Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Abdominal Angina Treatment & Management

  • Author: Faisal Aziz, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Apr 22, 2016
 

Medical Care

Patients should be counseled to stop smoking. No effective medical therapy exists. There is no role for screening asymptomatic patients. There is also no role for treating asymptomatic mesenteric artery disease.[9, 10]

Next

Surgical Care

Mesenteric revascularization relieves the symptoms of abdominal angina. The classic operation for relieving the symptoms of abdominal angina includes removal of the obstructing lesion, bypass of the obstructed portion of the blood vessel, or both. Because atherosclerosis involves systemic circulation, generally all three blood vessels (celiac artery, superior mesenteric artery [SMA], and inferior mesenteric artery [IMA]) are involved. Relieving the symptoms of abdominal angina requires revascularization of at least two of the three vessels.

With the advent of modern endovascular surgery, many new techniques have emerged as possible alternatives to bypass surgery. Its less invasive nature makes endovascular surgery ideal for patients with multiple comorbidities, who may be at high risk for complications from open surgery.

When endovascular surgery for mesenteric revascularization is performed, the patient is placed on a fluoroscopy table, and the procedure can be performed under conscious sedation. The groins are prepared bilaterally and draped in standard surgical fashion, the femoral pulse is palpated, and a needle is inserted into the artery. A guide wire is inserted through the needle with the Seldinger technique, and its position is checked with fluoroscopy. Selective catheterization of the mesenteric arteries is performed. An appropriate catheter is introduced through the sheath, and angiography is performed.[11]

Endovascular surgery

First, aortography is performed, and the origins of the celiac artery, the SMA, and the IMA are visualized. The left anterior oblique view is best for visualizing the origins of the celiac artery and the SMA. Once a narrowed artery is identified, a guide wire is passed through the catheters, and an attempt is made to pass the wire across the narrowed portion of the artery under direct fluoroscopy. Once the wire is passed across the stenotic area, the artery's narrowed portion can be dilated with a dilator, and a balloon angioplasty is performed.

If residual stenosis after the angioplasty is more than 50% of the expected arterial lumen, it is advisable to place a stent[12] across the narrowed portion of the blood vessel. A retrospective review by Oderich et al showed that mesenteric lesions treated with covered stents are associated with lesser incidence of restenosis, recurrence, and repeated interventions.[13]

Potential complications of endovascular mesenteric revascularization procedures are dissection of mesenteric arteries, rupture of mesenteric arteries, embolization of atherosclerotic plaques, groin hematoma, and acute limb ischemia.

Open surgery

Lesions that are not amenable to endovascular management are dealt with by means of an open surgical procedure. The patient is placed under general anesthesia, the abdomen is prepared and draped, and a midline incision is made from xiphoid to pubic tubercle. Skin, subcutaneous tissue, and anterior rectus fascia are divided, and the peritoneal cavity is then entered.

The transverse colon is reflected upwards, and the middle colic artery is identified and traced back to the origin of the SMA. Proximal and distal control of the SMA is obtained, and an arteriotomy is performed to open the artery, followed by removal of atherosclerotic plaques. The arteriotomy may be transverse or longitudinal. For transverse arteriotomies, primary closure is suitable, but for longitudinal arteriotomies, a vein patch closure is preferred to minimize residual stenosis of the artery.

Other surgical options include the following:

  • Antegrade bypass - A vascular conduit is used to bypass the stenosed area of the mesenteric vessel, and inflow is from the supraceliac aorta; unlike other vascular bypasses, for which native vein is the preferred conduit, antegrade bypass for mesenteric revascularization is preferentially done with prosthetic grafts (see the first three images below)
  • Retrograde bypass - In this bypass, inflow for the conduit comes from the distal, nondiseased portion of the aorta or common iliac arteries (see the fourth image below)
Celiac artery is exposed at its origin in preparat Celiac artery is exposed at its origin in preparation for antegrade bypass.
Superior mesenteric artery and several branches ar Superior mesenteric artery and several branches are exposed for antegrade bypass.
Antegrade bypass from aorta to superior mesenteric Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
Completed retrograde bypass to superior mesenteric Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.

Classic surgical operations have excellent outcomes.

Cardiac monitoring with transesophageal echocardiography or invasive monitoring may be needed. Intraoperative duplex ultrasonographic examination is performed to confirm the technical adequacy of the revascularization (see the image below). Postoperatively, most patients require monitoring in an intensive care unit.

Completion duplex ultrasonographic study shows exc Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.

Surgical controversies

Controversies in surgical treatment include the following:

  • The choice of reconstructive approach (ie, antegrade bypass vs transaortic endarterectomy vs retrograde bypass)
  • The role of duplex ultrasonography in follow-up
  • The best material for bypass (ie, vein vs prosthetic graft)

The specific approach to surgical reconstruction (bypass or endarterectomy; see the image below), depends on the location and number of stenoses, previous surgeries, patient comorbidities, and local operative conditions. Because patency rates, morbidity, and mortality are comparable for the two surgical approaches, the authors prefer to make the decision on a case-by-case basis, applying the technique best suited to the individual patient's specific circumstances. If a restenosis is identified on postoperative follow-up, it is treated according to the same criteria used for the original lesion.

