)) before bile application 57.5% (54.8-59.0%) versus median with bile mixture of the stomach 73.5% (66.8-85.8), p = < 2.2 * 10-16; median with bile mixture of small bowel 47.6% (41.8-50.8) versus median after bile removal 57.0% (54.7-58.6%), p = < 2.2 * 10-16). Finally, the VLS mucosal oxygen saturation values did not decrease towards a value of 0 in the first 25 min of asystole in contrast to the μPO2 values. CONCLUSIONS These results suggest that VLS measures the mixed venous oxygen saturation rather than mucosal capillary hemoglobin oxygen saturation. Further research is needed to establish if the mixed venous compartment is optimal to assess gastrointestinal ischemia.
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Date Y, Katoh H, Abe T, Nagamine H, Hara H, Kawase Y. Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery. CVIR Endovasc 2019; 1:18. [PMID: 30652149 PMCID: PMC6319509 DOI: 10.1186/s42155-018-0025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background Endovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation. Case presentation An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15-30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient's symptoms. Conclusions CMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.
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Affiliation(s)
- Yusuke Date
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hiromasa Katoh
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Takatoshi Abe
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hirhoshi Nagamine
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hiroiku Hara
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Yushi Kawase
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
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van Dijk LJ, van Noord D, de Vries AC, Kolkman JJ, Geelkerken RH, Verhagen HJ, Moelker A, Bruno MJ. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J 2018; 7:179-188. [PMID: 31080602 PMCID: PMC6498801 DOI: 10.1177/2050640618817698] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/15/2018] [Indexed: 12/26/2022] Open
Abstract
This
This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, ‘s-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.
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Affiliation(s)
- Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Annemarie C de Vries
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,Technical Medical Center, Faculty Science and Technology, University Twente, Enschede, the Netherlands
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Acar T, Çakır V, Acar N, Atahan K, Hacıyanlı M. Chronic visceral ischemia: An unusual cause of abdominal pain. Turk J Surg 2018; 34:158-161. [PMID: 30023986 DOI: 10.5152/turkjsurg.2017.3205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 08/30/2015] [Indexed: 11/22/2022]
Abstract
Chronic visceral ischemia is described as postprandial abdominal pain caused by intestinal hypoperfusion. Chronic visceral ischemia arising from the stenosis of major mesenteric arteries can cause death. Chronic abdominal pain, weight loss, and sitophobia are the major symptoms. The main cause of chronic visceral ischemia is atherosclerosis; Doppler ultrasonography, tomographic angiography, and magnetic resonance angiography can be used for diagnosis. The gold standard method is mesenteric catheterized angiography. Surgical bypass or endovascular balloon angioplasty and stent replacement can also be performed to prevent serious complications and death. A total of three patients, two male and one female, applied to emergency services with blunt abdominal pain lasting a few hours that started after meals and was located in the epigastric and periumblical regions. The patients were diagnosed with chronic visceral ischemia after screening tests and physical examination. Mesenteric catheterized angiography was performed immediately in all the cases. Balloon angioplasty and stent replacement were performed on the stenoses, and occlusions were detected. Mesenteric catheterized angiography may be preferred in cases with strong clinical suspicion; balloon angioplasty and stent replacement can also be used as treatments with lower rates of complications.
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Affiliation(s)
- Turan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Volkan Çakır
- Department of Interventional Radiology, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Nihan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Kemal Atahan
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Mehmet Hacıyanlı
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
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van Dijk LJD, van der Wel T, van Noord D, Moelker A, Verhagen HJM, Nieboer D, Kuipers EJ, Bruno MJ. Intraobserver and interobserver reliability of visible light spectroscopy during upper gastrointestinal endoscopy. Expert Rev Med Devices 2018; 15:605-610. [PMID: 29973094 DOI: 10.1080/17434440.2018.1496818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Louisa J D van Dijk
- a Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands.,b Department of Radiology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Twan van der Wel
- a Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Desirée van Noord
- a Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands.,c Department of Gastroenterology and Hepatology , Franciscus Gasthuis & Vlietland , Rotterdam , The Netherlands
| | - Adriaan Moelker
- b Department of Radiology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Hence J M Verhagen
- d Department of Vascular Surgery , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Daan Nieboer
- e Department of Public Health , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Ernst J Kuipers
- a Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Marco J Bruno
- a Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
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Gutsche H, Will U, Venth S, Lesser T. [Operative revascularization of visceral arteries in chronic mesenteric ischemia]. Chirurg 2018; 89:605-611. [PMID: 29808329 DOI: 10.1007/s00104-018-0650-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic mesenteric ischemia (CMI) is mostly the result of atherosclerotic occlusive processes of unpaired mesenteric arteries. Operative procedures are preferred in cases of occlusion of a long vessel segments and/or highly calcified stenoses near the ostium. Frequently, bypasses are constucted from the aorta to visceral arteries and autologous veins should be preferred. Due to atherosclerotic alterations aortic bypass anastomoses are difficult and prone to complications. Based on case descriptions a surgical technique is presented that simplifies the aortovisceral artery bypass procedure. In all 6 patients the bypasses were open after 27 months and the average increase in body weight was 13 kg within the first postoperative 6 months.
