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Mesenteric Ischemia
Brandt C. Wible, MD; Raymond W. Liu, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        TERMINOLOGY

        • Definitions

          • Acute mesenteric ischemia (AMI)
            • Life-threatening vascular emergency with 60-80% mortality
              • Mortality directly corresponds to diagnosis & treatment time
                • Mortality 39% when revascularization achieved < 12 h
                • Mortality 70% when time to diagnosis > 24 h
            • May be occlusive or nonocclusive in etiology
            • Clinical presentation of AMI
              • History may include atrial fibrillation, atherosclerotic disease, hypertension, myocardial infarction, postprandial pain, hypercoagulable or connective tissue disorder
                • Often elderly patients with significant comorbidities
              • Acute, severe, midabdominal pain; disproportionate to physical examination
                • May have associated nausea & gastrointestinal (GI) hemorrhage
                • May have peritoneal signs suggesting ischemia
              • Laboratory data: Leukocytosis, lactic acidosis, elevated liver enzymes
          • Occlusive AMI
            • Arterial embolism
              • Cause of AMI in up to 50% of cases
              • Superior mesenteric artery (SMA) very susceptible because of high flow & acute takeoff from aorta
              • 50% of emboli lodge 6-8 cm beyond SMA origin, just distal to middle colic origin
                • Emboli lodge at bifurcation points, more distally as arterial caliber decreases
              • Etiology often from cardiac sources: Risk factors include acute myocardial infarction, arrhythmia, ventricular aneurysm, or valvular disease
              • Lack of collaterals results in poor distal SMA flow
              • Inferior mesenteric artery (IMA) less common site of occlusion due to lower flow & smaller lumen
            • Arterial thrombosis
              • Cause of AMI in ~ 25% of cases
              • Acute thrombosis of preexisting stenosis, occurring near SMA origin
              • Associated with previous postprandial pain & intestinal angina
              • Collateral vessel may be present due to chronic stenosis
              • Onset may be less acute vs. arterial embolism
              • Often worse prognosis than arterial embolism because of more proximal occlusion
            • Aortic dissection
              • Cause of AMI in < 5% of cases
              • Dissection flap extends into SMA
            • Miscellaneous etiologies
              • Trauma, retroperitoneal fibrosis, fibromuscular dysplasia, segmental arterial mediolysis, & vasculitis
          • Nonocclusive AMI (NOMI)
            • Cause of AMI in 25% of cases
            • Associated with prolonged hypotensive event or vasopressors (e.g., digitalis, dopamine)
            • Other causes of NOMI include drugs (cocaine, digitalis), recent coarctation repair, & vasculitides
            • Diffuse vasospasm throughout SMA territory is characteristic
            • Delayed filling of superior mesenteric vein (SMV) occurs on imaging
          • Mesenteric venous thrombosis
            • Cause of AMI in 5-10% of cases
              • May involve SMV &/or smaller venous branches
            • Associated with hypercoagulability, trauma, abdominal surgery, neoplasm, inflammatory bowel disease, oral contraceptives, or sepsis
          • Chronic mesenteric ischemia (CMI)
            • a.k.a. intestinal angina
            • Chronic occlusion/stenosis of bowel arterial supply
              • Historically defined as occlusion/stenosis of ≥ 2 of 3 major mesenteric vessels (i.e., celiac, SMA, IMA)
              • Increasingly recognized that occlusion/stenosis of 1 of 3 major mesenteric vessels can result in CMI
            • Progression from CMI to AMI has > 50% mortality
            • Clinical presentation of CMI
              • Recurrent episodes of postprandial pain (dull, cramping) beginning shortly after eating & lasting 1-2 h in duration
              • 80% association with weight loss due to food aversion/fear of eating
              • Nonspecific nausea, vomiting, diarrhea
              • Relates to digestive demand for increased blood flow; perfusion restricted by occlusive process
            • Atherosclerotic CMI
              • Occurs more frequently in older women
              • Associated with peripheral vascular disease, coronary artery disease, smoking
              • May consider endovascular stent placement as 1st-line therapy
                • Especially for poor surgical candidates
                • Surgical options remain if endovascular treatment fails
            • Median arcuate ligament syndrome
              • Abdominal pain attributed to compression of celiac artery or ganglion by median arcuate ligament (fibrous arch formed by left & right diaphragmatic crura)
              • More common in women ages 20-40 yr
              • Symptoms may involve celiac ganglion compression
                • Worsened by stent placement
                • Should be surgically treated
              • Debatable whether this is CMI variant
            • Other causes of CMI
              • Arterial dissection, fibromuscular dysplasia, radiation

