Académique Documents
Professionnel Documents
Culture Documents
Disorders
1
Figure 150-10 A, Suprarenal coarctation (bracket) with superior mesenteric artery stenosis (arrow). B,
Subsequent thoracoabdominal bypass (broad arrow) with aortic implantation of superior mesenteric artery (arrow).
(From Stanley JC, et al: Abdominal aortic coarctation: surgical treatment of 53 patients with a thoracoabdominal
bypass, patch aortoplasty, or interposition aortoaortic graft. J Vasc Surg 48:1073-1082, 2008.)
S
E
C
TI
O
N
24
R
E
N
O
V
A
S
C
Figure 150-12 A, Absence of the abdominal aorta and agenesis of the proximal main renal arteries, with
reconstitution of the distal renal arter- ies and iliac arteries by way of extensive collateral vessels. B, Complex
thoracic aortobi-iliac bypass with bilateral renal artery reconstructions.
Figure
150-13
Bilateral
renal
artery-aortic
implantations. Note the residual origins of the native
renal arteries. (From Stanley JC, et al: Pedi- atric
renovascular hypertension: a thirty-year experience of
operative treatment. J Vasc Surg 21:212-227, 1995.)
Large clinical experiences with pediatric-aged renovascular hypertension are uncommon.7,49-55 The published University of Michigan series included 97 children (39 girls and 58
boys), ages 3 months to 17 years, who underwent operation
from 1963 to 2006.2 All but one patient had refractory hypertension not responsive to medical therapy. Renal artery
S
E
C
TI
O
N
24
R
E
N
O
V
A
S
C
treat lengthy CA or SMA stenoses in young patients. Anastomoses are fashioned with interrupted sutures when reconstructing small arteries 2 to 3 mm in diameter. In older
adolescents, a continuous suture may be used to complete
anastomoses of larger splanchnic arteries. In other children,
aortic implantation of the CA or SMA after spatulation of
the transected vessel beyond its stenotic origin is favored
over an aortosplanchnic bypass. Patients treated by both
methods are quickly able to gain weight and are rapidly freed
of abdominal discomfort. Developmental CA or SMA
stenoses in adults may be reconstructed with either vein
grafts or synthetic conduits. Percutaneous transluminal
balloon angio- plasty with or without stenting in children for
these splanch- nic ostial lesions is not appropriate and illadvised.
Splanchnic arterial occlusive disease encountered in
childhood has an uncertain natural history. Long-term
follow-up of these children with periodic imaging studies in
those operated upon seems appropriate, and regular clinical
assessment of those not subjected to surgical therapy is recommended. With regard to the latter, it is important to
remember that most CA and SMA stenoses are asymptomatic
because of the inferior mesenteric artery serving effectively
as a source of collateral circulation. Unoperated patients
should be aware of their splanchnic arterial anatomy and be
able to pass this information to a surgeon performing a later
abdominal operation. Inadvertently interrupting the collateral circulation might cause catastrophic intestinal ischemia
in these individuals.
ENDOVASCULAR TREATMENT
Figure
150-16
Superior
mesenteric
artery
implantation into infrare- nal aorta (arrow), as
treatment of intestinal ischemia due to an ostial
stenosis of this artery, in a child with near occlusion of
the supraceliac abdominal aorta who underwent a
concomitant thoracoabdominal bypass to the distal
aorta (not visualized on this lateral aortogram).
S
E
C
TI
O
N
24
R
E
N
O
V
A
S
C
2355.e1
REFERENCES
1. Stanley JC, et al: Abdominal aortic coarctation: surgical treatment of
53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft. J Vasc Surg 48:10731082, 2008.
2. Stanley JC, et al: Pediatric renovascular hypertension: 132 primary
and 30 secondary operations in 97 children. J Vasc Surg 44:12191228;
discussion 12191228, 2006.
3. Sen PK, et al: The middle aortic syndrome. Br Heart J 25:610618,
1963.
4. Messina LM, et al: Middle aortic syndrome. Effectiveness and
durability of complex arterial revascularization techniques. Ann Surg
204:331339, 1986.
5. Arnot RS, et al: The anatomy of the posterior wall of the abdominal
aorta. Its significance with regard to hypoplasia of the distal aorta. S
Afr Med J 47:899902, 1973.
6. Stanley JC, et al: Developmental occlusive disease of the abdominal
aorta and the splanchnic and renal arteries. Am J Surg 142:190196,
1981.
7. Stanley JC, et al: Pediatric renovascular hypertension: a thirty-year
experience of operative treatment. J Vasc Surg 21:212226; discussion
212226, 1995.
8. Connolly JE, et al: Middle aortic syndrome: distal thoracic and abdominal coarctation, a disorder with multiple etiologies. J Am Coll Surg
194:774781, 2002.
9. Delis KT, et al: Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment. Perspect Vasc Surg
Endovasc Ther 17:187203, 2005.
10.
Delis KT, et al: Neurofibromatosis type 1: from presentation and
diag- nosis to vascular and endovascular therapy. Perspect Vasc Surg
Endovasc Ther 18:226237, 2006.
11.West CA, et al: Middle aortic syndrome: surgical treatment in a child
with neurofibromatosis. J Vasc Surg 42:1236, 2005.
12.
Flynn PM, et al: Coarctation of the aorta and renal artery
stenosis in tuberous sclerosis. Ped Radiol 14:337339, 1984.
13.
Hall EK, et al: A case report of rapid progressive coarctation and
severe middle aortic syndrome in an infant with Williams syndrome.
Congen Heart Dis 4:373377, 2009.
14.
Radford DJ, et al: The middle aortic syndrome: an important
feature of Williams syndrome. Cardiol Young 10:597602, 2000.
15.
Salerno AE, et al: Vascular involvement in tuberous sclerosis.
Pediatr Nephrol 25:15551561, 2010.
16.
Shefler AG, et al: Middle aortic syndrome in a boy with
arteriohepatic dysplasia (Alagille syndrome). Pediatr Cardiol 18:232
234, 1997.
17.
Friedman JM, et al: Cardiovascular disease in neurofibromatosis
1: report of the NF1 cardiovascular task force. Genet Med 4:105111,
2002.
18.
Hamilton SJ, et al: Insights into the pathogenesis of
neurofibromatosis 1 vasculopathy. Clin Genet 58:341344, 2000.
19.
Lin AE, et al: Cardiovascular malformations and other
cardiovascular abnormalities in neurofibromatosis 1. Am J Med Genet
95:108117, 2000.
20.
Oderich GS, et al: Vascular abnormalities in patients with
neurofibro- matosis syndrome type I: clinical spectrum, management,
and results. J Vasc Surg 46:475484, 2007.
21.
Easton DF, et al: An analysis of variation in expression of
neurofibroma- tosis (NF) type 1 (NF1): evidence for modifying genes.
Am J Hum Genet 53:305313, 1993.
22.
Degterev A, et al: The role of NF1 factors in regulation of elastin
gene transcription. Matrix Biol 18:295307, 1999.
23.
Esterly JR, et al: Vascular lesions in infants with congenital
rubella.
Circulation 36:544554, 1967.
24.
Limbacher JP, et al: Hypoplasia of the abdominal aorta associated
with rubella syndrome. South Med J 72:617619, 1979.
25.
Singer DB, et al: Pathology of the congenital rubella syndrome. J
Pediatr
71:665675, 1967.
26.
Ogino H, et al: Overview of late outcome of medical and surgical
treat- ment for Takayasu arteritis. Circulation 118:27382747, 2008.
27.
54.
2355.e2
55.
SECTION 24
Renovascular Disease
62.