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Affiliation(s)
- H Gutsche
- Klinik für Thorax- und Gefäßchirurgie, Angiologie, SRH Wald-Klinikum Gera, Str. des Friedens 122, 07548, Gera, Deutschland
| | - U Will
- Klinik für Gastroenterologie, Hepatologie und Allgemeine Innere Medizin, SRH Wald-Klinikum Gera, Gera, Deutschland
| | - S Venth
- Klinik für Thorax- und Gefäßchirurgie, Angiologie, SRH Wald-Klinikum Gera, Str. des Friedens 122, 07548, Gera, Deutschland
| | - T Lesser
- Klinik für Thorax- und Gefäßchirurgie, Angiologie, SRH Wald-Klinikum Gera, Str. des Friedens 122, 07548, Gera, Deutschland.
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Abstract
Mesenteric ischemia is an uncommon disease most often seen in the elderly. This disease results from blood flow in the mesenteric circulation that inadequately meets metabolic needs of the visceral organs and, if untreated, eventually leads to necrosis of the bowel wall. Mesenteric ischemia is divided into 2 types: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Delayed diagnosis of CMI can lead to AMI. AMI is associated with extremely high mortalities. Early diagnosis via computed tomography angiography and prompt revascularization via endovascular therapy are recommended for symptomatic patients who have not developed bowel ischemia and necrosis.
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Affiliation(s)
- Robin M Lawson
- Academic Programs, The University of Alabama, Capstone College of Nursing, 650 University Boulevard, East, Tuscaloosa, AL 35401, USA.
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Abstract
The incidence of atherosclerotic mesenteric ischemia increases gradually with the aging of the population and rising of the incidence of atherosclerosis. In the last decade, mesenteric atherosclerosis has become the most common cause of acute and chronic mesenteric ischemia. Atherosclerotic mesenteric ischemia often presents with an insidious onset and slow evolvement, and is easily overlooked. The CT manifestations of advanced mesenteric ischemia are classic with high diagnostic accuracy, and the specific findings of CT angiography include: thromboembolus and stenotic or occlusive mesenteric artery in acute stage, single or multiple calcified or non-calcified plaques, and multiple stenotic and stiff mesenteric arteries with reduced branching vessels in chronic stage. Early mesenteric ischemia, however, has no or nonspecific CT sign and is difficult to detect. This article discusses the diagnostic value and limitations of multi-slice CT in atherosclerotic mesenteric ischemia as well as some new imaging techniques for diagnosis of this condition.
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Affiliation(s)
- Xiao-Jun Ren
- Department of Radiology, Xidian Group Hospital Affiliated to Shaanxi University of Chinese Medicine, Xi'an 710077, Shaanxi Province, China
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Wagenhäuser MU, Meyer-Janiszewski YK, Dueppers P, Spin JM, Floros N, Schelzig H, Duran M. Chronic Mesenteric Ischemia: Patient Outcomes Using Open Surgical Revascularization. Dig Surg 2017; 34:340-349. [PMID: 28301853 DOI: 10.1159/000464413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/18/2017] [Indexed: 12/10/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) is a rare disease. Open treatment (OT) remains a valuable treatment option. We analyzed patient outcomes after OT and investigated health-related quality of life (HRQoL). METHODS Data were analyzed retrospectively. The investigation period was from January 1, 2001, to December 31, 2014. We investigated mortality and patency rates using Kaplan-Meier analysis. HRQoL was measured using a 36-item health survey. Various statistical methods were employed. RESULTS A total of 100 patients (celiac trunk [TC: n = 23], superior mesenteric artery [SMA: n = 26], or both [n = 51]) were included. Median follow-up was 5 ± 35 months. One-year survival rate for TC was 75 ± 11%, for SMA: 79 ± 10%, and for both: 96 ± 3%. TC 5-year survival was 75 ± 11% (SMA: 57 ± 16%: both: 80 ± 8%). Obesity and the length of hospital stay were independently associated with patient survival (p < 0.05). Primary 1-year patency rate was 60 ± 13% for TC (SMA: 86 ± 10%; both: 71 ± 8%) and secondary 1-year patency rate was 84 ± 9% for TC (SMA: 100%; both: 79 ± 7%). HRQoL was inferior compared to the German normative data (p < 0.05). CONCLUSION CMI overlaps between gastrointestinal and vascular surgery. OT is safe, and simultaneous revascularization of the TC and the SMA does not affect mortality. Patients would not necessarily benefit from OT in terms of HRQoL.
