Mesenteric Ischemia

Post by: Dr. Ashish Gupta

Mesenteric ischemia refers to an insufficient oxygen supply to meet the metabolic demands of the intestine. There are four types of mesenteric ischemia. The most severe and life-threatening is Acute Mesenteric Ischemia, requiring immediate surgical intervention. Chronic Mesenteric Ischemia, the second type, affects at least two or more mesenteric arteries leading to ischemic symptoms in the gastrointestinal tract persisting for a minimum of three months. While less common than the acute form, it typically presents with symptoms like post-meal pain. Non-occlusive Mesenteric Ischemia is observed in critically ill patients where mesenteric arteries are patent, allowing for the redistribution of blood flow to vital organs. Lastly, there’s Mesenteric Venous Thrombosis.

 

Main pathways of collateral flow between the celiac trunk and the SMA may be schematically identified with:

  • The gastroduodenal and pancreaticoduodenal arteries arising from SMA
  • Replaced right hepatic artery, pancreatic arteries, or a middle colic artery arising from the celiac ax
  • Arc of Bühler

Main collateral flow patterns between the superior and the inferior mesentery artery involve:

  • Marginal artery of Drummond from which arise from the vasa recta
  • The arc of Riolan, a proximal junction of middle and left colic arteries
  • Villemin arcade
ConditionAetiologyClinical Features Radiological Investigations Bio Markers Interventional procedures
Acute Mesenteric Ischemia
- Embolic acute mesenteric ischaemia (EAMI)
- Thrombotic acute mesenteric ischaemia (TAMI)		1. Cardiac originated arterial embolus,
2. Atherosclerosis,
3. Arterial dissection,
4. Vasculitis 		1. Abdominal pain out of proportion
2. Progressive weight loss
3. Vomiting
4. Nausea
5. Malena
6. Diarrhea
7. Signs of peritonitis indicate bowel necrosis
8. Atrial fibrillation		CT dual phase angiography for all is gold standard Lactate dehydrogenase, D dimer 1. Medical management - Supportive oxygen and fluid resuscitation, and Antibiotic management
2. Mechanical thrombectomy,
3. Catheter directed thrombolysis (Contraindications should be evaluated prior to thrombolytic therapy), and
4. Angioplasty or stenting


Access to Superior Mesenteric artery - Brachial artery is preferred over femoral artery.
Non Occlusive Mesenteric Ischemia (NOMI) 1. Cardiac failure,
2. Low flow states,
3. Multi-organ dysfunction,
4. Vasopressors 		1. Recent history of major cardiac event, and
2. Acute Myocardial Infarction
3. It is a hypoperfusion syndrome which occurs when severe intestinal ischemia develops.


1. Unlikely or difficult diagnosis on Doppler ultrasound scan or CT angiography
2. Invasive methods like Digital subtraction angiography can show follow findings.
- Narrowing of the origins of multiple branches of the SMA.
- Alternate dilatation and narrowing of the intestinal branches (some times referred to as “the string of sausages sign).
- Spasm of the mesenteric arcades.
- Impaired filling of intramural vessels. 		-Patients experiencing life-threatening NOMI require immediate intervention in an operating room equipped for both open and endovascular procedures. Here, angiography will be conducted, and if a stenosis is identified, stenting may be performed. Additionally, intra-arterial or catheter-directed administration of vasodilators like papaverine hydrochloride, as well as laparotomy for potential bowel resection, are viable treatment options.
Mesenteric Venous Thrombosis 1. Prothrombotic states,
2. Cirrhosis of liver,
3. Surgery,
4. Inflammatory disease,
5. Malignancy,
6. (Oral Contraceptive Pills) OCP and
7. Pregnancy 		1. Abdominal pain out of proportion,
2. Nausea,
3. Vomiting,
4. Malena and
5. signs of peritonitis. 		CT dual phase angiography helps establish the diagnosisD dimer 1. Conservative management and anticoagulation therapy is the mainstay therapy.
2. Patients who deteriorate mechanical thrombectomy or thrombolysis through transhepatic or transjugular route can be offered.
Chronic Mesenteric Ischemia 1. Atherosclerosis,
2. Median arcuate ligament syndrome (MALS) - Stenting is contraindicated,
3. Vasculitis,
4. Mesenteric venous thrombosis 		1. Abdominal pain,
2. Chronic postprandial abdominal pain,
3. Weight loss
4. Early satiety,
5. Diarrhea or constipation (or both), and
6. Nausea or vomiting (or both),		The common Doppler US criteria for a SMA stenosis of 70% or greater is a peak systolic velocity (PSV) of 275 cm/s or more, whereas 200 cm/s or more indicates a similar stenosis of the CA with no flow in either vessel consistent with an occlusion Lactate dehydrogenaseGoal of the treatment is
- Resolution of symptoms,
- Weight gain and
- Prevention of mesenteric ischemia