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        • Things to Avoid

                          OUTCOMES

                          • Problems

                            • Complications

                              • Expected Outcomes

                                Selected References

                                1. Heo SH et al: Treatment strategy based on the natural course for patients with spontaneous isolated superior mesenteric artery dissection. J Vasc Surg. 65(4):1142-1151, 2017
                                2. Stone JR et al: Acute mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):24-30, 2015
                                3. Wilkins LR et al: Chronic mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):31-7, 2015
                                4. Beaulieu RJ et al: Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 59(1):159-64, 2014
                                5. Johnson JO: Diagnosis of acute gastrointestinal hemorrhage and acute mesenteric Ischemia in the era of multi-detector row CT. Radiol Clin North Am. 50(1):173-82, 2012
                                6. Arthurs ZM et al: A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg. 53(3):698-704; discussion 704-5, 2011
                                7. Barmase M et al: Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Eur J Radiol. 80(3):e582-7, 2011
                                8. Gupta PK et al: Morbidity and mortality after bowel resection for acute mesenteric ischemia. Surgery. 150(4):779-87, 2011
                                9. Hawkins BM et al: Endovascular treatment of mesenteric ischemia. Catheter Cardiovasc Interv. 78(6):948-52, 2011
                                10. Kohn GP et al: Treatment options and outcomes for celiac artery compression syndrome. Surg Innov. 18(4):338-43, 2011
                                11. Schoch DM et al: Management of chronic mesenteric vascular insufficiency: an endovascular approach. J Am Coll Surg. 212(4):668-75; discussion 675-7, 2011
                                12. Stein JJ et al: External compression of the superior mesenteric artery by the median arcuate ligament. Vasc Endovascular Surg. 45(6):565-7, 2011
                                13. Zeller T et al: Management of chronic atherosclerotic mesenteric ischemia. Vasa. 40(2):99-107, 2011
                                14. Gupta PK et al: Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther. 17(4):540-9, 2010
                                15. Harnik IG et al: Mesenteric venous thrombosis. Vasc Med. 15(5):407-18, 2010
                                16. Rawat N et al: Surgical or endovascular treatment for chronic mesenteric ischemia: a multicenter study. Ann Vasc Surg. 24(7):935-45, 2010
                                17. Oderich GS et al: Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg. 49(6):1472-9.e3, 2009
                                18. Walker TG: Mesenteric ischemia. Semin Intervent Radiol. 26(3):175-83, 2009
                                19. Walker TG: Mesenteric vasculature and collateral pathways. Semin Intervent Radiol. 26(3):167-74, 2009
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Preprocedure

                                    • Procedure

                                      TERMINOLOGY

                                      • Definitions

                                        • Acute mesenteric ischemia (AMI)
                                          • Life-threatening vascular emergency with 60-80% mortality
                                            • Mortality directly corresponds to diagnosis & treatment time
                                              • Mortality 39% when revascularization achieved < 12 h
                                              • Mortality 70% when time to diagnosis > 24 h
                                          • May be occlusive or nonocclusive in etiology
                                          • Clinical presentation of AMI
                                            • History may include atrial fibrillation, atherosclerotic disease, hypertension, myocardial infarction, postprandial pain, hypercoagulable or connective tissue disorder
                                              • Often elderly patients with significant comorbidities
                                            • Acute, severe, midabdominal pain; disproportionate to physical examination
                                              • May have associated nausea & gastrointestinal (GI) hemorrhage
                                              • May have peritoneal signs suggesting ischemia
                                            • Laboratory data: Leukocytosis, lactic acidosis, elevated liver enzymes
                                        • Occlusive AMI
                                          • Arterial embolism
                                            • Cause of AMI in up to 50% of cases
                                            • Superior mesenteric artery (SMA) very susceptible because of high flow & acute takeoff from aorta
                                            • 50% of emboli lodge 6-8 cm beyond SMA origin, just distal to middle colic origin
                                              • Emboli lodge at bifurcation points, more distally as arterial caliber decreases
                                            • Etiology often from cardiac sources: Risk factors include acute myocardial infarction, arrhythmia, ventricular aneurysm, or valvular disease
                                            • Lack of collaterals results in poor distal SMA flow
                                            • Inferior mesenteric artery (IMA) less common site of occlusion due to lower flow & smaller lumen
                                          • Arterial thrombosis
                                            • Cause of AMI in ~ 25% of cases
                                            • Acute thrombosis of preexisting stenosis, occurring near SMA origin
                                            • Associated with previous postprandial pain & intestinal angina
                                            • Collateral vessel may be present due to chronic stenosis
                                            • Onset may be less acute vs. arterial embolism
                                            • Often worse prognosis than arterial embolism because of more proximal occlusion
                                          • Aortic dissection
                                            • Cause of AMI in < 5% of cases
                                            • Dissection flap extends into SMA
                                          • Miscellaneous etiologies
                                            • Trauma, retroperitoneal fibrosis, fibromuscular dysplasia, segmental arterial mediolysis, & vasculitis
                                        • Nonocclusive AMI (NOMI)
                                          • Cause of AMI in 25% of cases
                                          • Associated with prolonged hypotensive event or vasopressors (e.g., digitalis, dopamine)
                                          • Other causes of NOMI include drugs (cocaine, digitalis), recent coarctation repair, & vasculitides
                                          • Diffuse vasospasm throughout SMA territory is characteristic
                                          • Delayed filling of superior mesenteric vein (SMV) occurs on imaging
                                        • Mesenteric venous thrombosis
                                          • Cause of AMI in 5-10% of cases
                                            • May involve SMV &/or smaller venous branches
                                          • Associated with hypercoagulability, trauma, abdominal surgery, neoplasm, inflammatory bowel disease, oral contraceptives, or sepsis
                                        • Chronic mesenteric ischemia (CMI)
                                          • a.k.a. intestinal angina
                                          • Chronic occlusion/stenosis of bowel arterial supply
                                            • Historically defined as occlusion/stenosis of ≥ 2 of 3 major mesenteric vessels (i.e., celiac, SMA, IMA)
                                            • Increasingly recognized that occlusion/stenosis of 1 of 3 major mesenteric vessels can result in CMI
                                          • Progression from CMI to AMI has > 50% mortality
                                          • Clinical presentation of CMI
                                            • Recurrent episodes of postprandial pain (dull, cramping) beginning shortly after eating & lasting 1-2 h in duration
                                            • 80% association with weight loss due to food aversion/fear of eating
                                            • Nonspecific nausea, vomiting, diarrhea
                                            • Relates to digestive demand for increased blood flow; perfusion restricted by occlusive process
                                          • Atherosclerotic CMI
                                            • Occurs more frequently in older women
                                            • Associated with peripheral vascular disease, coronary artery disease, smoking
                                            • May consider endovascular stent placement as 1st-line therapy
                                              • Especially for poor surgical candidates
                                              • Surgical options remain if endovascular treatment fails
                                          • Median arcuate ligament syndrome
                                            • Abdominal pain attributed to compression of celiac artery or ganglion by median arcuate ligament (fibrous arch formed by left & right diaphragmatic crura)
                                            • More common in women ages 20-40 yr
                                            • Symptoms may involve celiac ganglion compression
                                              • Worsened by stent placement
                                              • Should be surgically treated
                                            • Debatable whether this is CMI variant
                                          • Other causes of CMI
                                            • Arterial dissection, fibromuscular dysplasia, radiation

