Management Of Acute Mesenteric Ischemia Research Articles

Scoping Review of Clinical Presentations and Outcomes in Patients with Concomitant COVID-19 Infection and Acute Mesenteric Ischaemia.

COVID-19 infection confers an increased risk of coagulation dysfunction (1) predisposing to thromboembolism in many anatomical sites including the gastrointestinal tract (GIT) (2). This study investigates the clinical presentation and outcome in patients presenting with concurrent COVID-19 infection and gastrointestinal tract ischaemia. Furthermore, differentiation and comparisons are drawn between those with arterial and venous aetiology for mesenteric ischaemia. A systematic search was undertaken on EMBASE, PubMed, and MEDLINE. Two independent reviewers screened titles, abstracts, and full-text articles according to the inclusion criteria and extracted relevant data. Data analyses were conducted using Excel®. Forty-one studies were included in the data analyses, yielding 44 patients. Twenty-six patients had mesenteric arterial occlusion, sixteen patients had mesenteric venous occlusion, and two patients had both arterial and venous mesenteric occlusion. All patients had concurrent COVID-19 infection. The survival rate in patients with arterial aetiology was 38.5% in contrast to 68.8% in patients with venous aetiology. Twelve patients (29.3%) experienced respiratory symptoms in the community before the onset of gastrointestinal symptoms, and five (12.2%) developed gastrointestinal symptoms during their inpatient stay for COVID-19 pneumonitis. Acute mesenteric ischaemia presents a clinical challenge to diagnose due to its non-specific symptoms. Concurrent COVID-19 infection with its predominant respiratory symptoms adds a further challenge in recognising the non-specific symptoms of mesenteric ischaemia. Our study draws attention to the increased thromboembolic risk posed by COVID-19 infection and the need for a high index of suspicion to aid prompt diagnosis and management of acute mesenteric ischaemia, even in the post-pandemic era.

Advancements in Revascularization Strategies for Acute Mesenteric Ischemia: A Comprehensive Review.

Even with modern advancements in the management of acute mesenteric ischemia over the past decade, morbidity and mortality remain high, and the best primary treatment modality is still debated amongst interventionalists. Traditionally, interventionalists have favored an open surgical approach but are now trending for endovascular interventions due to apparent reduced mortality and complications. Newer studies suggest hybrid approaches, and intestinal stroke centers may be superior to either strategy alone. This narrative review will explore the natural history of acute mesenteric ischemia with the aim of increasing interventionalist awareness of modern advancements in revascularization strategies for this devastating disease.

Acute mesenteric ischemia - a persistent problem.

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.

Management of acute mesenteric ischaemia: Results of a worldwide survey

Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide. A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected. We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity. Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

Mortality and Delays of Management of Acute Mesenteric Ischemia: The Need of a Dedicated Program

To study the mortality and delays of management of patients with acute mesenteric ischemia (AMI) admitted to the emergency department of a tertiary hospital and identify risk factors for 1-month mortality. A single-center and retrospective study including all consecutive patients treated for AMI from January 2008 to December 2018 was conducted. Short- and medium-term survival was studied with a Kaplan-Meier analysis. Delays before diagnosis and surgical intervention were collected. To determine factors associated with mortality at 1month postoperatively, univariate and multivariate analyzes were performed. The survival rate of the 67 included patients was 55.22% at 1month and 37.31% at 1year. In-hospital mortality was 50.74%. The average delay between admission and diagnosis was 4.83±5.03hr (95% confidence interval [CI], 3.60-6.05), and the delay between admission and surgical treatment was 10.64±8.80hr (95% CI, 8.49-12.79). The independent variables associated with an increased mortality at 1month postoperatively in the univariate analysis were age >65years old (odds ratio [OR]=3.52; P=0.046), lactate >3.31mmol/l at admission (H0) (OR=7.38; P< 0.001), lactate >3.32mmol/l on day 1 (H24) (OR=5.60; P=0.002), creatinine >95.9μmol/l at H0 (OR=4.66; P=0.004), aspartate aminotransferase (AST)>59 U/l at H0 (OR=3.55; P=0.017), and having hypertension as comorbidity (OR=9.32; P=0.040). Early curative anticoagulation (z=-2.4; P=0.016) was an independent protective factor for mortality, and lactate >3.31mmol/l at H0 (z=2.62; P=0.009) was an independent predictor factor of mortality at 1month postoperatively in the multivariate analysis. AMI remains a serious and lethal condition with delays of surgical management remaining too long due to a lack of a dedicated therapeutic protocol allowing an early diagnosis.

