The real-world management of acute mesenteric ischemia in Spain: results from a multicenter national survey

Acute mesenteric ischemia is a disease with a relatively low incidence (0,02-0,9% of acute surgical hospitalizations) but a very high mortality rate which can reach up to 100% without early revascularization. Given the above, prompt and accurate diagnosis and subsequent surgical intervention is the cornerstone of treatment and essential to reduce the high mortality rate. Early revascularization can reduce overall mortality by up to 50%. Treatment of acute mesenteric ischemia requires the cooperation of gastrointestinal surgeons, vascular surgeons and interventional radiologists. Thorough clinical examination, contrast computed tomography performed at the initial stage, and the current possibilities of interventional radiology are the keys to improving the results of treatment of acute mesenteric ischemia. The purpose of this paper is to refresh knowledge in the management of acute mesenteric ischemia and summarize the most up-to-date information on the diagnosis and treatment of this disease.

Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. Avoiding delays, using hybrid operating rooms and contemporary revascularization techniques for arterial occlusive AMI, can significantly improve the prognosis. Regional health care systems should be developed to direct AMI patients into centers with sufficient capabilities for providing all aspects of care at all hours. The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. A significant share of patients with an arterial occlusive AMI can be managed by endovascular revascularization without the need for a laparotomy. There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. During laparotomy, an atherosclerotic occlusion at the root of the superior mesenteric artery can be stented by using a retrograde open mesenteric or percutaneous approach, and surgical bypass is seldom needed. Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI. In venous AMI, systemic anticoagulation is sufficient in most cases. In patients whose symptoms do not resolve, there are various options for endovascular and surgical revascularization. In nonocclusive mesenteric ischemia, prevention by maintaining sufficient abdominal perfusion pressure is key. High-level evidence is scarce, but with current knowledge, the prognosis of AMI patients has plenty of room for improvement.

Editors' commentary

Acute mesenteric ischemia is a rare disease entity associated with high morbidity and mortality. Disparate etiologies and nonspecific symptoms make the diagnosis challenging and often result in delayed diagnosis and intervention. Open laparotomy with mesenteric revascularization and resection of necrotic bowel has been considered the gold standard of care. With recent advances in percutaneous catheter-directed techniques, multiple retrospective studies have demonstrated the outcomes of endovascular therapy. Herein, we review the etiology, presentation, and diagnosis of acute mesenteric ischemia with contemporary outcomes associated with both open and endovascular treatments. The PubMed electronic database was queried in the English language using the search words mesenteric, acute ischemia, embolism, thromboembolism, thrombosis, revascularization, and endovascular in various combinations. Abstracts of the relevant titles were examined to confirm their relevance and the full articles then extracted. References from extracted articles were checked for any additional relevant articles. This systematic review encompassed literature for the past 5 years (between 2011 and 2016). Early diagnosis and intervention improves acute mesenteric ischemia outcomes. Early restoration of mesenteric flow minimizes morbidity and mortality. In comparison to open laparotomy with mesenteric revascularization and resection of necrotic bowel, several retrospective studies using administrative data and single-center chart reviews demonstrate noninferior outcomes of an endovascular first approach in acute arterial mesenteric occlusion. For acute mesenteric arterial occlusive disease, both endovascular and open revascularization techniques are viable options. Although there is lack of level 1 evidence, single-center retrospective studies and administrative database studies demonstrated that an endovascular first approach may have improved outcomes in the immediate postoperative period. However, selection and other bias in these studies necessitate the need for definitive randomized prospective studies between endovascular and open mesenteric intervention. In contrast, mesenteric venous thrombosis may be treated with systemic anticoagulation without surgical revascularization. Catheter-directed thrombectomy and thrombolysis can be considered at the discretion of the clinician.

Acute mesenteric ischemia: Pathophysiology, diagnosis, and treatment

The surgical treatment of occlusive acute mesenteric ischemia (AMI) without revascularization is associated with an 80% overall mortality. Early diagnosis is crucial, and revascularization may reduce overall mortality in AMI by up to 50%. A diagnosis of AMI requires a high index of clinical suspicion and the collaborative effort of emergency department physicians, general and vascular surgeons, and radiologists. This article provides an overview of the etiology, physiology, evaluation, and management of acute mesenteric ischemia.

Endovascular management of acute mesenteric ischemia in a young patient with thyrotoxicosis and atrial fibrillation: A case report and review of the literature

Acute mesenteric ischemia (AMI) is a life-threatening disease that leads to bowel infarction and death. The optimal management of AMI remains controversial. The present meta-analysis aimed to estimate the prognostic impact of surgical (SG) versus endovascular or hybrid intervention (EV) as the first-line treatment for acute arterial occlusive mesenteric ischemia and to assess whether endovascular strategy was actually effective in reducing bowel resection. MEDLINE, Scopus and the Cochrane Library databases were searched. There have been no randomized controlled trials comparing SG versus EV for the treatment of AMI. We undertook this systematic review and meta-analysis according to MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines, assessing the included study quality with the Newcastle-Ottawa scale. Seven studies comparing EV versus SG as first strategy for the treatment of AMI were selected for the analyses, reporting of 3020 patients. EV was associated with a reduced risk of in-hospital mortality (RR 0.68; 95% CI 0.59-0.79; fixed-effects analysis; p<0.0001; I 2=4.9%; τ 2=0.025). Pooled prevalence of mortality was 19% for EV and 34% for SG. EV also showed a benefit impact on risk of bowel resection and second-look laparotomy. The present meta-analysis outlines that endovascular revascularization strategy seems to offer advantages in terms of in-hospital mortality and morbidity in case of arterial occlusive AMI. A multidisciplinary team consisting of radiologists, interventional radiologists, cardiovascular and general surgeons comes out to be essential to tailor the right procedure to the patient and improve the outcomes associated with AMI.