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Preprocedure Imaging

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      • Things to Avoid

                                                        OUTCOMES

                                                        • Problems

                                                          • Complications

                                                            • Expected Outcomes

                                                              Selected References

                                                              1. Heo SH et al: Treatment strategy based on the natural course for patients with spontaneous isolated superior mesenteric artery dissection. J Vasc Surg. 65(4):1142-1151, 2017
                                                              2. Stone JR et al: Acute mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):24-30, 2015
                                                              3. Wilkins LR et al: Chronic mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):31-7, 2015
                                                              4. Beaulieu RJ et al: Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 59(1):159-64, 2014
                                                              5. Johnson JO: Diagnosis of acute gastrointestinal hemorrhage and acute mesenteric Ischemia in the era of multi-detector row CT. Radiol Clin North Am. 50(1):173-82, 2012
                                                              6. Arthurs ZM et al: A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg. 53(3):698-704; discussion 704-5, 2011
                                                              7. Barmase M et al: Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Eur J Radiol. 80(3):e582-7, 2011
                                                              8. Gupta PK et al: Morbidity and mortality after bowel resection for acute mesenteric ischemia. Surgery. 150(4):779-87, 2011
                                                              9. Hawkins BM et al: Endovascular treatment of mesenteric ischemia. Catheter Cardiovasc Interv. 78(6):948-52, 2011
                                                              10. Kohn GP et al: Treatment options and outcomes for celiac artery compression syndrome. Surg Innov. 18(4):338-43, 2011
                                                              11. Schoch DM et al: Management of chronic mesenteric vascular insufficiency: an endovascular approach. J Am Coll Surg. 212(4):668-75; discussion 675-7, 2011
                                                              12. Stein JJ et al: External compression of the superior mesenteric artery by the median arcuate ligament. Vasc Endovascular Surg. 45(6):565-7, 2011
                                                              13. Zeller T et al: Management of chronic atherosclerotic mesenteric ischemia. Vasa. 40(2):99-107, 2011
                                                              14. Gupta PK et al: Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther. 17(4):540-9, 2010
                                                              15. Harnik IG et al: Mesenteric venous thrombosis. Vasc Med. 15(5):407-18, 2010
                                                              16. Rawat N et al: Surgical or endovascular treatment for chronic mesenteric ischemia: a multicenter study. Ann Vasc Surg. 24(7):935-45, 2010
                                                              17. Oderich GS et al: Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg. 49(6):1472-9.e3, 2009
                                                              18. Walker TG: Mesenteric ischemia. Semin Intervent Radiol. 26(3):175-83, 2009
                                                              19. Walker TG: Mesenteric vasculature and collateral pathways. Semin Intervent Radiol. 26(3):167-74, 2009