Possible incision for trapdoor aortotomy. Plaque a Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
Previous
Next

Complications

In addition to the usual cardiac problems traditionally associated with major vascular repairs, major postoperative complications of surgical treatment include the following:

  • Bleeding
  • Coagulopathy
  • Hepatic failure
  • Renal failure
Previous
Next

Diet

Although most of these patients are cachectic, preoperative central venous nutrition has not been shown to decrease complications and is used only selectively.

No particular dietary restrictions are associated with the surgery.

Previous
Next

Long-Term Monitoring

Duplex ultrasonography is the most common modality used for follow-up.

Previous
 
Contributor Information and Disclosures
Author

Faisal Aziz, MD Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine

Faisal Aziz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony J Comerota, MD, FACS, FACC, FRACS Director of Jobst Vascular Institute, Program Director of General Vascular Surgery Residency, Toledo Hospital; Director of Jobst (ProMedica) Vascular Laboratories; Adjunct Professor of Surgery, Department of Surgery, University of Michigan Medical School

Anthony J Comerota, MD, FACS, FACC, FRACS is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Society for Vascular Surgery, Society of University Surgeons, American Stroke Association, American Venous Forum, Eastern Vascular Society, Society for Clinical Vascular Surgery

Disclosure: Received honoraria from BMS for speaking and teaching; Received consulting fee from BMS for consulting; Received grant/research funds from BMS for research studies; Received honoraria from Covidien for speaking and teaching; Received consulting fee from Covidien for consulting; Received honoraria from Otsuka for speaking and teaching; Received honoraria from Sanofi/Aventis for speaking and teaching; Received consulting fee from Sanofi/Aventis for consulting; Received grant/research funds from Sa.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, DSc, MSc, 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; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

We wish to thank Carol EH Scott-Conner, MD, PhD, and Beth Ballinger, MD, for their previous contributions to this article.

References
  1. Tyson RL. Diagnosis and treatment of abdominal angina. Nurse Pract. 2010 Nov. 35(11):16-22; quiz 22-3. [Medline].

  2. Moschetta M, Stabile Ianora AA, Pedote P, et al. Prognostic value of multidetector computed tomography in bowel infarction. Radiol Med. 2009 Aug. 114(5):780-91. [Medline].

  3. Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S, et al. Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. J Vasc Surg. 2008 Mar. 47(3):485-91. [Medline].

  4. Sundermeyer A, Zapenko A, Moysidis T, Luther B, Kröger K. Endovascular treatment of chronic mesenteric ischemia. Interv Med Appl Sci. 2014 Sep. 6 (3):118-24. [Medline].

  5. Cai W, Li X, Shu C, Qiu J, Fang K, Li M, et al. Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis. Ann Vasc Surg. 2015 Jul. 29 (5):934-40. [Medline].

  6. Fields JM, Dean AJ. Systemic causes of abdominal pain. Emerg Med Clin North Am. 2011 May. 29(2):195-210, vii. [Medline].

  7. Danse EM, Kartheuser A, Paterson HM, et al. Color Doppler sonography of small bowel wall changes in 21 consecutive cases of acute mesenteric ischemia. JBR-BTR. 2009 Jul-Aug. 92(4):202-6. [Medline].

  8. Pellerito JS, Revzin MV, Tsang JC, et al. Doppler sonographic criteria for the diagnosis of inferior mesenteric artery stenosis. J Ultrasound Med. 2009 May. 28(5):641-50. [Medline].

  9. Cunningham CG, Reilly LM, Rapp JH, Schneider PA, Stoney RJ. Chronic visceral ischemia. Three decades of progress. Ann Surg. 1991 Sep. 214(3):276-87; discussion 287-8. [Medline]. [Full Text].

  10. Thomas JH, Blake K, Pierce GE, et al. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998 May. 27(5):840-4. [Medline].

  11. Schermerhorn ML, Giles KA, Hamdan AD, et al. Mesenteric revascularization: management and outcomes in the United States, 1988-2006. J Vasc Surg. 2009 Aug. 50(2):341-348.e1. [Medline]. [Full Text].

  12. Aksu C, Demirpolat G, Oran I, et al. Stent implantation in chronic mesenteric ischemia. Acta Radiol. 2009 Jul. 50(6):610-6. [Medline].

  13. Oderich GS, Erdoes LS, Lesar C, Mendes BC, Gloviczki P, Cha S, et al. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg. 2013 Nov. 58(5):1316-23. [Medline].

 
Previous
Next
 
Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is termed meandering mesenteric artery. As seen on angiography, this is sign of chronic mesenteric ischemia.
Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.
Celiac artery is exposed at its origin in preparation for antegrade bypass.
Superior mesenteric artery and several branches are exposed for antegrade bypass.
Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.
Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
Upper gastrointestinal series (barium swallow) shows ulcer.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.