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Affiliation(s)
- Markus U Wagenhäuser
- Department of Vascular and Endovascular Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Murakami Y, Toya N, Fukushima S, Ito E, Akiba T, Ohki T. Ascending aorta-common hepatic artery bypass for mesenteric revascularization. Int J Surg Case Rep 2017; 32:51-3. [PMID: 28235651 DOI: 10.1016/j.ijscr.2017.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/24/2022] Open
Abstract
We report the case of a patient who underwent hemodialysis because of a bilateral renal occlusion. He also had occlusion of the superior mesenteric artery and stenosis of the celiac artery. We performed antegrade bypass using great saphenous vein from the ascending aorta to the common hepatic artery. The bypass remained patent 20 months after the procedure, and the patient was asymptomatic. There is no report using the common hepatic artery as a revascularization outflow in patients with CMI.
Introduction Chronic aortic occlusion usually occurs from the infrarenal branch to the terminal aorta. We report the case of a patient with an occlusion that began at the suprarenal artery, and there was also occlusion of the superior mesenteric artery and extreme stenosis of the celiac artery. Antegrade bypass from the ascending aorta to the common hepatic artery was performed. Presentation of case A 59-year-old patient presented to our hospital with uremia due to acute anuric renal failure and anorexia. CT revealed long-segment occlusion of the thoracoabdominal aorta including the superior mesenteric artery and bilateral renal arteries. Additionally, there was high-grade stenosis in the celiac artery. We treated the patient using an antegrade bypass from the ascending aorta to the common hepatic artery. His recovery and postoperative course were uneventful. Antegrade bypass from the ascending aorta is an effective alternative for patients who have visceral ischemia. Discussion A recent study showed that surgical revascularization for chronic mesenteric ischemia (CMI) provides good midterm patency and mortality. Descending aorta or the common iliac artery is usually used as an inflow. In our patient, we decided to use the ascending aorta to provide more absolute flow, and the CHA was used as an outflow because it was easy to expose. To our knowledge, there is no report of using the CHA as a revascularization outflow for patients with CMI. Conclusion In an extensively occluded aorta, the ascending aorta is an excellent alternate inflow for revascularization of the mesenteric artery.
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van Noord D, Kolkman JJ. Functional testing in the diagnosis of chronic mesenteric ischemia. Best Pract Res Clin Gastroenterol 2017; 31:59-68. [PMID: 28395789 DOI: 10.1016/j.bpg.2016.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/03/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Chronic mesenteric ischemia (CMI) results from insufficient oxygen delivery or utilization to meet metabolic demand. Two main mechanisms may lead to mesenteric ischemia: occlusion in the arteries or veins of the gastrointestinal tract, or reduced blood flow from shock states or increased intra-abdominal pressure, so-called non-occlusive mesenteric ischemia. Severe stenoses in the three main mesenteric vessels as demonstrated with CT-angiography or MR-angiography are sufficient to proof mesenteric ischemia, for example in patients who present with weight loss, postprandial pain and diarrhea. Still in many clinical situations mesenteric ischemia is only one of many possible explanations. Especially in patients with a single vessel stenosis in the celiac artery or superior mesenteric artery with postprandial pain, mesenteric ischemia remains a diagnosis of probability or assumption without functional proof of actual ischemia. This review is aimed to provide an overview of all past, present and future ways to functionally proof CMI.
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Affiliation(s)
- Desirée van Noord
- Erasmus MC University Medical Center Rotterdam, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands; Franciscus Gasthuis & Vlietland, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands.
| | - Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology and Hepatology, Enschede, The Netherlands; Universitair Medisch Centrum Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands.