Outcome of Acute Mesenteric Ischemia in Patients with COVID 19 Infection Our Experience at Royal Medical Services

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.

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

BackgroundEarly diagnosis and prompt management of acute mesenteric ischaemia (AMI) are key to survival but remain extremely difficult, due to vague and non-specific symptoms. Serum lactate (SL) is commonly presented as a useful biomarker for the diagnosis or prognosis of AMI. The aim of our study was test SL (1) as a diagnostic marker and (2) as a prognostic marker for AMI. Study designThis was an ancillary multicentre case-control study. Patients with AMI at intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). SL was measured and compared on day 0 (D0) and day 1 (D1). Diagnosis and prognosis accuracy were assessed by receiver operating characteristic (ROC) and their area under the curve (AUC). ResultsEach group consisted of 137 matched ICU patients. There was no significant difference of SL between the two groups at D0 or at D1 (p = 0.26 and p = 0.29 respectively). SL was a poor marker of AMI: at D0 and D1, AUC were respectively 0.57 [0.51; 0.63] and 0.60 [0.53; 0.67]. SL at D0 and D1 correctly predicted ICU mortality, independently of AMI (AUC D0: 0.69 [0.59; 0.79] vs. 0.74 [0.65; 0.82]; p = 0.51 and D1: 0.74 [0.64; 0.84] vs. 0.76 [0.66; 0.87]; p = 0.77, respectively, for control and AMI groups]. ConclusionsSL has no specific link with AMI, both for diagnosis and prognosis. SL should not be used for the diagnosis of AMI but, despite its lack of specificity, it may help to assess severity.

Acute Mesenteric Ischemia.

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.

Surgical Management of Acute Mesenteric Ischemia; Review Article

Mesenteric ischemia is a condition in which the amount of oxygen available is insufficient to meet the needs of the intestines. The small intestine, colon, or both can be affected by ischemia. The most common cause of occlusive ischemia is an abrupt obstruction of a major artery, which causes a considerable drop in intestinal blood flow. Early diagnosis is one of the most essential components in achieving a favorable outcome. The most prevalent treatment is surgical management. However, there are minimally invasive therapy alternatives that have been shown in observational studies. For arterial thrombosis, endovascular stenting is an option, and anticoagulation is an option for venous thrombosis. Endovascular aspiration, mechanical embolectomy, and local thrombolysis are all possibilities for patients with arterial embolism.

Acute mesenteric ischemia in SARS CoV 2: A conventional approach

SARS CoV 2, a novel coronavirus, an airborne virus has been investigated for its inconspicuous prothrombotic states, the mesenteric vessels are one of the many devoured by the virus. Gastrointestinal symptoms may range from a mild gastroenteritis to a grave ischemia indicating a possibility of a severe infection. The hypercoagulability in SARS Cov -2 is possibly related to the hypercoagulable state attributed by the heightened systemic inflammatory response. The interplay of anticoagulants and the immune response is crucial in the management of critical patients , D dimer a fibrin degradation product has demonstrated efficacy in the surveille of coagulability .This case study involved in the scrutiny of a case with the initial presentation of symptoms of lower respiratory tract infection progressing into gastrointestinal symptoms focusses on the medical management of acute mesenteric ischemia in SARS CoV 2, stressing on the importance of early detection and prompt management of the hypercoagulable condition in systems other than the pulmonary system associated with SARS CoV 2. A meticulous analysis of ischemic states in various other organs should be sought in the pandemic.