CHAPTER 151
Based on a chapter in the seventh edition by Juan Carlos Jimenez and William J. Quinones-Baldrich
aorta to the SMA in 1962. Stoney and Wylie 7 at the University of California, San Francisco, first described antegrade
aortovisceral bypass and transaortic visceral thromboendarterectomy in 1966. Ushering in the current era of percutaneous treatment of visceral arterial occlusive disease, Furrer8
and Novelline9 separately published the initial reports of
endovascular dilatation of the SMA in 1980, and Finch 10 first
reported the treatment of a celiac artery stenosis with a
Palmaz stent.
CHAPTER 151
Considerations
collateral vessel in response to significant stenosis or occlusion of the SMA or IMA.11 Sigmoidal branches lead to the
left and right superior rectal arteries, which collateralize with
branches of the hypogastric arteries in the pelvis.
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
EPIDEMIOLOGY
Asymptomatic occlusive disease of the visceral arteries is a
common finding in elderly patients. Wilson et al15 demonstrated that 17.5% of 553 consecutive patients older than 65
years examined with duplex ultrasonography (DUS) had a
critical stenosis of at least one visceral vessel. In addition,
autopsy studies have estimated the prevalence of atherosclerosis involving the mesenteric arteries to be between 6%
and 10%.19
Despite an aging population, hospitalizations for AMI in
the United States have declined from 9.6 to 6.7 per 100,000
from 1998 to 2010.20 There is some evidence that this decline
may be related to the increasing and widespread use of
statins and the efficacy of warfarin in the prevention of
thromboem- bolic events in patients with atrial fibrillation. 21
Probably in part because of differences in longevity, AMI
and CMI dis- proportionately affect women, with a femaleto-male ratio of approximately 3 : 1.22
Because the majority of patients with mesenteric
occlusive disease manifest no symptoms, the exact incidence
of CMI is not known. However, admissions for CMI
account for less than 1 per 100,000 admissions23 and have
been increasing steadily in recent years in the United
States.22 Whether these figures represent an actual increasing
incidence or simply increased re-intervention due to
restenosis from endovascular therapy remains to be
determined. Despite the high preva- lence of individuals
with asymptomatic mesenteric arterial occlusive disease,
patients usually demonstrate involvement of two or more
mesenteric vessels before symptoms arise owing to the
development of extensive collateralization over time. In fact,
in a study by Thomas et al,24 who observed 980 consecutive
patients with asymptomatic significant (50%) stenosis of at
least one mesenteric artery, only four patients developed
mesenteric ischemia and all of them had signifi- cant threevessel disease after follow-up of 1 to 6 years. The variability
of symptoms in patients with chronic abdominal pain often
makes the diagnosis challenging, resulting in treat- ment
delays and increased morbidity.
PATHOPHYSIOLOGY
Chronic Mesenteric Ischemia
Atherosclerosis is the most common cause of CMI, and
patients frequently have a history of smoking, hypertension,
and hyperlipidemia. They may also have evidence of atherosclerotic disease in other vascular beds, particularly
coronary, cerebrovascular, renal, aortoiliac, and other
peripheral arter- ies. Although it is much more uncommon,
CMI may also be
Arterial Thrombosis
14
SECTION 25
Disease
Mesenteric Vascular
Figure 151-1 A, Operative findings typical of acute mesenteric ischemia secondary to an embolus. Note that the
first portion of the jejunum is spared because the embolus lodged distal to the middle colic artery. B, Operative
findings typical of acute mesenteric ischemia secondary to arterial thrombosis. Note that the entire bowel is
affected. C, Appearance of the small bowel at second-look surgery after revascularization. Note the hemorrhagic
changes in the mesentery.
Proximal
jejunum
Nonocclusive Mesenteric Ischemia
A
B
Impaired intestinal perfusion in the absence of thromboembolic occlusion is termed nonocclusive mesenteric ischemia
(NOMI) and makes up approximately 5% to 15% of cases.31
Visceral ischemia can occur from a low-flow state, which is
exacerbated by the presence of any intestinal atherosclerotic
disease. It is theorized that in such circumstances, in an effort
to maintain cardiac and cerebral perfusion, excessive sympathetic output results in mesenteric vasospasm. NOMI most
commonly occurs secondary to cardiac disease, particularly
severe congestive heart failure, and in patients who have
undergone cardiac surgery. Atrial fibrillation, commonly a
cause of cardiac thrombi and visceral embolization, can also
induce NOMI by reducing left ventricular function and
causing low cardiac output. Other risk factors for NOMI
include age, hypovolemia, systemic vasoconstrictors,
vasoac- tive drugs (e.g., digoxin, -adrenergic agents, receptor blocking agents, cocaine), aortic insufficiency,
cardiopulmo- nary bypass, abdominal and cardiovascular
surgery, abdomi- nal compartment syndrome, and liver
failure.25,32
In recent years, NOMI has been increasingly observed in
patients on hemodialysis. Quiroga et al33 reported incidence
rates more than 40 times greater among patients on hemodialysis compared with the general population. Using the
Taiwan National Health Insurance Research Database, Li
et al34 similarly reported a 44-fold higher risk of mesenteric
ischemia in patients on hemodialysis or peritoneal dialysis
compared with the general population. Older age and a
heavier burden of cardiovascular risk factors undoubtedly
contribute to these disparities. In addition, patients with endstage renal disease are frequently taking erythropoietin,
which elevates red cell mass and can lead to relative hyperviscosity. However, hypotension during dialysis has been
implicated as the most important and immediate precipitating risk factor for development of NOMI. 35 Therefore,
special care should be made to avoid dialysis-related
hypotension in patients at particularly high risk. High-risk
patients include those who are older, are taking
erythropoietin, have a longer history of dialysis, and are
diabetics.33,35
C
MVT constitutes 5% to 15% of all cases of mesenteric
ischemia.36,37 Involvement is usually limited to the superior
mesenteric vein, but the inferior mesenteric, splenic, and
portal veins can also be involved. MVT is classified as
either primary (idiopathic) or secondary. Secondary MVT
occurs when an underlying disease process is present; this
type accounts for 90% of all patients with this disorder.
Conditions associated with MVT can be categorized into
three major categories: direct injury, local venous stasis or
congestion, and thrombophilia. Causes of direct injury
include abdominal surgery, trauma, and local inflammation,
such as that seen with inflammatory bowel disease, pancreatitis, and diverticulitis.38,39 Splanchnic venous stasis may
occur in the case of increased intra-abdominal pressure,
obesity, and intraoperative manipulation of the mesenteric
vessels. Inherited or acquired hypercoagulable diseases,
including protein C and protein S deficiency, myeloproliferative disorders, antithrombin III deficiency, antiphospholipid antibody syndrome, and factor V Leiden mutation,
are frequent causes of thrombophilia and thus also
predispose to MVT.40
The extent of bowel ischemia depends largely on the
degree of venous involvement and the presence of collateral
vessels. The transition from normal to ischemic intestine
is slower with MVT than with arterial occlusive disease.25
Edema and hemorrhage of the intestinal wall are frequently
seen, followed by focal sloughing of the mucosa. 25 The
origin of thrombosis varies, depending on the etiologic
process. When an intra-abdominal process is the cause,
thrombosis begins in the larger mesenteric veins and progresses to involve the smaller venous arcades and arcuate
channels.41 MVT caused by hypercoagulable conditions
usually begins in the smaller mesenteric veins. Symptomatic
acute MVT is associated with a 20% to 50% mortality
rate.41 A Swedish population-based autopsy study showed
that MVT-related death is more likely in patients with
portal vein thrombosis, systemic venous thromboembolism,
and obesity.42
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
CLINICAL PRESENTATION
Acute Mesenteric Ischemia
The most common symptom of AMI associated with arterial
thromboembolic disease is the sudden onset of abdominal
pain. Because of a lack of collateral flow to the visceral
organs, the presentation of AMI is more dramatic and severe,
often with rapid clinical deterioration. Nausea, vomiting,
diarrhea, emptying symptoms, and distention can also occur.
