Abdominal Angina Treatment & Management
- Author: Faisal Aziz, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
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]
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.
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 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.
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.
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)
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.
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.
In addition to the usual cardiac problems traditionally associated with major vascular repairs, major postoperative complications of surgical treatment include the following:
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.
Duplex ultrasonography is the most common modality used for follow-up.
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