Percutaneous transluminal angioplasty or stenting should be offered to symptomatic patients.
- SMA (Superior Mesenteric Artery) > CA (Coeliac Axis) > IMA (Inferior Mesenteric Artery)
- Proximal SMA - balloon-expandable stents are preferred
- Distal or longer occlusion of SMA - self expanding metallic stents are preferred
- Uncovered stents preferred over covered stent
- 6-8 mm diameter stent is used and is positioned such that 2-3 mm of the stent is protruding into the aorta and no greater than 1mm size from reference vessel.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Recommendations
1A1. Computed tomography angiography (CTA) should be performed as soon as possible for any patient with suspicion for AMI.
2. Endovascular revascularization procedures may have a role with partial arterial occlusion.
1B1. Severe abdominal pain out of proportion to physical examination findings should be assumed to be AMI until disproven.
2. Clinical scenario differentiates AMI as mesenteric arterial emboli, mesenteric arterial thrombosis, NOMI or mesenteric venous thrombosis.
3. Conventional plain X-ray films have limited diagnostic value in evaluating AMI, although signs of intestinal perforation may be seen.
4. There are no laboratory studies that are sufficiently accurate to identify the presence or absence of ischemic or necrotic bowel, although elevated l-lactate, and D-dimer may assist.
5. Non-occlusive mesenteric ischemia (NOMI) should be suspected in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multi-organ dysfunction.
6. When the diagnosis of AMI is made, fluid resuscitation should commence immediately to enhance visceral perfusion.
7. Electrolyte abnormalities should be corrected, and nasogastric decompression initiated.
8. Broad-spectrum antibiotics should be administered immediately.
9. Unless contraindicated, patients should be anticoagulated with intravenous unfractionated heparin.
10. Prompt laparotomy should be done for patients with overt peritonitis.
11. Damage control surgery (DCS) is an important adjunct for patients who require intestinal resection due to the necessity to reassess bowel viability and in patients with refractory sepsis.
12. Planned re-laparotomy is an essential part of AMI management.
13. The finding of massive gut necrosis requires careful assessment of the patients underlying co-morbidities and advanced directives in order to judge whether comfort carries the best treatment.
1CMesenteric venous thrombosis can often be successfully treated with a continuous infusion of unfractionated heparin.

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery

RecommendationGradeEvidence
Diagnostic Evaluation
1. Expedited workup for abdominal pain, weight loss, and food fear including esophagogastroduodenoscopy, colonoscopy, abdominal CT scan, and abdominal ultrasound.
2. Diagnosis of chronic mesenteric ischemia in patients with appropriate clinical scenario and significant stenoses (>70%) in celiac axis and/or SMA.
3. Use mesenteric duplex ultrasound (DUS) examination as preferred screening test for mesenteric artery occlusive disease (MAOD).
4. Use CT arteriography (CTA) as preferred definitive imaging test for MAOD, unless unusual anatomy requires catheter-based arteriogram.		1B
Indications for Treatment1. Revascularization in patients with CMI to reverse presenting symptoms and improve quality of life.1A
1. Total parenteral nutrition not an acceptable alternative to revascularization for patients with CMI.1B
1. Follow-up schedule for asymptomatic patients with severe MAOD.
2. Revascularization for combined MAOD and mesenteric artery aneurysms if repair alone disrupts collateral network.		1C
1. SMA is the primary target for revascularization.
2. Celiac axis and inferior mesenteric artery are secondary targets for revascularization.		2B
1. Shared decision-making (between patient and treating physician) for revascularization in patients with isolated occlusive disease.
2. Shared decision-making for asymptomatic patients with severe MAOD.
3. Shared decision-making for patients with severe MAOD involving the SMA undergoing aortic reconstruction. 		2C
Choice of Treatment1. Endovascular revascularization as initial treatment for patients with CMI and suitable lesions.
2. Open surgical revascularization for patients with CMI not amenable to endovascular therapy or endovascular failures.		1B
Shared decision-making process for choice of treatment in CMIUngraded good practice guidelines
Preoperative Evaluation1. Obtain a CTA to delineate vascular anatomy before any revascularization. 1A
1. Patients undergoing revascularization for CMI should be optimized medically before intervention.Ungraded good practice guidelines
Endovascular Revascularization1. Use balloon-expandable covered intraluminal stents for treatment of MAOD in patients with CMI.2C
Open Surgical RevascularizationChoice of open surgical revascularization should be determined by anatomy, comorbidities, prior interventions, and provider preference.Ungraded good practice guidelines
Surveillance and Remediation1. Perform CTA or catheter-based arteriograms to confirm any restenosis detected by DUS examination in patients with symptoms consistent with CMI.
2. Remedial treatment for recurrent stenoses as recommended for de novo lesions. 		1C
1. Surveillance with mesenteric DUS examination to identify recurrent stenoses after revascularization for CMI.
2. Shared decision-making approach for asymptomatic recurrent stenosis.
3. Choice of revascularization for recurrent stenoses should be similar to de novo lesions. 		2C
1. Educate and counsel patients undergoing revascularization for CMI about recurrent symptoms.
2. Follow-up in outpatient setting after revascularization for CMI.		Ungraded good practice guidelines
1 (Strong)
2 (Weak)
A (High)
B (Moderate)
C (Low)