Classi- cally, the pain is out of proportion to the findings on
physical examination. Initially, bowel sounds are hyperactive
as the failure to relax the bowel smooth muscle leads to
emptying symptoms. Bowel sounds are typically diminished
in the later stages. Abdominal guarding and rebound
tenderness are absent in the early stages of AMI; however,
as intestinal ischemia and infarction progress, these signs
become more pronounced. They are typically late findings,
so their absence should not delay the diagnosis and treatment
of AMI. Other late findings include fever, oliguria,
dehydration, confusion, tachycardia, and shock.25 Metabolic
abnormalities can include leukocytosis, metabolic acidosis,
hyperamylasemia, elevated liver function values, and lactic
acidemia.
Patients with NOMI or MVT typically present with a
slower, more insidious clinical course. Frequently, patients
with NOMI are critically ill, hospitalized, intubated patients
who experience a sudden deterioration in their clinical condition. These patients are often administered intravenous
pressors, worsening mesenteric vasoconstriction and thus
decreasing splanchnic perfusion. In patients with MVT,
fever, abdominal pain and distention, nausea and vomiting,
and bloody stools are the most common findings.
Dehydration and profound fluid shifts lead to bloody ascites
and a hypo- volemic state, causing further propagation of
venous throm- bosis.25 Although nonspecific, normal Ddimer levels may help rule out MVT.43
To develop better diagnostic criteria to reduce delays in
diagnosis, Mitsuyoshi et al44 reviewed their 13-year experience treating 22 patients with NOMI. Multidetector row
computed tomography (MDCT) was unavailable at the time
the first 13 patients were treated, and 9 subsequently died
of intestinal necrosis. These first 13 cases were used to
devise four criteria for determining which patients
warranted MDCT evaluation once this technology
became available:
(1) ileus or abdominal pain, (2) catecholamine
requirement,
(3) episode of hypotension, and (4) gradual rise in serum
transaminase level. If three of the four criteria were present,
patients received MDCT and underwent treatment with
high-dose intravenous prostaglandin E1. Of the nine patients
treated with this algorithm, only one died.
DIAGNOSTIC EVALUATION
Noninvasive Evaluation
DUS is a useful tool for the early, noninvasive diagnosis of
visceral ischemic syndromes. Color Doppler scanning can be
used to assess the flow velocities and resistance index in the
splanchnic arteries and their arterial beds as well as to evaluate end-organ vascularity. The intestinal wall can also be
assessed with a high degree of accuracy by high-resolution
CHAPTER 151
Considerations
47
transabdominal ultrasound. Transmural hemorrhage, inflammation, and necrotic thickening in the bowel wall can be
imaged sonographically. Asymmetrical wall thickening with
associated ileus as well as ascites and free peritoneal air can
be seen in patients with AMI.48 DUS combined with expiratory maneuvers is also an excellent screening examination
for median arcuate ligament syndrome.
Moneta et al49 performed blinded DUS studies in 100
patients who previously underwent arteriography of the
celiac trunk and SMA. They hypothesized that lack of flow
or a peak systolic velocity (PSV) in the SMA of greater
than 275 cm/s, or no flow or a PSV of greater than 200 cm/s
in the celiac trunk, was a reliable indicator of 70% or greater
angiographic stenosis.50 With use of these criteria, duplex
sensitivity for detection of lesions in the SMA and celiac
artery was 92% and 87%, respectively. Overall accuracy for
detection of a 70% lesion in the SMA and celiac artery
was 96% and 82%, respectively. The IMA is not generally
assessed because it is generally difficult to visualize and is
of lower clinical importance. However, patency of the IMA
can usually be determined.
Limitations of transabdominal duplex scanning include
the wide variation in examination quality, which is operator
dependent. Patient-related factors, such as obesity, excessive
intraluminal bowel gas, variation in local anatomy, and
effects of respiration, can affect image quality.51 Care must be
taken to clearly define the origin of each vessel to avoid
inac- curate measurements. DUS is generally not
recommended in the workup of AMI.
DUS is also the primary imaging modality used for surveillance after both bypass and stenting. However, no
specific criteria exist for determining restenosis. Baker et al 52
evalu- ated the accuracy and utility of DUS for detection of
in-stent stenosis in 23 patients who underwent successful
(<20% residual stenosis on completion angiography)
mesenteric stenting for CMI (20 SMA alone, 3 both SMA
and celiac artery). Preprocedure DUS was performed in 13
patients with a mean PSV of 464 cm/s. Initial surveillance
DUS was per- formed in 21 patients at a mean of 0.9
month after revas- cularization. Mean PSV at this time
was 335 cm/s, and for 12 of these patients, the first
postoperative PSV in success- fully stented vessels was
higher than the 275 cm/s threshold used to diagnose highgrade native SMA stenosis. In addi- tion, there was no
correlation between surveillance PSV and the degree of
angiographic stenosis seen at the time of re-intervention.
In their review of 107 patients who underwent endovascular therapy for CMI, Schoch et al53 similarly reported that
although 83% of patients had recurrent stenosis on surveillance DUS, 53% of patients remained asymptomatic and
required no further intervention. These findings therefore
mandate obtaining an early baseline DUS against which
future surveillance scans can be compared. They also stress
the importance of considering the clinical context and
symptom recurrence in making the decision to re-intervene.
The predictive value of DUS for detection of disease
recurrence after mesenteric bypass has also been studied.
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Invasive Evaluation
Conventional angiography remains the gold standard in
the diagnosis of mesenteric ischemia. Anteroposterior and
lateral views of the visceral aorta (Fig. 151-3) as well as
selective catheterization of the celiac trunk, SMA, and
IMA provide the most accurate and specific localization of
stenotic and occlusive lesions. Therapeutic alternatives such
as balloon angioplasty, stenting, and thrombolysis and percutaneous thrombus extraction can all be used to restore
luminal visceral blood flow. These options are discussed in
more detail in the next section.
Gastric tonometry, or the measurement of PCO2 levels in
the gastric, jejunal, or colonic mucosa through a nasogastric
catheter, has been shown to be a useful adjunct for the diagnosis of mesenteric ischemia56,57 but is not currently widely
used in the United States.
SMA
stenosis
Meandering
collateral
C
Figure 151-3 A, Anteroposterior angiogram of a patient
with chronic mesenteric ischemia. Note the
meandering mesenteric collateral
vessels. B, Lateral aortogram of a patient with chronic
mesenteric
Medical Treatment
Preventive risk factor modification helps control the progression of atherosclerosis in the mesenteric circulation, but
medical treatment alone is not effective in patients with
symptomatic mesenteric ischemia. Patients with known risks
for inheritable hypercoagulable disorders should undergo
screening and should be treated with systemic anticoagulation if indicated.
Before operation, aggressive fluid resuscitation with
resto- ration of adequate urine output is required owing to
the frequent finding of severe dehydration on presentation.
Elec- trolyte abnormalities and metabolic acidosis should
also be corrected. Patients with CMI are frequently
malnourished, so albumin, prealbumin, transferrin, and Creactive protein
levels should be checked before revascularization. Preoperative total parenteral nutrition or enteral nutrition should be
considered in severely malnourished patients. Finally,
because the intestinal mucosa is damaged during periods of
prolonged ischemia, bacterial translocation can occur,
contributing to systemic sepsis. Broad-spectrum intravenous
antibiotics with aggressive fluid resuscitation can lead to
decreased mortality in these patients.58 Treatment against
gram-negative and anaerobic organisms is especially
important.