Early catheter-directed thrombolysis without bowel resection in acute mesenteric ischaemia for a symptomatic COVID-19 patient

Newer evidence states that COVID-19 pneumonia induces a hypercoagulable state leading to vascular and microvascular thrombotic events. Acute mesenteric ischaemia (AMI) is a potentially fatal vascular emergency with overall mortality of 60%–80%. However, till date, only a few cases of superior mesenteric artery thrombosis in COVID-19 positive patients are reported and most have succumbed to COVID-19 or mesenteric ischemia. Physicians treating COVID-19 usually treat respiratory symptoms and may completely overlook any other uncommon pathology. This case report emphasizes that a patient with early detection and management of acute mesenteric ischaemia being symptomatic for COVID-19 can avoid major bowel surgery and negates any morbidity or mortality associated with the same.

A clinical approach to acute mesenteric ischemia.

To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management. A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved. Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI.

The role of bed-side laparoscopy in the management of acute mesenteric ischemia of recent onset in post-cardiac surgery patients admitted to ICU.

Acute mesenteric ischemia with non-occlusive mechanism (NOMI) is a possible complication after cardiac surgery in patients admitted to Intensive Care Unit (ICU). Since the diagnosis is often difficult with CT-scan, some authors have evaluated the role of bed-side diagnostic laparoscopy (DL). We aimed to contribute to this topic with a personal series. We retrospectively evaluated patients admitted to ICU after cardiac surgery since 2009 up to 2019, successively operated on for a suspected NOMI of recent onset with non-conclusive CT. They were divided into laparoscopic (Ls) and laparotomic (Lt) group, depending on whether or not they had a DL. They were compared for the CT false-positive (FP) and true-positive (TP) rate and the surgical outcome. Seventy-three patients were enrolled. Lt included 30 patients (41%), Ls 43 (59%). The overall FP were 38 (52%), with a higher incidence in Ls. There was no difference in the mortality rate. The morbidity rate was higher in Lt, and especially in Lt-FP. The TP were 35 (47.9%). The mean operating time (OT) in the Lt-TP group was similar to the sum of the mean OT of the laparotomies plus that of the laparoscopies in the Ls-TP group. Conversely, when considering only laparotomic procedures, the Lt-TP had higher mean OT, such as an increased blood loss CONCLUSIONS: Post-cardiosurgical patients admitted to ICU have a relatively high rate of NOMI, in which CT-scan is often initially non-conclusive. Our data and those from the literature seem to show that in such cases bed-side DL may be an advantageous and safe procedure to avoid needless laparotomy and enables a more tailored open surgery.

Contrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia.

OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.

The Surgical Management of Acute Mesenteric Ischemia - a Retrospective Study in a 2nd Grade Emergency Hospital

The Surgical Management of Acute Mesenteric Ischemia - a Retrospective Study in a 2nd Grade Emergency Hospital

Open and Endovascular Management of Acute Mesenteric Ischaemia: A Systematic Review.

Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency resulting from thromboembolic occlusion of the mesenteric vasculature. Traditional management of AMI has been open revascularisation with or without bowel resection-a procedure which carries considerable morbidity and mortality in an already unwell, compromised patient. Endovascular and more minimally invasive management approaches to AMI have been reported. Proponents of endovascular management suggest this approach may be associated with reduced morbidity and mortality compared with open surgery. To assess the impact of endovascular approach for AMI on mortality and need for subsequent laparotomy and/or bowel resection. The search bodies PubMed and Medline were interrogated. All studies in English with greater than 10 patients examining outcomes for patients undergoing endovascular intervention for acute mesenteric ischaemia were included. All patients over 18years presenting with a diagnosis of acute mesenteric ischaemia secondary to an arterial thromboembolic source were included. Studies examining endovascular intervention alone or endovascular and open intervention were selected. The 30-day mortality for endovascular approach from all 13 studies was 16-42%. Of the 7 comparative studies including results of open revascularisation, the 30-day mortality for patient treated with an endovascular approach was 15-39% versus 33-50% for open revascularisation. Laparotomy rates post-initial endovascular intervention ranged from 13 to 73%. Bowel resection post-endovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel resection in the endovascular group ranged 14-28% and 33-63% in the open cohort. Endovascular intervention also demonstrated lower median length (s) of bowel resected. Heterogeneity of studies and patient populations studied including selection bias. Endovascular management may be associated with reduced mortality and need for/length of bowel resection compared with the traditional open approach, but there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more insidious onset may garner benefit from endovascular intervention.

