Abdominal Angina 

Updated: Aug 13, 2018
Author: Faisal Aziz, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF 

Overview

Background

Abdominal angina is defined as the postprandial pain that occurs in individuals who have mesenteric vascular occlusive disease that has advanced to the point where blood flow cannot increase enough to meet visceral demands.[1] This mechanism is similar to that of the angina pectoris that occurs in individuals with coronary artery disease or the intermittent claudication that accompanies peripheral vascular disease.

Schnitzler first described the clinical picture of postprandial pain in 1901. However, the true description of postprandial abdominal angina is attributed to Baccelli or Goodman (1918). In 1957, Mikkelsen proposed surgical treatment of occlusive mesenteric vascular disease. Shaw and Maynard reported the first transarterial thromboendarterectomy of the superior mesenteric artery (SMA) in 1958. With the advancements in imaging technology, the degree of stenosis in mesenteric arteries can be defined accurately and treated accordingly.

Pathophysiology and Etiology

Intestinal ischemia results from the imbalance of oxygen supply to and oxygen consumption by the gastrointestinal (GI) tract. Diminished blood flow results from narrowing of the mesenteric vessels. The most common cause of abdominal angina is atherosclerotic vascular disease. It commonly involves the ostia of the mesenteric vessels.[2]

The three arteries supplying the gut are the celiac artery, the SMA, and the inferior mesenteric artery (IMA; see the image below). There are collaterals between the celiac artery and the SMA (pancreaticoduodenal arcades) and between the SMA and the IMA (meandering mesenteric artery). In cases of severe ostial narrowing, internal iliac arteries also serve as important sources of collateral hindgut and midgut perfusion in the presence of IMA occlusion.

Superior mesenteric artery and inferior mesenteric 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 pathway Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.

SMA occlusion almost invariably is observed in patients with symptomatic occlusive mesenteric ischemia.

Within a few minutes of eating, there is increased blood flow in the celiac and superior mesenteric vessels in normal individuals. Patients with abdominal angina are unable to sufficiently increase flow in the mesenteric vessels. This leads to fear associated with eating and significant weight loss.

The etiology includes the following:

  • Atherosclerosis
  • Smoking

Epidemiology

The syndrome is extremely rare, and the true incidence is unknown.

The mean age of affected individuals is slightly older than 60 years. Median arcuate ligament syndrome (see Pathophysiology and Etiology) has been reported in young individuals. In contrast to the usual male predilection of atherosclerotic vascular disease, females outnumber males by approximately 3 to 1 in most series. No data are available regarding relative incidence figures among different races.

Prognosis

Surgical management is the criterion standard for treatment of this disease.[3]  Despite advances in surgery, the mortality associated with acute mesenteric ischemia is in the range of 60-95%.

Reocclusion is more prevalent in males than in females.

Several series have demonstrated that 86-96% of patients remain asymptomatic at 5 and 10 years, with similar graft patency rates.

Research suggests that after successful endovascular treatment, symptom relief is immediately achieved in 85% of patients. An overall morbidity of 30.8% has been reported. The most common complication has been reported to be access site hematoma/pseudoaneurysm/thrombosis (15.4%), followed by bowel infarction (4.6%).[4]

A retrospective review by Sundermeyer et al (N = 27) found endovascular SMA treatment to be suitable and safe for patients with chronic mesenteric ischemia, though the authors noted that long-term results were limited.[5]

Cai et al carried out a meta-analysis comparing the clinical outcomes of endovascular revascularization for chronic mesenteric ischemia with those of open revascularization.[6]  The two approaches were similar with regard to 30-day mortality and 3-year cumulative survival rate. The endovascular approach was associated with a lower rate of in-hospital complications but a higher rate of recurrence within the 3 years following revascularization. 

 

Presentation

History

The classic description of abdominal angina is abdominal pain that is out of proportion with physical examination findings. The classic feature is abdominal pain that occurs a few minutes after eating and slowly subsides over next few hours.[7] Gradually, most patients develop fear of eating and lose significant weight. A history of peripheral vascular disease and significant smoking is common.

Physical Examination

Physical examination reveals stigmata of weight loss. The abdomen typically is scaphoid and soft, even during an episode of pain.

In one series, approximately 10% of patients had positive test results for guaiac. Abdominal bruit is present in 60-90% of patients, but this is a common finding in many elderly persons who are not affected by this syndrome.

Signs of peripheral vascular disease, particularly aortoiliac occlusive disease, may be present.

 

Workup

Laboratory Studies

No laboratory tests are diagnostic. Usually, nutritional parameters are suggestive of malnutrition. If malignancy or gastric ulcer disease is suspected, consider obtaining appropriate laboratory and other diagnostic studies.

Imaging Studies

Mesenteric angiography is the classic criterion standard diagnostic study. Because the vessels emerge from the anterior wall of the aorta, the ostia are visualized only on a lateral view (see the first image below). A prominent meandering mesenteric artery (see the second image below) is another clue.

Lateral aortogram shows abrupt cutoffs at origin o 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 arte Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.

Duplex ultrasonography (US) is emerging as a useful screening modality in this setting. It currently is most useful in cases where the diagnosis is suspected.[8, 9]

Indices that are studied include the following:

  • Peak systolic flow - This is increased if a stenosis is present
  • Normal vasodilatory response in response to eating - This is lost, especially in the superior mesenteric artery (SMA)

Computed tomography angiography (CTA) of the aorta and mesenteric arteries is now considered an alternative to mesenteric angiography by most authorities.

Other Tests

Because most of these patients have generalized vascular disease, it is prudent to carry out a cardiovascular evaluation before performing surgery.

 

Treatment

Medical Care

Patients should be counseled to stop smoking. No effective medical therapy for abdominal angina exists. There is no role for screening asymptomatic patients. There is also no role for treating asymptomatic mesenteric artery disease.[10, 11]

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.[12]

Percutaneous approaches via the brachial or radial artery in the upper limb have been described.[13]

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[14] 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.[15]

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

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 US 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 following:

  • Location and number of stenoses
  • Previous surgeries
  • Patient comorbidities
  • Local operative conditions
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.

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.

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

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.

Long-Term Monitoring

Duplex US is the modality most commonly used for follow-up.