eMedicine Specialties > General Surgery > Abdomen

Abdominal Angina: Treatment & Medication

Author: Carol EH Scott-Conner, MD, PhD, Professor, Department of Surgery, University of Iowa College of Medicine
Coauthor(s): Beth Ballinger, MD, Assistant Professor, Department of Surgery, Section of Vascular Surgery, University of Iowa College of Medicine
Contributor Information and Disclosures

Updated: Sep 6, 2007

Treatment

Medical Care

No effective medical therapy exists. Percutaneous transluminal angioplasty (PTA) may be an alternative therapy for selected patients.

  • The role of PTA (with or without stenting) as an alternative to surgery is currently under investigation.
  • The use of PTA has been reported for severe stenoses, but follow-up data are limited. It may not be feasible if the ostial stenosis is caused by a calcified aortic plaque. In one series of 25 patients, 24 were treated successfully. Of the patients with recurrent stenoses, which developed in 4 patients, 2 were treated angiographically and 2 were treated surgically.
  • Reperfusion syndrome does not appear to occur after angiographic dilatation. Stenting may increase the durability of this procedure, but, as yet, long-term patency rates have not been described for this relatively new form of treatment.

Surgical Care

Mesenteric revascularization relieves the symptoms and may prevent intestinal infarction.

  • Generally, at least 2 of the 3 vessels must be revascularized. Sometimes, all 3 are corrected. In one series, recurrent symptoms developed in 50% of patients in whom only 1 vessel was revascularized. Also, several perioperative deaths occurred from intestinal infarction.
  • Several surgical options are available as follows:
    • The first is transarterial endarterectomy, which also was the first type of procedure developed. The artery is dissected, and proximal and distal control is achieved. A longitudinal arteriotomy is made, and the plaque is removed from the visceral vessel. The artery is closed, with or without a patch.
    • The next procedure developed was the retrograde bypass (see Media file 5). In this procedure, a graft is brought from a convenient nondiseased (ie, healthy) origin on the distal aorta or even the iliac vessels. It is routed retrograde and anastomosed to a healthy segment distal to the occlusion or stenosis in the visceral vessel. The major advantage of this procedure is ease of dissection; however, in some series, the more indirect route and the length of the graft (ie, with susceptibility to kinking) have resulted in an increased risk of graft occlusion.
    • Antegrade bypass probably is the most common procedure performed today. Typically, the proximal trunk of a small-caliber bifurcated prosthetic graft is anastomosed to the supraceliac aorta, and the distal limbs are sewn to the celiac artery and the SMA, just beyond the stenotic segments (see Media files 6-8). The conduit may be the autogenous saphenous vein or it may be a prosthetic graft. Prosthetic graft alternatives are ePTFE or Dacron. Although some favor prosthetics over vein grafts and vice-versa, no clear patency advantages exist for either. Most surgeons concur that a vein is the material of choice in a contaminated field.
    • Trapdoor aortotomy is an alternative used in some centers. The aorta is exposed, and vascular control is obtained. A flap is developed that includes the orifices of all the visceral vessels. Endarterectomy is performed, and the flap is sutured back in place (see Media file 9). The difficulties associated with working with a diseased aorta and concerns about complicating future aortic surgery have resulted in the failure of this method to attain widespread adoption.
  • Intraoperative duplex ultrasound examination is performed to confirm the technical adequacy of the revascularization (see Media file 10). 
  • Controversies in surgical treatment include the following:
    • Antegrade bypass versus transaortic endarterectomy
    • The role of duplex ultrasound in follow-up
    • The role of magnetic resonance imaging in follow-up
    • The management of asymptomatic occlusion detected at follow-up
    • The best material for bypass, ie, vein or prosthetic graft
  • The specific approach for surgical reconstruction, ie, bypass versus endarterectomy, depends on the location and number of stenoses, previous surgeries, patient comorbidities, and local operative conditions. Because patency and morbidity and mortality rates are similar for both, the authors prefer to individualize each patient, applying the technique best suited to the circumstances. Follow-up of patients with duplex ultrasound is performed yearly for the first several years. Asymptomatic occlusions are followed expectantly. Most patients succumb to other atherosclerotic comorbidities before developing symptomatic restenoses or occlusions. However, if a restenosis is identified, it is treated based on the same criteria as the original lesion.
  • Whether to use a vein of a prosthetic graft usually is addressed in the same manner as the choice of the surgical approach. Local individual patient characteristics dictate the choice of conduit material. Often, synthetic material is chosen for ease of use and availability. However, in the face of a contaminated field, a vein is clearly preferred.

Diet

  • Although most of these patients are cachectic, preoperative central venous nutrition has not been shown to decrease complications and is employed only selectively.
  • No particular dietary restrictions are associated with the surgery. After adequate surgical correction, patients may resume the usual diet for their particular underlying medical condition (if any).

Medication

No effective medical therapy exists.

More on Abdominal Angina

Overview: Abdominal Angina
Differential Diagnoses & Workup: Abdominal Angina
Treatment & Medication: Abdominal Angina
Follow-up: Abdominal Angina
Multimedia: Abdominal Angina
References
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References

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Further Reading

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Keywords

intestinal angina, chronic mesenteric ischemia, abdominal angina, postprandial abdominal angina, occlusive mesenteric vascular disease, postprandial pain, symptomatic occlusive mesenteric ischemia, central abdominal pain

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Contributor Information and Disclosures

Author

Carol EH Scott-Conner, MD, PhD, Professor, Department of Surgery, University of Iowa College of Medicine
Carol EH Scott-Conner, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Gastroenterology, American College of Surgeons, American Medical Association, American Society for Gastrointestinal Endoscopy, Association for Academic Surgery, Association for Surgical Education, Association of VA Surgeons, Iowa Medical Society, Sigma Xi, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Society of Surgical Oncology, Society of University Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Coauthor(s)

Beth Ballinger, MD, Assistant Professor, Department of Surgery, Section of Vascular Surgery, University of Iowa College of Medicine
Beth Ballinger, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Medical Association, Iowa Medical Society, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Marc D Basson, MD, PhD, Chief of Surgery, John D Dingell VA Medical Center; Professor, Department of Surgery, Wayne State University School of Medicine
Marc D Basson, MD, PhD is a member of the following medical societies: American College of Surgeons and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of 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 Other; AMGEN Consulting fee Consulting

 
 
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