Contemporary Management of Acute Mesenteric Ischemia in the Endovascular Era.

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.

Successful medical management of acute mesenteric ischemia due to superior mesenteric and portal vein thrombosis in a 27-year-old man with protein S deficiency: a case report

BackgroundAcute mesenteric ischemia poses a diagnostic challenge due to nonspecific clinical clues and lack of awareness owing to its rarity. Ischemia due to mesenteric venous thrombosis has a good prognosis compared to arterial cause and can be managed conservatively with early diagnosis. The portomesenteric venous system is an unusual site of thrombosis in patients with protein S deficiency, and its thrombosis is an uncommon cause of acute mesenteric ischemia.Case presentationWe present a case of a 27-year-old Mongolian man who presented with acute abdominal pain increasing in severity, and refractory to repeated attempts at treatment with a misdiagnosis of acute peptic ulcer disease. Contrast-enhanced computed tomography of his abdomen detected complete occlusion of the superior mesenteric vein, an extension of acute thrombus into the portal vein, and ischemic mid-jejunal loops. Early diagnosis and immediate anticoagulation with continuous intravenous infusion of unfractionated heparin prevented subsequent consequences. On further workup, our patient was diagnosed with isolated protein S deficiency. We started lifelong thromboprophylaxis with warfarin to prevent recurrence and our patient was asymptomatic on the latest follow-up 5 months after discharge.ConclusionDespite accurate detection of acute mesenteric ischemia by contrast-enhanced computed tomography, high index of suspicion is indispensable for its early diagnosis. Early diagnosis and immediate anticoagulation will prevent subsequent complications and need for surgical intervention. Young patients without known risk factors presenting with venous thrombosis in atypical sites should be investigated for prothrombotic diseases.

Teaching Hospital Management of Acute Mesenteric Ischaemia: Room for Improvement?

Teaching Hospital Management of Acute Mesenteric Ischaemia: Room for Improvement?

Engglis

The mortality rate of acute mesenteric ischemia (AMI) is high due to the delay in diagnosis. Determination of potent biomarker for early AMI is the key in reducing the mortality. As a proinflammatory cytokine, the level of TNF-α might be affected during the ischemia and reperfusion, with the prediction duration of 60-120 min. High TNF-α level may stimulate the upregulation of IL-10 as an inhibitor of TNF-α. This provides a new opportunity for early diagnosis of AMI by measuring the ratio between those two cytokines. The purpose of this study was to investigate the effect of duration of the mesenteric artery to the ratio of TNF-α/IL-10 in a AMI rat model. This was an experimental study using Wistar rat. We performed mesenteric artery in 28 male rats to produce an AMI model, with ligation duration of 0, 30, 60, 90, 120, 150, and 180 minutes. At the end of ligation, blood samples were taken for measurement of TNF-α and IL-10 level using ELISA. For the microscopic examination of tissue necrosis, intestinal organ samples were taken and made into paraffin blocks and stained using Haematoxylin-Eosin. TNF-α increased in minute 120 compared to other treatment groups (p<0.05). IL-10 increased in minute 180 compared to control group (p<0.05). Microscopic examination showed that the duration of ligation affects the structure and morphology of intestinal mucosa characterized by discoloration of organs along with increasing the ligation duration. Ligation of the superior mesenteric artery was found to be significantly increased the TNF-α level and to be compensated by increasing IL-10. It is assumed that when the IL-10 level, that has protective effect as an inhibitor, higher than TNF-α level as a proinflammatory cytokine on duration 150 minutes, it means no more inflammatory or cells is dead. Therefore TNF-α/IL-10 ratio can be used as a biomarker candidate of prognosic factor management of AMI.