A recent Cochrane review of 22 randomized controlled
trials investigating the use of different antiplatelet regimens
after endovascular treatment of peripheral vascular disease
concluded that there is limited evidence to support the use
Endovascular Treatment
General Principles
Advances in endovascular techniques have greatly expanded
the role of percutaneous interventions for patients with mesenteric ischemia in recent years. Balloon angioplasty with
stenting has surpassed open surgery as the dominant method
of revascularization for CMI,22 and an endovascular approach
is now generally accepted as primary therapy.60-62 In contrast,
the adoption of endovascular modalities for treating AMI has
been slower, and a decline in the number of open revascularizations has not been observed.22 This is likely because most
patients with AMI have some degree of bowel ischemia
and many require laparotomy for adequate evaluation and
potential resection. In those with short-segment stenoses,
cardiac and pulmonary comorbidities, prior abdominal
surgery, coagulopathy, or malnutrition, endovascular therapy
is often favored.
Efficacy
Acute Mesenteric Ischemia. Because AMI occurs
so infre- quently and most revascularizations for AMI until
recently have been performed open, there are relatively few
retrospec- tive reviews describing outcomes after
endovascular treat- ment of AMI. Arthurs et al63 at the
Cleveland Clinic reported their experience with
revascularization in 70 consecutive patients with AMI from
1998 to 2008. Over time, their institution adopted an
endovascular-first approach, such that 81% of the patients
in their series were treated with endo- vascular therapy.
The etiology was more often thrombotic (endovascular
72% vs open 36%) than embolic (endovascu- lar 28% vs
open 64%), and age was older in patients undergo- ing
endovascular-first therapy (65 years vs 60 years), but there
were no other significant differences in comorbidities or
clini- cal presentation between the treatment groups.
Technical success was 87%, and 31% of patients were
able to avoid laparotomy. Compared with patients
undergoing open revas- cularization, those who underwent
endovascular revascular- ization had shorter lengths of
bowel resected, developed fewer complications, and had
lower perioperative mortality (39% vs 50%; P < .05).
Ryer et al64 also published their institutions 2-decade
(1990-2010) experience with revascularization for 93
patients with AMI. In addition, they performed a subgroup
analysis
between
the
45
patients
undergoing
revascularization in the first decade compared with the 48
treated in the second decade. More patients underwent
endovascular revasculariza- tion in the latter decade (7% vs
17%), but this difference was not significant, and the
majority (88%) of all patients still underwent open
revascularization. Improvements in mortal- ity between the
first and second decade were modest and
nonsignificant (30-day mortality: 27% vs 17%, P = .28; 1year mortality: 51% vs 31%, P = .11).
Chronic Mesenteric Ischemia. A large body of
literature now exists documenting early success and
favorable outcomes for patients with CMI undergoing
percutaneous endovascular therapy,53,65-71 and several
institutions have recently published their midterm outcomes.
Between 1995 and 2007, Dias et al72 successfully stented 47
of 49 mesenteric vessels in 43 patients with CMI. No
technical failures occurred after a 3-year learn- ing curve.
Intraoperative complications occurred in seven (15%)
patients, but all were successfully managed with endovascular techniques. No patient died within 30 days, and
87% of patients experienced symptom relief. Three-year
survival was 76%, and re-interventionfree survival was
60%.
Peck et al62 also published their intermediate outcomes
with similar results. From 2002 to 2008, 66 mesenteric arteries were treated in 49 patients. All patients had at least one
mesenteric vessel successfully treated, but five technical failures occurred (four mesenteric occlusions could not be
crossed and one IMA could not be stented). There was one
in-hospital death due to a myocardial infarction in a patient
who under- went a peripheral bypass during the same
admission. Symptom relief was achieved in 90%, and major
complications occurred in 16%. Three-year primary patency
was 64%, and freedom from symptomatic recurrence was
63%.
Compared with traditional open approaches, endovascular
revascularization results in lower or similar perioperative
mortality, fewer complications, and shorter hospital stays but
is associated with higher rates of recurrence of symptoms,
restenosis, and re-intervention73-75 Oderich et al73 performed
a risk-stratified comparison of 146 patients who underwent
open and 83 patients who underwent endovascular revascularization for CMI. Operative risk was assessed by the
Society for Vascular Surgery scores, and patients were
classified as high risk by the presence of at least one highrisk
criterion.
Patients
undergoing
endovascular
revascularization were sig- nificantly older (71 years vs 65
years; P < .5) and higher risk (58% vs 31%; P < .001).
Angiographic features and extent of disease were similar
between the endovascular and open treatment groups. For
both low- and high-risk patients, there were no differences in
procedure-related mortality, but patients in the endovascular
group had fewer complications and shorter intensive care
unit and hospital stays. At 5-year follow-up, patients who
had undergone open revasculariza- tion had superior
recurrence-free survival (89% vs 51%) and primary patency
(88% vs 41%). Patients undergoing endo- vascular
revascularization had 5.1-fold higher odds of reste- nosis and
4.3-fold higher odds of re-intervention than did patients
undergoing open revascularization.
In a study by Atkins et al, 74 42 mesenteric vessels treated
with angioplasty (with stenting in 87%) were compared with
88 vessels treated with open revascularization. Mean followup was 15 months in the percutaneous transluminal
angioplasty (PTA) group and 42 months in the open surgery
group. No difference was noted in major morbidity or
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Limitations
Endovascular therapy should be the treatment of choice in
high-risk patients with CMI. High technical success rates
and decreased patient morbidity and mortality rates have
been reasonably well established in such individuals.
However, in patients who are good surgical candidates,
the advantage is not so clear. Restenosis and symptomatic
recurrence rates remain relatively high, as documented in
the current litera- ture, and re-intervention is often
required earlier and more frequently than with open
surgery. Placement of stents in the mesenteric arteries
may also complicate future surgical inter- vention,
especially in the celiac trunk, which is relatively short
before branching. However, anastomosis to the hepatic
artery is usually not compromised by prior celiac stent
placement. Because the origins of the visceral arteries are
Recommendations
At our institution, we perform mesenteric angiography for all
patients with CMI and attempt primary stenting as first-line
therapy. The brachial approach has been preferred for selective catheterization of the SMA owing to its acute downward
angle at its origin. However, recently we have started using
a deflecting tip sheath from a femoral approach with good
results in selected patients. Patients with isolated stenosis of
the celiac artery due to extrinsic compression by the median
arcuate ligament and appropriate symptoms undergo laparoscopic lysis of the median arcuate ligament first (Fig. 151-5).
Balloon angioplasty and stenting are avoided initially in
these patients but may be used after median arcuate ligament
release in patients with persistent abdominal symptoms and
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Inspiration:
no stenosis
A
Expiration:
stenosis
B
Figure 151-5 A and B, Angiographic documentation
of extrinsic compression of the celiac artery by the
median arcuate ligament. Note that the stenosis is
more severe on expiration.
