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 older adult patients with significant comorbidities
Acute, severe, midabdominal pain disproportionate to physical examination
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)
Najdawi M et al: Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit. Eur Radiol. ePub, 2022
Rebelo A et al: Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery. BMC Surg. 22(1):56, 2022
Acosta S et al: Management of spontaneous isolated mesenteric artery dissection: a systematic review. Scand J Surg. 110(2):130-8, 2021
Karaolanis G et al: Spontaneous isolated superior mesenteric artery dissection: systematic review and meta-analysis. Vascular. 27(3):324-37, 2019
Ullah W et al: Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circ J. 49(5):400-18, 2019
Bala M et al: Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 12:38, 2017
Expert Panel on Interventional Radiology et al: ACR Appropriateness Criteria® radiologic management of mesenteric ischemia. J Am Coll Radiol. 14(5S):S266-71, 2017
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):1142-51, 2017
Stone JR et al: Acute mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):24-30, 2015
Wilkins LR et al: Chronic mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):31-7, 2015
Beaulieu RJ et al: Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 59(1):159-64, 2014
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
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
Barmase M et al: Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Eur J Radiol. 80(3):e582-7, 2011
Gupta PK et al: Morbidity and mortality after bowel resection for acute mesenteric ischemia. Surgery. 150(4):779-87, 2011
Hawkins BM et al: Endovascular treatment of mesenteric ischemia. Catheter Cardiovasc Interv. 78(6):948-52, 2011
Kohn GP et al: Treatment options and outcomes for celiac artery compression syndrome. Surg Innov. 18(4):338-43, 2011
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
Stein JJ et al: External compression of the superior mesenteric artery by the median arcuate ligament. Vasc Endovascular Surg. 45(6):565-7, 2011
Zeller T et al: Management of chronic atherosclerotic mesenteric ischemia. Vasa. 40(2):99-107, 2011
Gupta PK et al: Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther. 17(4):540-9, 2010
Rawat N et al: Surgical or endovascular treatment for chronic mesenteric ischemia: a multicenter study. Ann Vasc Surg. 24(7):935-45, 2010
Oderich GS et al: Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg. 49(6):1472-9.e3, 2009
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 older adult patients with significant comorbidities
Acute, severe, midabdominal pain disproportionate to physical examination
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)
Najdawi M et al: Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit. Eur Radiol. ePub, 2022
Rebelo A et al: Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery. BMC Surg. 22(1):56, 2022
Acosta S et al: Management of spontaneous isolated mesenteric artery dissection: a systematic review. Scand J Surg. 110(2):130-8, 2021
Karaolanis G et al: Spontaneous isolated superior mesenteric artery dissection: systematic review and meta-analysis. Vascular. 27(3):324-37, 2019
Ullah W et al: Diagnosis and management of isolated superior mesenteric artery dissection: a systematic review and meta-analysis. Korean Circ J. 49(5):400-18, 2019
Bala M et al: Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 12:38, 2017
Expert Panel on Interventional Radiology et al: ACR Appropriateness Criteria® radiologic management of mesenteric ischemia. J Am Coll Radiol. 14(5S):S266-71, 2017
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):1142-51, 2017
Stone JR et al: Acute mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):24-30, 2015
Wilkins LR et al: Chronic mesenteric ischemia. Tech Vasc Interv Radiol. 18(1):31-7, 2015
Beaulieu RJ et al: Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg. 59(1):159-64, 2014
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
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
Barmase M et al: Role of multidetector CT angiography in the evaluation of suspected mesenteric ischemia. Eur J Radiol. 80(3):e582-7, 2011
Gupta PK et al: Morbidity and mortality after bowel resection for acute mesenteric ischemia. Surgery. 150(4):779-87, 2011
Hawkins BM et al: Endovascular treatment of mesenteric ischemia. Catheter Cardiovasc Interv. 78(6):948-52, 2011
Kohn GP et al: Treatment options and outcomes for celiac artery compression syndrome. Surg Innov. 18(4):338-43, 2011
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
Stein JJ et al: External compression of the superior mesenteric artery by the median arcuate ligament. Vasc Endovascular Surg. 45(6):565-7, 2011
Zeller T et al: Management of chronic atherosclerotic mesenteric ischemia. Vasa. 40(2):99-107, 2011
Gupta PK et al: Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther. 17(4):540-9, 2010
Rawat N et al: Surgical or endovascular treatment for chronic mesenteric ischemia: a multicenter study. Ann Vasc Surg. 24(7):935-45, 2010
Oderich GS et al: Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg. 49(6):1472-9.e3, 2009