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Kolkman JJ, Geelkerken RH. Diagnosis and treatment of chronic mesenteric ischemia: An update. Best Pract Res Clin Gastroenterol 2017; 31:49-57. [PMID: 28395788 DOI: 10.1016/j.bpg.2017.01.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 01/17/2017] [Accepted: 01/30/2017] [Indexed: 02/06/2023]
Abstract
Although the prevalence of mesenteric artery stenoses (MAS) is high, symptomatic chronic mesenteric ischemia (CMI) is rare. The collateral network in the mesenteric circulation, a remnant of the extensive embryonal vascular network, serves to prevent most cases of ischemia. This explains the high incidence of MAS and relative rarity of cases of CMI. The number of affected vessels is the major determinant in CMI development. Most subjects with single vessel mesenteric stenosis do not develop ischemic complaints. Our experience is that most subjects with CA and SMA stenoses with abdominal complaints have CMI. A special mention should be made on patients with median arcuate ligament compression (MALS). There is ongoing debate whether the intermittent compression, caused by respiration movement, can cause ischemic complaints. The arguments pro and con treatment of MALS will be discussed. The clinical presentation of CMI consists of postprandial pain, weight loss, and an adapted eating pattern caused by fear of eating. In end-stage disease more continuous pain, diarrhea or a dyspepsia-like presentation can be observed. Workup of patients suspected for CMI consists of three elements: the anamnesis, the vascular anatomy and proof of ischemia. The main modalities to establish mesenteric vessel patency are duplex ultrasound, CT angiography or MR angiography. Assessing actual ischemia is still challenging, with only tonometry and visual light spectroscopy as tested candidates. Treatment consists of limiting metabolic demand, treatment of the atherosclerotic process and endovascular or operative revascularisation. Metabolic demand can be reduced by using smaller and more frequent meals, proton pump inhibition. Treatment of the atherosclerotic process consists of cessation of smoking, treatment of dyslipidemia, hypertension, hyperglycaemia, and medication with trombocyte aggregation inhibitors.
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Affiliation(s)
- Jeroen J Kolkman
- Medisch Spectrum Twente, Department of Gastroenterology, Enschede, The Netherlands; University Medical Center Groningen, Department of Gastroenterology, Groningen, The Netherlands.
| | - Robert H Geelkerken
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, The Netherlands; University of Twente, Faculty of Science and Technology, Enschede, The Netherlands.
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41
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van Dijk LJ, van Petersen AS, Moelker A. Vascular imaging of the mesenteric vasculature. Best Pract Res Clin Gastroenterol 2017; 31:3-14. [PMID: 28395786 DOI: 10.1016/j.bpg.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 10/31/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023]
Abstract
Imaging of the mesenteric vasculature is crucial in diagnosing vascular disease of the gastro-intestinal tract such as acute or chronic mesenteric ischemia caused by arterial stenosis, embolism or thrombosis, mesenteric vein thrombosis and mesenteric aneurysm or dissection. The reference standard for imaging of the mesenteric vasculature is digital subtraction angiography. However, modalities as duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are developing rapidly and may provide accurate imaging non-invasively. This review provides an up-to-date overview of the anatomic resolution, clinical application, emerging techniques and future perspectives of these four radiological modalities for imaging of the mesenteric vasculature.
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42
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Kamana VK, Shetty R, Krishnan AM, Rao MS, Malpe UP. Abdominal Angina Treated by Urgent Percutaneous Angioplasty: An Excellent Alternative to Surgical Revascularisation. J Clin Diagn Res 2017; 10:OD03-OD04. [PMID: 28050424 DOI: 10.7860/jcdr/2016/20577.8779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/23/2016] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Vamsi Krishna Kamana
- Fellow in Interventional Cardiology, Department of Cardiology, Kasturba Medical College , Manipal, Karnataka, India
| | - Ranjan Shetty
- Professor, Department of Cardiology, Kasturba Medical College , Manipal, Karnataka, India
| | - Anand M Krishnan
- Student, Department of Cardiology, Kasturba Medical College , Manipal, Karnataka, India
| | - M Sudhakar Rao
- Resident, Department of Cardiology, Kasturba Medical College , Manipal, Karnataka, India
| | - Umesh Pai Malpe
- Assistant Professor, Department of Cardiology, Kasturba Medical College , Manipal, Karnataka, India