Surgical Treatment
General Considerations
Laparotomy with visceral revascularization can be used to
treat patients with both AMI and CMI. Patients presenting
with signs and symptoms of AMI require urgent abdominal
exploration, assessment of bowel viability, and revascularization. Several techniques for the restoration of intestinal perfusion are available to the vascular surgeon, and familiarity
with a variety of options is crucial. Before revascularization,
large segments of both small and large intestine may appear
dusky, ischemic, or necrotic. Because SMA emboli typically
lodge distal to its origin, the middle colic artery and ileocolic
branches may remain patent. Thus, the pattern of bowel
L renal
Celiac
L renal
Figure 151-7 A, Transaortic endarterectomy
using a trap-door incision in a patient with severe aortic, mesenteric,
and renal occlusive disease. B, Appearance of the visceral vessel orifice after transaortic endarterectomy. The
SMA
aortotomy is usually closed with pledgeted
sutures because the arterial wall is very thin after endarterectomy. C,
Celiac
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Typical specimen after transaortic endarterectomy of an orificial lesion. Note the tapered end- point. Patients
selected for this technique should have lesions limited to the proximal segment of the artery. Failure to obtain an
endpoint can be corrected by intraoperative placement of a stent under direct vision. L, Left; SMA, superior
mesenteric artery.
CHAPTER 151
Considerations
Figure
151-8
Right iliomesenteric bypass for
retrograde
revascularization
of
the
superior
SMA
mesenteric artery (SMA). The graft is passed between
the leaves of the base of the mesentery to avoid contact
R common
with the intestines.
iliac artery
Outcomes of Open
Repair
Acute Mesenteric Ischemia. Although AMIrelated mortal- ity after open revascularization has declined
from 50% in the 1990s to 30% in the 2000s, 22 mortality
remains high in patients with AMI even after successful
surgical revascular- ization. One of the contributing factors is
ischemia- reperfusion intestinal injury. Although the goal of
therapy is prompt restoration of mesenteric blood flow,
revasculariza- tion may lead to a paradoxical exacerbation of
tissue damage. Although the exact mechanism is not
reviewed 265
Chronic Mesenteric Ischemia.
Oderich et al
completely under- stood, the production of toxic oxygen
radicals is thought to
89%. All patients with recurrent symptoms underwent reintervention. Half of these (n = 4) required emergency
operation for acute thrombosis. The other half underwent
angioplasty and stent- ing. Table 151-1 presents the results
of revascularization for CMI from selected series.
Table 151-1
No. of
Vessels
Immediate
Technical
Success
N/A
InHospital
Complications
36
3
12Month
Patenc
100
Sympto
m
Recurre
6
Series
Year
No. of
Patients
Oderich
et al73
Kruger
et al112
Atkins et al74
English
et al97
Park et al46
Jimenez
et al95
Cho et al113
2009
146
265
2007
39
41
97
12
95
39
2007
2004
49
50
88
80
100
N/A
39
62
2
29
90
97
22
6
42
42
2002
2002
98
47
179
92
97
100
20
66
3
11
N/A
69
5
9
23
31
2002
25
25
N/A
60
57
41
60
TREATMENT OF NONOCCLUSIVE
MESENTERIC ISCHEMIA
NOMI represents an insidious disease process that is distinct
from thromboembolic AMI but has a similarly high
mortality. Cardiac surgery and low-flow states are the
most common causes of this disorder, and treatment is
directed toward improving circulatory support and increasing
cardiac output. Selective mesenteric angiography remains
the best invasive diagnostic modality, which can be followed
by catheter-based interventions. These include direct infusion
of intra-arterial vasodilators, such as papaverine and
prostaglandin E1, as well as angioplasty and stenting if
necessary.28 Intravenous
rather
than
intra-arterial
prostaglandin E1 has also demonstrated efficacy in treatment
of vasospasm associated with NOMI. 44 In a model of cardiac
tamponadeinduced acute
NOMI, Kang et al114
demonstrated that low doses of intra-arterial iloprost
(prostacyclin), a potent inhibitor of platelet aggrega- tion
with fibrinolytic activity, exhibited a significant vasodilatory effect on mesenteric blood flow.
TREATMENT OF MESENTERIC
VENOUS THROMBOSIS
A detailed discussion of the diagnosis and treatment of MVT
is contained in Chapter 154. The mainstay for treatment of
acute and subacute MVT is the prompt initiation of systemic
anticoagulation, which improves survival and reduces the
risk of recurrence.41 Heparin should be initiated with a bolus
fol- lowed by a continuous infusion to keep the partial
throm- boplastin time between 50 and 70 seconds.
Intravenous antibiotics should be administered to decrease
bacterial trans- location from the intestinal mucosa.
Aggressive fluid resusci- tation and circulatory support
should be performed because of severe bowel edema and
shifting of fluid into the peritoneal cavity. Nasogastric
decompression, bowel rest, and adminis- tration of total
parenteral nutrition are also indicated.
Mean Follow-Up
(Mo)
36
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
237
2
SECTION 25
Disease
Mesenteric Vascular
REFERENCES
1. Bacelli F, cited by Goodman EH: Angina abdominis. Am J Med Sci
155:524528, 1918.
2. Dunphy JE: Abdominal pain of vascular origin. Am J Med Sci
192:109 113, 1936.
3. Warren S, et al: Mesenteric venous thrombosis. Surg Gynecol Obstet
61:102121, 1935.
4. Klass AA: Embolectomy in acute mesenteric occlusion. Ann Surg
134:913917, 1951.
5. Shaw RS, et al: Acute and chronic thrombosis of the mesenteric arteries associated with malabsorption; a report of two cases successfully
treated by thromboendarterectomy. N Engl J Med 258:874878, 1958.
6. Morris GC, Jr, et al: Revascularization of the celiac and superior mesenteric arteries. Arch Surg 84:95107, 1962.
7. Stoney RJ, et al: Recognition and surgical management of visceral
ischemic syndromes. Ann Surg 164:714722, 1966.
8. Furrer J, et al: Treatment of abdominal angina with percutaneous dilatation of an arteria mesenterica superior stenosis. Preliminary communication. Cardiovasc Intervent Radiol 3:4344, 1980.
9. Novelline RA: Percutaneous transluminal angioplasty: newer applications. AJR Am J Roentgenol 135:983988, 1980.
10.Finch IJ: Use of the Palmaz stent in ostial celiac artery stenosis. J Vasc
Interv Radiol 3:633635; discussion 636637, 1992.
11.Lin PH, et al: Embryology, anatomy, and surgical exposure of the great
abdominal vessels. Surg Clin North Am 80:417433, xiv, 2000.
12.Gallavan RH, et al: Pathophysiology of the gastrointestinal system,
Bethesda, Md, 1989, American Physiological Society.
13.
Rosenblum JD, et al: The mesenteric circulation. Anatomy and
physi- ology. Surg Clin North Am 77:289306, 1997.
14.
Perko MJ, et al: Mesenteric, coeliac and splanchnic blood flow in
humans during exercise. J Physiol 513(Pt 3):907913, 1998.
15.
Wilson DB, et al: Clinical course of mesenteric artery stenosis in
elderly Americans. Arch Intern Med 166:20952100, 2006.
16.
Ulker P, et al: Nitric oxide generated by red blood cells following
exposure to shear stress dilates isolated small mesenteric arteries under
hypoxic conditions. Clin Hemorheol Microcirc 2012 [Epub ahead of
print].
17.
Hansen MB, et al: Profile of neurohumoral agents on mesenteric
and intestinal blood flow in health and disease. Physiol Res 47:307
327, 1998.
18.
Vollmar B, et al: Intestinal ischemia/reperfusion: microcirculatory
pathology and functional consequences. Langenbecks Arch Surg
396:13 29, 2011.
19.
Foley MI, et al: Revascularization of the superior mesenteric
artery alone for treatment of intestinal ischemia. J Vasc Surg 32:3747,
2000.
20.
Lo RC, et al: The decline of mesenteric ischemia-related mortality
in the last decade. Abstract presented at the 41st Annual Symposium
of the Society for Clinical Vascular Surgery, Miami, Fla., March 16,
2013.
21.