A decade's experience with retrograde open mesenteric stenting for acute mesenteric ischemia

Objectives: To present our experience and outcome in the management of acute mesenteric ischemia (AMI) as a thromboembolic complication of COVID 19 infection at king hussein medical center/ Royal Medical Services. Methods: A retrospective single center study conducted on patients with active COVID 19 infection who presented with AMI between the period of March 2020 and December 2021. Results: 23 patients have presented to our vascular surgery department with AMI, mean age was 69 years old. 12 patient were males and 11 patients were females. 6 patients had abdominal pain with no peritonitis while 15 patients had physical signs of peritonitis. Two patients presented with sepsis and hemodynamic unstability. 8 patients were managed conservatively with mortality rate reaching up to 50% among them. 15 patients had exploratory laparatomy, 5 of them found to have total dead bowel and 10 patients were managened with superior mesenteric artery thromboembolectomy leading to a mortality rate as low as 10% among them. Including total number of patients, 10 has died while 13 survived successfully with the mortality rate reaching up to 43.4% all over. Conclusion: Early recognition and prompt management with subsequent revascularization has improved the survival rate of COVID 19 patients presenting with AMI.

Acute mesenteric ischemia (AMI) represents a severe and potentially life-threatening condition caused by an abrupt reduction in intestinal blood flow. This ischemic event, if not promptly addressed, leads to intestinal necrosis. The clinical presentation of AMI is commonly nonspecific and variable, complicating early diagnosis. Without timely detection and intervention, AMI can progress to devastating complications including intestinal necrosis, sepsis, multiple organ dysfunction syndrome (MODS), or short bowel syndrome secondary to extensive bowel resection. Early identification is therefore paramount to optimizing treatment and reducing both morbidity and mortality associated with this condition. This review explores the pivotal role of computed tomography (CT) in the diagnosis of AMI, evaluates the diagnostic accuracy of CT in comparison with alternative imaging modalities, and discusses future advancements aimed at enhancing CT-based diagnostic capabilities. A comprehensive review of the existing literature was conducted, focusing on studies investigating the utility of CT and other imaging techniques in the evaluation of AMI. Relevant diagnostic parameters were analyzed, including bowel wall thickening, pneumatosis intestinalis, and damage within the superior mesenteric artery (SMA) and its branches. The role of CT angiography was also assessed in diagnosing abnormalities of the mesenteric arterial and venous systems. The findings underscore that CT is a highly effective diagnostic tool for AMI, offering superior sensitivity and specificity compared to other imaging technologies such as X-ray, ultrasound, and magnetic resonance imaging (MRI). However, certain limitations — such as suboptimal image quality in specific patient populations, the risks associated with ionizing radiation, and adverse reactions to contrast agents — must be acknowledged and addressed. Despite these challenges, CT has emerged as a cornerstone in the early detection and management of AMI, facilitating rapid and accurate assessments that are critical to improving patient outcomes. Advances in CT technology and integration of artificial intelligence and machine learning algorithms into CT imaging workflows could refine diagnostic accuracy and reduce time-to-diagnosis. A multidisciplinary approach that combines CT imaging with other diagnostic modalities may further optimize the patient management of with AMI. Keywords: acute mesenteric ischemia, mesenteric circulation disorder, computed tomography, CT angiography, early diagnosis, intestinal ischemia, superior mesenteric artery, artificial intelligence, machine learning, multidisciplinary approach. For citation: Kuznetsov M.R., Chernookov A.I., Atayan A.A., Belykh E.N., Kanadashvili O.V., Ramazanov A.A., Ivanova M.I., Tsedinov S.O. Computed tomography in acute mesenteric ischemia: diagnostic possibilities, limitations and the future. RMJ. 2024;10:23–26. DOI: 10.32364/2225-2282-2024-10-4

Acute mesenteric ischaemia is a life-threatening vascular emergency that requires early diagnosis and intervention to adequately restore mesenteric blood flow and to prevent bowel necrosis and patient death. Its overall mortality is 60–80% and the reported incidence is increasing. This case report emphasises that a patient with early detection and radiological management of acute mesenteric ischaemia being symptomatic for COVID-19 can avoid major bowel surgery and negate any morbidity or mortality associated with the same.

Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The standard practice after making the diagnosis includes aggressive resuscitation, anticoagulation, followed by revascularization and resection of necrotic bowel. The role of empiric antibiotics in the management of AMI is not well defined in the literature. This review article aims to examine our current understanding on this matter, based on bench research and clinical studies. It is demonstrated in animal study model that the ischemia/reperfusion (I/R) injury damages intestinal epithelium, and subsequently lead to barrier dysfunction, a condition that can support bacterial translocation through a complex interplay between the intestinal epithelium, the intestinal immune system and the intestine’s endogenous bacterial population. Based on this mechanism, it is possible that the use of antibiotics may help mitigate the consequences of I/R injury, which is examined in few animal studies. In clinical practice, many guidelines support the use of prophylactic antibiotics, based on a meta-analysis of randomized control trials (RCTs) demonstrating the benefit of antibiotics in multi-organ dysfunction syndrome. However, there is no direct reference to AMI in this meta-analysis. Most clinical studies that focus on AMI and mentions the use of antibiotics are retrospective and single institution, and very few comments on the role of antibiotics in their discussions. We conclude that there is limited evidence in literature to support the use of prophylactic antibiotic in AMI to improve outcome. More clinical studies with high level of evidence and basic science research are needed to improve our understanding on this topic and ultimately help build a better clinical pathway for patients with AMI.

Serum lactate and acute mesenteric ischaemia: An observational, controlled multicentre study

Management of acute mesenteric ischaemia: Results of a worldwide survey