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Chronic Mesenteric Ischemia Treatment & Management

  • Author: Aref Alrayes, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Mar 24, 2014
 

Approach Considerations

After the diagnosis of chronic mesenteric ischemia (CMI) is made or confirmed with arteriography, patients should undergo open or endovascular revascularization because of the risk of continued weight loss, acute infarction, perforation, sepsis, and death. Because of the high rate of thrombosis, medical management as the sole therapy is warranted only when the risks of revascularization outweigh the benefits. Nitrate therapy may provide short-term relief but is not curative. Anticoagulation therapy with warfarin is indicated.

Because of the high rate of coronary artery disease (CAD) in these patients, consultation with a cardiologist is warranted to evaluate the potential risks associated with surgery. All CMI patients should be evaluated for cardiopulmonary and renal disease before surgery is considered.

The prothrombin time (PT) and international normalized ratio (INR) should be monitored. Routine visceral duplex ultrasonography is recommended every 4-6 months. Obtaining a pretreatment base line is important.

In 2000, the American Gastroenterological Association released recommended algorithms for the diagnosis and management of mesenteric ischemia (see the image below).[22] However, these recommendations were formulated before the availability of improved data from multidetector computed tomography (CT), as a result of which CT now plays a larger role in the diagnosis of mesenteric ischemia.

Management of chronic mesenteric ischemia. Solid l Management of chronic mesenteric ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA=magnetic resonance angiography; CT=computed tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
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Surgical Intervention

Indications for surgical management of CMI include the following[23] :

  • Peritonitis
  • Massive hemorrhage
  • Recurrent fever or sepsis
  • Continuation of symptoms beyond 2-3 weeks
  • Chronic protein-losing colopathy
  • Chronic segmental colitis with ulceration
  • Symptomatic ischemic stricture

Management options for CMI are as follows:

  • Angioplasty, with or without stent placement
  • Surgical revascularization

The choice between endovascular and open approaches to the treatment of CMI depends on multiple factors and should be tailored to the individual case. The 2 approaches have similar technical success and survival rates. Compared with open revascularization, stenting is associated with lower perioperative morbidity and mortality and shorter hospital stays. However, it is also associated with lower patency rates and higher recurrence rates, with increased need for repeat intervention.

Currently, it is common practice is to proceed with open revascularization if the patient has good life expectancy and fair nutritional status. Endovascular therapy is a good alternative in cases of poor nutritional status as a bridge to surgery or in cases with short life expectancy. Patient preference, age, comorbidities, and center expertise all play major roles in the decision.[3, 24, 25, 26, 27, 28]

The anatomy and the vessels affected also contribute to the treatment decision. In a study in which patients were treated with endovascular revascularization, clinical primary patency and primary patency were significantly higher for the superior mesenteric artery (SMA) group than for the celiac trunk group.[29]

Several studies have found a high rate of success with percutaneous stent revascularization for CMI, though repeated interventions may be necessary.[30, 31, 32] A nonrandomized study showed that covered stents were associated with less restenosis, recurrences, and repeat interventions than bare metal stents in patients undergoing primary interventions or repeat interventions for CMI.[29]

Surgical correction is accomplished by means of the following techniques:

  • Transaortic endarterectomy of the celiac trunk or the SMA
  • Retrograde bypass from the external iliac artery
  • Anterograde bypass, which provides the best orientation of the graft to the aorta

Mesenteric artery reimplantation has been performed but, because of its technical difficulty, is not widely recommended.

Once a diagnostic arteriogram is obtained and surgery is deemed appropriate, intra-arterial papaverine is started to reduce the risk of arterial spasm. Any nutritional deficiencies (from the long period of malnutrition) or electrolyte imbalances should be corrected. In addition to arteriography, preoperative chest radiography and dipyridamole-thallium scanning may be considered. Bowel preparation is carried out the night before surgery, and the patient is on nil per os (NPO) status from midnight on.

After the procedure, because of the high rate of postoperative ileus, the patient is encouraged to ambulate as early as possible. Blood pressure is monitored to prevent hypotension, which can induce ischemia.