Go AS, et al: Anticoagulation therapy for stroke prevention in
atrial fibrillation: how well do randomized trials translate into clinical
prac- tice? JAMA 290:26852692, 2003.
22.
Schermerhorn ML, et al: Mesenteric revascularization:
management and outcomes in the United States, 1988-2006. J Vasc
Surg 50:341348. e1, 2009.
23.
Mitchell EL, et al: Mesenteric duplex scanning. Perspect Vasc
Surg Endovasc Ther 18:175183, 2006.
24.
Thomas JH, et al: The clinical course of asymptomatic mesenteric
arterial stenosis. J Vasc Surg 27:840844, 1998.
25.
Bradbury AW, et al: Mesenteric ischaemia: a multidisciplinary
approach.
Br J Surg 82:14461459, 1995.
26.
Shih MC, et al: CTA and MRA in mesenteric ischemia: part 1,
role in diagnosis and differential diagnosis. AJR Am J Roentgenol
188:452 461, 2007.
27.
Mansour MA: Management of acute mesenteric ischemia. Arch
Surg
134:328330; discussion 331, 1999.
28.
Oldenburg WA, et al: Acute mesenteric ischemia: a clinical
review.
29.
intestinal permeability in conven- tional and antibioticdecontaminated rats. Crit Care Med 18:529536, 1990.
42.
Acosta S, et al: Mesenteric venous thrombosis with transmural
intestinal infarction: a population-based study. J Vasc Surg 41:5963,
2005.
43.
Acosta S, et al: D-dimer testing in patients with suspected acute
throm- boembolic occlusion of the superior mesenteric artery. Br J
Surg 91: 991994, 2004.
44.
Mitsuyoshi A, et al: Survival in nonocclusive mesenteric
ischemia: early diagnosis by multidetector row computed tomography
and early treatment with continuous intravenous high-dose
prostaglandin E1. Ann Surg 246:229235, 2007.
45.
White CJ: Chronic mesenteric ischemia: diagnosis and management.
Prog Cardiovasc Dis 54:3640, 2011.
46.
Park WM, et al: Current results of open revascularization for
chronic mesenteric ischemia: a standard for comparison. J Vasc Surg
35:853 859, 2002.
47.
Dietrich CF, et al: Sonographic assessment of splanchnic arteries
and the bowel wall. Eur J Radiol 64:202212, 2007.
48.
Rhee RY, et al: Mesenteric venous thrombosis: still a lethal
disease in the 1990s. J Vasc Surg 20:688697, 1994.
49.
Moneta GL, et al: Mesenteric duplex scanning: a blinded
prospective study. J Vasc Surg 17:7984; discussion 8586, 1993.
50.
Moneta GL, et al: Duplex ultrasound criteria for diagnosis of
splanch- nic artery stenosis or occlusion. J Vasc Surg 14:511518;
discussion 518520, 1991.
51.
Geelkerken RH, et al: Pitfalls in the diagnosis of origin stenosis
of the coeliac and superior mesenteric arteries with transabdominal
color duplex examination. Ultrasound Med Biol 22:695700, 1996.
52.
Baker AC, et al: Application of duplex ultrasound imaging in
deter- mining in-stent stenosis during surveillance after mesenteric
artery revascularization. J Vasc Surg 56:13641371, 2012.
53.
Schoch DM, et al: Management of chronic mesenteric vascular
insuf- ficiency: an endovascular approach. J Am Coll Surg 212:668
675; dis- cussion 675677, 2011.
54.
Liem TK, et al: Duplex scan characteristics of bypass grafts to
mesen- teric arteries. J Vasc Surg 45:922927; discussion 927928,
2007.
E
RI
C
V
A
S
C
U
L
A
R
DI
S
E
A
S
E
2372.e2
55.
SECTION 25
79.
80.
92.
CHAPTER 151
Considerations
106. Schoenberg MH, et al: Oxygen radicals in intestinal ischemia and
reperfusion. Chem Biol Interact 76:141161, 1990.
107. McCallion K, et al: Ischemic preconditioning ameliorates
ischemiaand
reperfusion-induced
intestinal
epithelial
hyperpermeability in rats. Shock 14:429434, 2000.
108. Aksoyek S, et al: Intestinal ischemic preconditioning protects the
intestine and reduces bacterial translocation. Shock 18:476480, 2002.
109. Moore-Olufemi SD, et al: Intestinal ischemic preconditioning
after ischemia/reperfusion injury in rat intestine: profiling global gene
expression patterns. Dig Dis Sci 55:18661877, 2010.
110. Liu KX, et al: Immediate postconditioning during reperfusion
attenu- ates intestinal injury. Intensive Care Med 35:933942, 2009.
111. Kougias P, et al: Determinants of mortality and treatment outcome
following surgical interventions for acute mesenteric ischemia. J Vasc
Surg 46:467474, 2007.
112. Kruger AJ, et al: Open surgery for atherosclerotic chronic
mesenteric ischemia. J Vasc Surg 46:941945, 2007.
113. Cho JS, et al: Long-term outcome after mesenteric artery
reconstruc- tion: a 37-year experience. J Vasc Surg 35:453460, 2002.
114. Kang H, et al: Intravenous iloprost increases mesenteric blood
flow in experimental acute nonocclusive mesenteric ischemia. Crit
Care Med 30:25282534, 2002.
2372.e3
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
CHAPTER 152
Based on a chapter in the seventh edition by Thomas S. Huber and W. Anthony Lee
Mesenteric
Vascular Pathophysiology
Disease:
T
Chronic Ischemia
he first clinical and anatomic descriptions of intestinal
ischemia were recognized by Chienne in 1869 and
Councilman in 1894.1,2 Goodman in 1918 associated the
symptoms of postprandial abdominal pain with those of
patients with angina pectoris.3 Dunphy from the Peter Bent
Brigham Hospital reported in 1936 the correlation between
recurrent abdominal pain and fatal intestinal infarction
from occlusive mesenteric arterial disease.4 In that report,
60% of patients who died of intestinal infarction had a
history of recurrent abdominal pain that preceded the fatal
event by weeks, months, or years. Since then, the term
intestinal angina has been coined to describe the classic
symptom of chronic abdominal pain that occurs after meals,
which is the cardinal symptom of chronic mesenteric
ischemia.
BACKGROUND
Incidence
Current estimates indicate that chronic mesenteric ischemia
accounts for less than 1 per 100,000 hospital admissions
in the United States and less than 2% of all admissions
for gastrointestinal conditions.5 Since the first successful
mesenteric endarterectomy by Shaw and Maynard in 1958,
techniques of revascularization have greatly evolved.6
Advances in diagnostic imaging, medical therapy, surgical
techniques, and endovascular technology resulted in
improved outcomes. Balloon angioplasty was reported for
treatment of mesenteric arterial stenoses by Uflacker, Furrer,
Gruntzig, and colleagues in 1980.7,8 During the last decade,
mesenteric angioplasty and stenting gained widespread
acceptance and became the most frequently used treatment
of chronic mesenteric ischemia, relegating open surgery to
patients who fail to respond to endovascular therapy or
who have complex lesions unsuitable to it. 9 This chapter
provides a comprehensive review of the pathophysiology,
clinical presentation, indications, techniques, and outcomes
of revascularization in patients with chronic mesenteric
ischemia.