Research and Publications related to Mesenteric ischemia:
Bala, Miklosh et al. “Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery.” World journal of emergency surgery : WJES vol. 12 38. 7 Aug. 2017, doi:10.1186/s13017-017-0150-5Laparotomy should be done for patients with overt peritonitis
Björck, M et al. “Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS).” European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery vol. 53,4 (2017): 460-510. doi:10.1016/j.ejvs.2017.01.0101. Open surgery vs endovascular revascularisation shows overall 30 day mortality rate after endovascular therapy was 17.2% , compared with 38.5% after open surgery.
2. Acute mesenteric arterial revascularisation is preferably done before any bowel surgery, even if there is a limited length of necrotic bowel that could be rapidly resected
Ottinger LW. Mesenteric ischemia. New England Journal of Medicine. 1982 Aug 26;307(9):535-7.Patients who presented with profound visceral ischemia may have been as- signed to open revascularization
Huber, Thomas S et al. “Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.” Journal of vascular surgery vol. 73,1S (2021): 87S-115S. doi:10.1016/j.jvs.2020.10.0291. Isolated revascularization of the CA or IMA may be justified in select patients when the SMA is not suitable for revascularization
2. Symptoms of CMI do not typically develop unless both the CA and SMA have hemodynamically significant lesions / stenosis (>70%)
Semiz-Oysu A, Keussen I, Cwikiel W. Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system. Cardiovasc Intervent Radiol 2007;30(4):688e95.TIPS was associated with immediate symptomatic improvement and successful recanalisation in 83% of patients treated in an acute stage of MVT
Role of Endovascular Therapies in Chronic Mesenteric Ischemia: Current Status and Technical ConsiderationsIf artery of Drummond and arc of Riolan is prominent suggestive of high grade stenosis in SMA OR IMA
  1. Björck M, Koelemay M, Acosta S, Goncalves FB, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P. Editor’s choice–management of the diseases of mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery. 2017 Apr 1;53(4):460-510. 
  2. Clair DG, Beach JM. Mesenteric ischemia. New England Journal of Medicine. 2016 Mar 10;374(10):959-68. 
  3. Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. Journal of vascular surgery. 2021 Jan 1;73(1):87S-115S 
  4. Bala M, Kashuk J, Moore EE, Kluger Y, Biffl W, Gomes CA, Ben-Ishay O, Rubinstein C, Balogh ZJ, Civil I, Coccolini F. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2017 Dec;12(1):1-1. 
  5. Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, Boyer L, Corcos O, van Dijk LJ, Duran M, Geelkerken RH. European guidelines on chronic mesenteric ischaemia–joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric …. United European gastroenterology journal. 2020 May;8(4):371-95.
  6. Cognet F, Salem DB, Dranssart M, Cercueil JP, Weiller M, Tatou E, Boyer L, Krausé D. Chronic mesenteric ischemia: imaging and percutaneous treatment. Radiographics. 2002 Jul;22(4):863-79
  7. Wang, Xuan et al. “Diabetic foot ulcers: Classification, risk factors and management.” World journal of diabetes vol. 13,12 (2022): 1049-1065. doi:10.4239/wjd.v13.i12.1049
  8. Aboyans, Victor et al. “2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS).” European heart journal vol. 39,9 (2018): 763-816. doi:10.1093/eurheartj/ehx0951996;348:1329–133
  9. Gerhard-Herman, Marie D et al. “2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.” Circulation vol. 135,12 (2017): e686-e725. doi:10.1161/CIR.0000000000000470
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