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Complications

Because of the high prevalence of atherosclerosis, myocardial infarction (MI) is a common postoperative complication. The risk of MI can be reduced with the following steps:

  • Identify patients at risk (eg, from correctable CAD) preoperatively
  • Place a Swan-Ganz catheter perioperatively to monitor fluid status and cardiac function
  • Inform the anesthesiologist when cross-clamping the celiac aorta, so that he or she can employ myocardial protective maneuvers and afterload reduction to maximize cardiac output

Another common complication is acute renal failure in the immediate postoperative period. This can be prevented with the following steps:

  • Adequately hydrate the patient before and during the procedure
  • Administer mannitol before cross-clamping the aorta
  • Monitor blood urea nitrogen (BUN) and creatinine levels in the preoperative and postoperative periods

Other possible complications include bleeding, infection, bowel infarction, prolonged ileus, and graft infection.

Outcomes for open vs endovascular revascularization

Kougias et al compared the effectiveness of balloon angioplasty or endovascular stenting (48 patients, 58 vessels) with that of open revascularization (96 patients, 157 vessels) in the treatment of CMI.[33] The investigators found that members of the endovascular group had a shorter hospital stay than patients in the open revascularization group did (3 vs 12 days; P < .03) and that the 30-day mortality, frequency of in-hospital complications, and 3-year cumulative survival rate were the same for the 2 groups.

At 3 years after the procedures, however, the rate of cumulative freedom from recurrent symptoms was higher in the open-revascularization group than in the endovascular group (66% vs 27%; P < .02).[33] The authors suggested that this was because the percentage of patients who underwent a 2-vessel procedure rather than a 1-vessel intervention was higher in the open group than in the endovascular group.

Another study compared the outcomes of patients with CMI who were treated with open mesenteric revascularization before (pre-endo) and after (post-endo) the preferential use of endovascular revascularization.[34] The results showed that patients in the post-endo group presented with higher rates of hypertension, hyperlipidemia, cardiac interventions, and dysrhythmias; higher comorbidity scores; and more extensive mesenteric arterial disease.

However, the pre-endo and post-endo groups had similar outcomes for operative mortality, morbidity, length of stay, and immediate symptom improvement.[34] At 5 years, primary patency rates, secondary patency rates, and recurrence-free survival rates were 82%, 86%, and 84% in the pre-endo group, respectively, and 81%, 82%, and 76% in the post-endo group, respectively.

Oderich et al studied 156 patients treated for mesenteric artery complications during angioplasty and stent replacement for CMI.[35] The investigators concluded that complications occurred in 7% of patients, who experienced higher mortality, higher morbidity, and longer hospital stays.

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Diet and Activity

Because CMI is a complication of diffuse atherosclerosis of the arterial tree, patients with this condition should maintain a low-fat diet, similar to that of patients with cardiac disease. Some patients report increased postprandial pain after eating large or fatty meals. Therefore, the diet should be appropriately altered to include small, multiple meals or low-fat meals.

As in patients with cardiac disease, regular exercise should be encouraged.

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Contributor Information and Disclosures
Author

Aref Alrayes, MD Fellow, Department of Gastroenterology, Providence Hospital

Aref Alrayes, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michael H Piper, MD Clinical Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine; Consulting Staff, Digestive Health Associates, PLC

Michael H Piper, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, Michigan State Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgements

Mounzer Al Samman, MD Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Texas Tech University School of Medicine

Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association

Disclosure: Nothing to disclose.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: lippincott Royalty textbook royalty; wiley Royalty textbook royalty

Burt Cagir, MD, FACS Assistant Professor of Surgery, State University of New York Upstate Medical University; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association of Program Directors in Surgery, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Southern Surgical Association, andTennessee Medical Association

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Chandler Long, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center-Knoxville

Disclosure: Nothing to disclose.

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership

Daniel K Nishijima, MD Assistant Professor, Department of Emergency Medicine, University of California Davis Medical Center

Daniel K Nishijima, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Yale D Podnos, MD, MPH Consulting Surgeon, Department of Surgery, City of Hope National Medical Center

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Mark Su, MD, FACEP, FACMT Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital

Mark Su, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Deron J Tessier, MD Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA

Deron J Tessier, MD is a member of the following medical societies: American College of Surgeons and American Medical Association

Disclosure: Nothing to disclose.

Russell A Williams, MBBS Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine

Disclosure: Nothing to disclose.

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Angiogram of patient with chronic mesenteric ischemia. Note diffuse occlusive disease.
Radiograph showing tortuous, dilated, meandering artery.
Narrowing of superior mesenteric artery.
Chronic aortic occlusion (Leriche syndrome) with acute embolic occlusion of superior mesenteric artery.
Gas in colon wall, typical of advanced ischemia.
Meandering artery, sign of chronic mesenteric arterial ischemia.
Management of chronic mesenteric ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA=magnetic resonance angiography; CT=computed tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
 
 
 
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