237
4
SECTION 25
Disease
Mesenteric Vascular
Etiology
CHAPTER 152
2375
theIschemia
origin or the proximal 2 to 3 cm of the mesenteric
arteries, frequently with associated plaque in the aorta
and renal
Natural History
The natural history of mesenteric arterial disease has not
been completely defined. It is generally accepted that asymptomatic lesions carry a benign course, not justifying prophylactic revascularization. Nonetheless, the observation that
15% to 50% of patients who present with bowel gangrene
have thrombosis of preexisting lesions with no antecedent
warning signs suggests that these lesions are not entirely
benign.22,23 The likelihood of symptom progression seems to
depend on the extent of disease. Wilson et al24 reported a
large prospective cohort study of 553 elderly patients who
were screened for mesenteric artery disease with duplex
ultra- sound. The prevalence of mesenteric stenosis greater
than 70% or occlusion was 18%. After a follow-up period
of 7 years, none of the patients developed symptoms of
mesenteric ischemia, but most had single-vessel disease,
only 14% had SMA stenoses, and none had three-vessel
involvement. Thomas et al25 reviewed 980 aortograms and
found 60 patients (6%) with significant mesenteric artery
disease (>50% stenosis). Of these, 15 had involvement of
all three visceral arteries. During follow-up of 2.6 years, four
patients (27%) developed symptoms, three had successful
revascular- ization, but one died of acute ischemia.
The natural history of patients with symptoms of chronic
mesenteric ischemia is even less well understood because
revascularization is typically recommended. There are no
cohort studies with a control or medical treatment arm.
It is generally accepted that once a patient develops symptoms of chronic ischemia, there is considerable risk of
progression to cachexia or bowel gangrene, and revascularization is indicated.
DIAGNOSTIC EVALUATION
The diagnosis of chronic mesenteric ischemia is suggested
by clinical history and confirmed by one or more diagnostic
studies, such as duplex ultrasonography, magnetic resonance
Clinical Presentation
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
or
malnutrition (decreased serum albumin, transferrin, and prealbumin levels), systemic inflammation (e.g., vasculitis), and
elevation of L-lactate and D-dimer after meal challenge.31
The clinical presentation can be less specific in some
patients. Vague abdominal pain, nausea, vomiting, or change
in bowel habits, without the classic postprandial component
to the pain, can make the diagnosis difficult to ascertain; in
these patients, 24-hour gastric tonometry has been useful if
it is available.32-39 Liver function abnormalities or endoscopic
evidence of diffuse small ulcerations in the stomach or proximal duodenum or patchy areas of ischemia in the colon are
not uncommon. A previous history of smoking and the diagnoses of hypertension and hyperlipidemia are documented in
60% to 70%.19,40,41 Consequently, patients often have other
manifestations of atherosclerotic disease affecting the coronary (50% to 70%), cerebrovascular (20% to 45%), and
peripheral (20% to 35%) arteries. Concomitant renal artery
disease with difficult to control hypertension or ischemic
nephropathy is not uncommon.42 The presence of severe
aortic or peripheral arterial occlusive disease represents a
challenge in terms of source of inflow for bypass, access for
percutaneous procedures, or sequence of revascularization in
patients with limb-threatening ischemia.
Diagnostic Tests
It is not infrequent for patients with chronic mesenteric
ischemia to experience significant delay in diagnosis or to
undergo an extensive evaluation to rule out other causes of
chronic abdominal pain and weight loss. The differential
diagnosis is extensive, including inflammatory, infectious,
and malignant disease. The investigation often includes
upper and lower gastrointestinal endoscopy and crosssectional imaging of the abdomen with either computed
tomography or magnetic resonance imaging. Often, the
finding of mesenteric artery stenosis in an imaging study is
the first clue to the diagnosis. If chronic mesenteric ischemia
Figure 152-2 Mesenteric duplex ultrasound with normal and abnormal waveform patterns during the fasting state.
IMA, Inferior mesenteric artery; PSV, peak systolic velocity; SMA, superior mesenteric artery.
Figure
152-3
Computed
tomography angiography with
three-dimensional
reconstruction in a patient with
severe three- vessel mesenteric
occlusive
disease. A, Note
occlusion of the celiac axis and
su- perior mesenteric artery
(SMA), with collat- eral flow via a
large inferior mesenteric artery
(IMA) and meandering artery.
Collat- eralization from the IMA to
SMA via arc of Riolan (curved
arrow) and marginal artery of
Drummond (arrowhead) and from
the SMA to celiac axis via a large
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Focal Disease
Complex Disease
Figure 152-4 Computed tomography angiography is the most useful imaging study to plan revascularization.
Anatomic characteristics of the superior mesenteric artery can be used to identify patients with focal disease (A),
for which angioplasty and stenting are favored, and patients with complex disease (B), for which endovascular
therapy is technically more challenging. Lesions with unfavorable anatomy for stenting include heavily calcified
occlusions, long-segment occlusions, and long-segment stenosis involving multiple branches.
Contrast Arteriography
Diagnostic
A catheter-based arteriography is considered the
B
gold standard diagnostic study for evaluation of mesenteric
artery disease in patients with chronic mesenteric ischemia.
During the last decade, its role as a confirmatory test and for
planning revascularization diminished in favor of the aforementioned noninvasive modalities. Since 2002, the use of
contrast arteriography to plan mesenteric reconstructions at
the Mayo Clinic decreased from 97% to 57%, with an
increase in the use of CTA (55% to 88%) and MRA (12% to
33%).60 Mesenteric arteriography is rarely needed to confirm
the diag- nosis, and it typically does not add anatomic
detail to plan an intervention. More frequently, angiography
is obtained in conjunction with a planned endovascular
intervention. Exceptions are patients with suboptimal
imaging studies and
Figure 152-5 Abdominal aortogram with right anterior oblique view demonstrates a large patent inferior mesenteric
artery (IMA). Selective IMA angiography confirms collateralization to the superior mesenteric artery via the arc of
Riolan (arrow) and collateralization to the celiac axis via the gastroduodenal artery (arrow).
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
2380
SECTION 25
Disease
Mesenteric Vascular
Endoscopy
Endoscopy is often obtained as part of the investigation of
abdominal pain. It can demonstrate inflammatory and ischemic changes, most noticeable in the stomach, duodenum, or
right colon. Erosive ischemic gastritis, gastroduodenitis, or
ischemic colitis noted on endoscopy has been described in
association with chronic mesenteric ischemia. 61 In a study of
55 patientsAtreated for mesenteric ischemia, endoscopy demonstrated ischemic duodenitis in 38% of patients and ischemic colitis in 57%.62 Clinical experience from European
centers has shown that endoscopy can be useful to assess
mucosal perfusion, to confirm ischemia, and to differentiate
causes of abdominal pain in patients with atypical symptoms
of chronic mesenteric ischemia.32-34,36-39,63-70
Gastric Tonometry
Gastric tonometry has been shown to be a valuable
diagnostic test to assess intestinal perfusion. The initial
concept was described in 1965 and later developed into
clinical protocols32-34,36-39,61
in the late
The study is based on the premise
1980s.
that PCO2 levels rise above normal from reduced carbon
dioxide washout in the ischemic tissue. Higher PCO2 levels
measured in the gastric, jejunal, or colonic mucosa correlate
with poor mucosal perfusion. Tonometry can be performed as
part of a 24-hour monitoring study during the fasting and
postprandial states or as an exercise test using a small nasogastric tonometry catheter with serial PCO2 measurements in
the stomach, duodenum, or upper jejunum.33,35,38 Most
recently, jejunal tonometry has been used with additional
diagnostic value.37 For exercise tonometry, the patient uses a
bicycle ergometer and the gastric-arterial P CO2 gradient is
measured at incremental workloads.36 Excessive or
inadequate exercise can result in false-positive or falsenegative results. Whereas several studies have shown the
clinical utility of tonometry for diagnosis of ischemia, this
modality has not gained widespread acceptance in the
United States.32-39
TREATMENT STRATEGIES
There is no role for a conservative approach with chronic
parenteral nutrition and noninterventional therapy in patients with symptomatic mesenteric artery disease. Excessive
delays in proceeding with definitive revascularization and
CHAPTER 152
REVASCULARIZATION TECHNIQUES
AND
PERIPROCEDURAL
MANAGEMENT
Endovascular Revascularization
Endovascular mesenteric revascularization carries definitive
risk. The average 30-day mortality in a recent systematic
review was 6% (0% to 21%), surpassing the mortality
reported for other types of endovascular interventions,
including aortic, renal, and carotid procedures.73 Even though
most interventions are done with local anesthesia, these
patients typically undergo a comprehensive medical
evaluation to identify and to optimize cardiovascular risk
factors and their nutritional status.