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Abe S, Yamakawa T, Kawashima H, Yoshida M, Takanashi S, Kashiyama M, Ishigooka M, Shingu Y, Matsui Y. Surgery for acute exacerbation of chronic mesenteric ischemia: a case report. Surg Case Rep 2016; 2:146. [PMID: 27921277 PMCID: PMC5138179 DOI: 10.1186/s40792-016-0272-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) is a rare disease; however, symptomatic CMI has a risk of acute exacerbation without timely revascularization. CASE PRESENTATION A 54-year-old man who had had postprandial pain for 6 months was admitted to our hospital because of vomiting and diarrhea. Although the celiac and superior mesenteric arteries were occluded at the proximal portion, contrast enhancement of the bowel wall was good in contrast-enhanced computed tomography (CECT). Endoscopic examination revealed only a healed gastric ulcer and slight mucosal erosions in the colon. He was diagnosed as having acute enteritis or inflammatory digestive disease and observed with conservative therapy, which improved his acute symptoms. On hospitalization day 42, he suddenly complained of lower back pain. CECT showed abdominal free air, which indicated gastrointestinal perforation. Emergency surgery was performed for jejunum resection. Two days later, a second operation was performed for a leak in the anastomotic site of the jejunum. Necrotic change in the small intestinal serosa was also observed and required broad resection of the small intestine. He was diagnosed with acute exacerbation of CMI, and we performed surgical retrograde bypass to the gastroduodenal artery using a saphenous vein graft as the third operation. After the surgery, he was free from digestive symptoms and was discharged. CONCLUSIONS When patients complain of chronic and gradual digestive symptoms, we should always consider symptomatic CMI. Timely mesenteric revascularization is important for symptomatic CMI before severe complications occur.
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Affiliation(s)
- Shinji Abe
- Department of Cardiovascular Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan.
| | - Tomoji Yamakawa
- Department of Cardiovascular Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Hideaki Kawashima
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Makoto Yoshida
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Setsuji Takanashi
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Motoya Kashiyama
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Masahiro Ishigooka
- Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505, Japan
| | - Yasushige Shingu
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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Jaster A, Choudhery S, Ahn R, Sutphin P, Kalva S, Anderson M, Pillai AK. Anatomic and radiologic review of chronic mesenteric ischemia and its treatment. Clin Imaging 2016; 40:961-9. [PMID: 27232932 DOI: 10.1016/j.clinimag.2016.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Adam Jaster
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX.
| | - Sadia Choudhery
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Richard Ahn
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Patrick Sutphin
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Sanjeeva Kalva
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Matthew Anderson
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Anil K Pillai
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX
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Kärkkäinen JM, Saari P, Kettunen HP, Lehtimäki TT, Vanninen R, Paajanen H, Manninen H. Interpretation of Abdominal CT Findings in Patients Who Develop Acute on Chronic Mesenteric Ischemia. J Gastrointest Surg 2016; 20:791-802. [PMID: 26553268 DOI: 10.1007/s11605-015-3013-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND We studied whether ischemia-specific computed tomography (CT) findings are consistently detectable in patients who develop acute on chronic mesenteric ischemia (AOCMI), whereas absent in chronic mesenteric ischemia (CMI). METHODS Consecutive patients with symptomatic angiography-verified atherosclerotic obstruction of the superior mesenteric artery (SMA) were categorized as AOCMI (n = 27) or CMI (n = 20). Three experienced radiologists blindly evaluated the contrast-enhanced CTs for vascular and intestinal findings. Kappa statistics was used to test interobserver agreement. RESULTS Two observers had substantial agreement (k = 0.66) that two thirds of AOCMI patients showed ischemia-specific CT findings (decreased bowel wall enhancement, pneumatosis, or thrombotic SMA clot); the third observer agreed only fairly regarding pneumatosis and thrombosis (k = 0.3-0.4). All observers had substantial agreement (k = 0.65-0.71) that most patients with AOCMI had unspecific intestinal findings such as mesenteric fat stranding in up to 96%, bowel lumen dilatation in 93%, and bowel wall thickening in 70%, while only few patients with CMI had such findings (due to chronic ischemic colitis) (P < 0.001). CONCLUSION One third of AOCMI patients presented without any ischemia-specific CT signs. However, any intestinal abnormality in CT together with SMA obstruction should raise suspicion of intestinal ischemia. Furthermore, clinicians need to be aware of the interobserver variability in the CT interpretation.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland. .,Department of Gastrointestinal Surgery, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
| | - Petri Saari
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Hannu-Pekka Kettunen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Tiina T Lehtimäki
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Hannu Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland
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Barret M, Martineau C, Rahmi G, Pellerin O, Sapoval M, Alsac JM, Fabiani JN, Malamut G, Samaha E, Cellier C. Chronic Mesenteric Ischemia: A Rare Cause of Chronic Abdominal Pain. Am J Med 2015; 128:1363.e1-8. [PMID: 26291907 DOI: 10.1016/j.amjmed.2015.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/27/2015] [Accepted: 07/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia is a rare disease with nonspecific clinical symptoms, such as chronic postprandial abdominal pain and weight loss. Diagnostic modalities and revascularization techniques have evolved during the past 20 years. The significance of stenosis in a single splanchnic vessel remains unclear. Our aims were to assess the outcomes of 2 revascularization techniques and report on the diagnostic modalities of splanchnic vessel stenoses. METHODS The demographic data, medical history, technical characteristics, and outcomes of the revascularization procedures were recorded for all of the patients admitted for endovascular revascularization or open surgical revascularization of the splanchnic vessels as treatment for chronic mesenteric ischemia in our tertiary referral center since 2000. RESULTS Fifty-four patients were included in this study: 43 received endovascular revascularization, and 11 had open surgical revascularization. The symptoms were abdominal pain, weight loss, and diarrhea in 98%, 53%, and 25% of the cases, respectively. Computed tomography angiography was the key diagnostic tool for 60% of the patients. A single-vessel stenosis was found in one-third of the patients. Endovascular and open revascularization had similar early and late outcomes, and no 30-day mortality was observed. However, we did observe higher morbidity in the open revascularization group (73% vs 19%, P <.03). CONCLUSIONS Chronic mesenteric ischemia may be diagnosed in the presence of a splanchnic syndrome and stenosis of a single splanchnic vessel, typically assessed using computed tomography angiography. In selected patients, endovascular revascularization had similar efficacy as, and lower complication rates than open revascularization.
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Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France.
| | - Chloé Martineau
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Gabriel Rahmi
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Olivier Pellerin
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Marc Sapoval
- Paris Descartes University, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, Paris, France; Inserm U970 équipe 2, Paris, France
| | - Jean-Marc Alsac
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Jean-Noël Fabiani
- Paris Descartes University, Paris, France; Vascular Surgery Department, Georges Pompidou European Hospital, Paris, France
| | - Georgia Malamut
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Elia Samaha
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France
| | - Christophe Cellier
- Gastroenterology Department, Georges Pompidou European Hospital, Paris, France; Paris Descartes University, Paris, France
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Wohlauer M, Kobeiter H, Desgranges P, Becquemin JP, Cochennec F. Inferior Mesenteric Artery Stenting as a Novel Treatment for Chronic Mesenteric Ischemia in Patients with an Occluded Superior Mesenteric Artery and Celiac Trunk. Eur J Vasc Endovasc Surg 2014; 27:e21-3. [PMID: 24920877 DOI: 10.1016/j.ejvsextra.2014.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Chronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions. REPORT We report a case series of four patients with chronic mesenteric ischemia who were not candidates for CA or SMA revascularization who were successfully treated with inferior mesenteric artery (IMA) angioplasty and stent placement to improve collateral circulation and palliate symptoms. DISCUSSION To our knowledge, this is the largest case series to date reporting the use of an IMA stent to improve collateral circulation in patients with CMI.
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Abstract
This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.
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Jun HJ. Isolated bypass to the superior mesenteric artery for chronic mesenteric ischemia. Korean J Thorac Cardiovasc Surg 2013; 46:146-9. [PMID: 23614103 PMCID: PMC3631791 DOI: 10.5090/kjtcs.2013.46.2.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 11/29/2012] [Accepted: 12/03/2012] [Indexed: 11/16/2022]
Abstract
Mesenteric ischemic symptoms appear only when two of the three major splanchnic arteries from the abdominal aorta are involved. Recently, we encountered a case of chronic mesenteric ischemia in a 50-year-old female patient caused by atherosclerotic obstruction of the celiac trunk and superior mesenteric artery. She was treated with a retrograde bypass graft from the right common iliac artery to the superior mesenteric artery (SMA) in a C-loop configuration. Complete revascularization is recommended for treatment of intestinal ischemia. When the celiac trunk is a not suitable recipient vessel, bypass grafting to the SMA alone appears to be both an effective and durable procedure for treating intestinal ischemia.
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Affiliation(s)
- Hee Jae Jun
- Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Korea
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Keese M, Schmitz-Rixen T, Schmandra T. Chronic mesenteric ischemia: Time to remember open revascularization. World J Gastroenterol 2013; 19:1333-7. [PMID: 23539677 PMCID: PMC3602490 DOI: 10.3748/wjg.v19.i9.1333] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/10/2012] [Accepted: 09/19/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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