Preprocedure Evaluation
Many of the comorbidities may require medical therapy to be
started before or after the intervention, depending on their
severity. Revascularization should not be excessively
delayed. Patients who present with deterioration of
symptoms should be admitted, prescribed intravenous
heparin, and treated urgently within 24 to 48 hours. Patients
with allergy to iodin- ated contrast agents should be
premedicated with a steroid and antihistamine preparation.
Those with chronic kidney disease who have a serum
creatinine level above 1.5 to
2.0 mg/dL (133 to 177 mmol/L) undergo intravenous hydration with sodium bicarbonate and oral acetylcysteine,
starting the day before intervention. Review of preprocedure
imaging (CTA, MRA, or conventional angiography) is key to
selec- tion of the ideal approach based on the angle of origin
of the mesenteric vessels in relation to the aorta, the amount
of calcium and thrombus load, and the presence of
Diagnostic
Mesenteric
Angiography. Diagnostic angiogra- phy is
most often done immediately before a planned
inter- vention, through either the femoral or
brachial approach. Access is established with
ultrasound guidance and a 0.035- inch guide
wire system. A 5F sheath is positioned in the
external iliac artery and a 5F diagnostic flush
catheter is advanced to T12 level over a 0.035inch guide wire.
Modest
intravenous
heparinization (40 units/kg) is recommended
before selective catheterization of the mesenteric
arteries. The use of a low-osmolarity contrast
agent (e.g., Visipaque) minimizes abdominal
discomfort during selective injections. Choice of
catheter shape depends on access site, angle
of origin, and individual preference. A
multipurpose catheter is ideal for selective
catheterization through a brachial approach,
whereas a secondary curve catheter (e.g., SOS or
Simmons) or a catheter with a more acute curve
(e.g., Cobra 2) can be used for interventions
done through a femoral approach. A complete
study includes abdominal aortography with
anterior- posterior and lateral views to define
the location, severity, and extent of visceral
artery involvement and to identify concomitant
lesions in the aorta and renal or iliac arteries.
The optimal projection to display the proximal
celiac axis and SMA is a lateral view; for the
origin of the IMA, it is a 15-degree right lateral
oblique view. Selective angiography is necessary
to confirm the severity of disease and to
Principles
The primary goal of percutaneous treatment is to restore
antegrade flow into at least one of the three mesenteric arteries, preferentially the SMA. First reports described
successful results with balloon angioplasty alone, but elastic
recoil and restenosis limited its utility for ostial lesions. 81,90-99
Although there are no prospective comparisons between
angioplasty alone and primary stenting, most agree that
routine stenting is indicated, given that mesenteric lesions
resemble renal artery stenoses.84,100-114 Although there are no
randomized comparisons between SMA and celiac stent
placement, ret- rospective studies suggest that celiac
stenting is associated with more recurrences in the first
year after treatment.84 In patients with compression of the
celiac axis by the median arcuate ligament, there is risk of
stent fracture and compres- sion. The role of two-vessel
stenting remains controversial. Two retrospective studies by
the Massachusetts General Hospital group109 and by Silva et
al106 have shown a nonsig- nificant trend toward less
recurrence with two-vessel stent- ing. Malgor et al84 from the
Mayo Clinic reported nearly identical recurrence rates at 2
years in patients treated by SMA stents (78%) compared
with two-vessel stenting of the SMA and celiac axis (60%).
Two-vessel mesenteric interven- tions may have a role in
select patients with severe gastric ischemia who do not have
a good collateral network between the celiac axis and SMA.
However, there is no proven benefit that routine two-vessel
stenting provides more durable relief,
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
238
2
SECTION 25
Disease
Mesenteric Vascular
Technique
Percutaneous access is established by a 0.018-inch micropuncture set with ultrasound guidance, after which the
system is exchanged for a 0.035-inch guide wire system. Full
systemic heparinization (80 mg/kg) is administered before
Figure 152-6 Angioplasty and stenting of a focal stenosis of the superior mesenteric artery (SMA) by a brachial
approach. After selective angi- ography (A), the lesion is crossed and a 0.014-inch SpiderRX filter wire is
deployed in the main trunk of the SMA (B), avoiding jejunal branches. The entire lesion is treated by a balloonexpandable stent (C), which is extended 1 to 2 mm into the aorta and flared proximally (D). Completion
angiography demonstrates patency of the stent without embolization or dissection (E).
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Figure 152-9 Recanalization of superior mesenteric artery (SMA) occlusion by the technique described in Figure
152-8. After the stump is engaged by the catheter, guide catheter, and sheath (A, arrow), the lesion is crossed
(B) and stented with use of embolic protection (C). Note that the balloon is used to flare the proximal part of the
stent (C, arrow). Completion angiography shows a flared, widely patent SMA stent (D).
Complications
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Techniques
Antegrade Supraceliac Aortato Celiacand
SMABypass. The distal thoracic or supraceliac aorta is
often spared from severe atherosclerotic disease. Bypass with
an antegrade graft con- figuration based in the supraceliac or
lower thoracic aorta120 offers a potential hemodynamic
advantage while avoiding kinks that can occur with grafts
placed in a retrograde fashion. Reconstruction of the celiac
axis and the SMA with a bifur- cated polyester graft
originating from the supraceliac aorta compromises more
than 80% of open mesenteric reconstruc- tions.19,121 This
approach is preferentially selected in lower risk patients who
have multivessel disease and no evidence of significant
supraceliac aortic calcification or atheromatous debris.
The operation is performed through a transperitoneal
upper midline or bilateral subcostal incision, depending on
the patients body habitus and costal cartilage flare. Abdominal exploration includes an evaluation for other intraabdominal disease and careful inspection of the small bowel
for unsuspected ischemic perforations. A third-arm retractor
assists with exposure of the upper abdomen. Alternatively,
an Omni self-retaining retractor can be used. The lesser
omentum is opened, and the left lobe of the liver is retracted
after division of the left triangular ligament. The esophagus
is retracted toward the patients left side with a nasogastric
tube in place, and the stomach is gently retracted caudally.
The diaphragmatic crura are divided longitudinally, exposing
the supraceliac aorta (Fig. 152-10). Approximately 5 to
10 cm of supraceliac aorta is dissected free in preparation
for clamping. While doing so, care should be taken not to
enter the pleural cavity on either side of the aorta. Usually
only the celiac trunk and the proximal hepatic and splenic
arteries need isolation; but with more extensive disease,
the common hepatic artery may be a better target for the
anastomosis. The left gastric artery is often small and may
be divided without sequelae, which facilitates celiac anastomosis and makes tunneling of the SMA graft behind the
pancreas easier.
A
B
anastomosed to the celiac axis or hepatic
artery.
S
E
C
TI
O
N
25
M
E
S
E
N
T
E
RI
C
V
A
Figure 152-11 Bifurcated supraceliac aorta to common hepatic artery (A) and superior mesenteric artery bypass (B).
Computed tomography angiogram (C) demonstrates a widely patent bypass
graft.