Management Of Acute Mesenteric Ischemia Research Articles

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.

What is the Best Revascularization Strategy for Acute Occlusive Arterial Mesenteric Ischemia: Systematic Review and Meta-analysis.

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.

Regarding "Management of Acute Mesenteric Ischemia: A Critical Review and Treatment Algorithm".

Regarding "Management of Acute Mesenteric Ischemia: A Critical Review and Treatment Algorithm".

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Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities.

Mesenteric ischemia (MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI (CMI), with the first being subdivided into four categories. Therefore, acute MI (AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography (CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.

Acute mesenteric ischemia: The what, why, and when?

Acute mesenteric ischemia (AMI) is a complex clinical problem with a high mortality. The mortality associated with AMI has declined steadily over the last three decades. This is due to higher index of suspicion among clinicians, advances in radiographic diagnostic modalities, aggressive surgical approach, endovascular intervention, nutritional supplementation, and better perioperative care. Early diagnosis and prompt, effective treatment are essential to improve the clinical outcome. This article reviews the etiopathogenesis, clinical features, management, and outcomes of AMI.

Editors' commentary

Notwithstanding the headline debate about whether an “endovascular-first” or an “open surgery-first” strategy is preferable or safer, the most important issue raised by our debaters—and one which should concern all of us—is that a diagnosis of acute mesenteric ischemia (AMI) is still invariably delayed and usually only considered once the patient has become too ill to undergo any form of meaningful intervention. The data from the United States National Inpatient Sample, which showed that only 15% of AMI patients were actually treated and that only 3% had the chance to benefit from endovascular or open revascularization, make extremely depressing reading. Put another way; almost nine of every 10 patients with a diagnosis of suspected AMI will undergo no active treatment. Such bleak statistics demand that medical professionals (of all disciplines) be made more aware of the importance of at least considering a diagnosis of AMI in their patients. Returning to the “meat” of the debate, our contributors have provided positive and negative data regarding their respective positions. That is not surprising, given the nature of a debate. We suspect, however, that a significant proportion of our surgical readers will rarely (or never) consider an endovascular-first strategy for the treatment of their AMI patients (unlike patients with chronic mesenteric ischemia), largely because of an intuitively held belief (espoused by Drs Orr and Endean) that endovascular strategies have little to offer in these acute life-threatening situations and that emergency laparotomy is mandatory to gauge the severity of ischemia, enable revascularization, as well as allowing the resection of compromised bowel before it worsens and precipitates multiorgan failure. However, Martin Björck has also shown that surgeons may have been wrong to uncritically dismiss a role for an endovascular-first strategy. This is supported by international registries reporting that up to 50% of contemporary arterial revascularizations for AMI now follow an endovascular-first strategy, with bailout surgical bypass possible in up to half of those cases where an endovascular intervention failed to recanalize the superior mesenteric artery. One would not expect to have observed such an increase in the proportion of interventional therapies if an endovascular-first strategy was associated with poorer outcomes compared with the traditional open surgical approach. There are obvious advantages to either strategy. Endovascular therapy is less invasive, can be done under local anesthesia, avoids a major laparotomy in compromised individuals, and (perhaps most importantly) finishes with completion angiography to identify and treat residual thrombus and defects, thereby optimizing the overall quality of the revascularization. The Achilles' heel of an endovascular-first strategy, however, is determining exactly when someone needs a second-look laparotomy to identify the patient with persisting focal bowel ischemia before it perforates. Martin Björck advocates a liberal approach to second-look laparotomy, but when one is required is not always apparent. The open surgery-first approach, as stated by Drs Orr and Endean, is more generalizable and does not require complex endovascular skills, which may not be available in most hospitals. This type of patient is usually too ill to transfer to another more experienced endovascular institution, usually because of the delay in diagnosis. As with most issues in medicine, a “one size fits all” strategy rarely works, and it is inevitable that endovascular and open surgery will evolve complementary roles in the management of AMI. This will be particularly true in the era of hybrid endovascular theaters where the patient can undergo any combination of the two approaches as well as laparoscopy. Moreover, the addition of open retrograde SMA angioplasty or stenting, or both, will increase revascularization options while at the same time permitting the surgeon to inspect the bowel for areas of doubtful viability. However, any meaningful debate about whether an endovascular-first or an open surgery-first strategy is safer in AMI patients is pointless unless the medical profession becomes much better at diagnosing AMI early. That remains the most important challenge facing all of us. Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemiaJournal of Vascular SurgeryVol. 62Issue 3PreviewAcute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Full-Text PDF Open Archive

Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience.

Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA). From 2003 to 2014, we analysed the in-hospital mortality of 37 patients with acute mesenteric embolism who underwent primary endovascular therapy with subsequent on-demand laparotomy. Transcatheter embolus aspiration was used in all 37 patients (19 women, 18 men, median age 76years) with embolic occlusion of the SMA. Adjunctive local thrombolysis (n=2) and stenting (n=2) were also utilised. We achieved complete recanalization of the SMA stem in 91.9%. One patient was successfully treated by surgical embolectomy due to a failed endovascular approach. Subsequent exploratory laparotomy was performed in 73.0% (n=27), and necrotic bowel resection in 40.5%. The total in-hospital mortality was 27.0%. Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0%.

Acute mesenteric ischemia of arterial origin: Importance of early revascularization

The goal of our study was to show that survival was better when early revascularization was performed rather than gastrointestinal resection in the management of acute mesenteric ischemia of arterial origin. The reports of patients managed in our center between January 2005 and May 2012 for acute mesenteric ischemia of arterial origin were analyzed retrospectively. Data on clinical, laboratory and radiologic findings, the interval before treatment, the operative findings and the surgical procedures were collected. Follow-up information included the postoperative course, and mortality at 48 h, 30 days and 1 year, the latter being compared between patients undergoing revascularization versus gastrointestinal resection. Of 43 patients treated during this period, 20 had gastrointestinal lesions deemed to be beyond all therapeutic resources, 13 were treated with gastrointestinal resection without revascularization, while 10 underwent early revascularization. There were no statistically significant differences found in the extent of involvement between the two groups (P=0.22). Mortality at 48 h, 30 days and 1 year was 8% (n=1), 30% (n=4) and 68% (n=8) in patients who underwent enterectomy vs. 0% (n=0), 0% (n=0) and 10% (n=1) in patients who underwent revascularization procedures. The difference at 1 year was statistically significant (P=0.02). At 1 year, two patients in the revascularized group had a short bowel syndrome vs. one in the non-revascularized group. Acute mesenteric ischemia of arterial origin is associated with high morbidity and mortality. Optimal management should include early revascularization.

Successful Management of Acute Mesenteric Ischaemia in a Pregnant Woman with Protein S Deficiency

Successful Management of Acute Mesenteric Ischaemia in a Pregnant Woman with Protein S Deficiency

Local thrombolytic therapy in acute mesenteric ischemia.

BackgroundThe aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).MethodsFrom January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.ResultsLTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.ConclusionEarly intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia

Few centers have adopted endovascular therapy for the treatment of acute mesenteric ischemia (AMI). We sought to evaluate the effect of endovascular therapy on outcomes for the treatment of AMI. A single-center, retrospective cohort review was performed on all consecutive patients with thrombotic or embolic AMI presenting between 1999 and 2008. Patients with mesenteric venous thrombosis, nonocclusive mesenteric ischemia, and ischemia associated with aortic dissection were excluded. Demographic factors, preoperative metabolic status, and etiology were compared. Primary clinical outcomes included endovascular technical success, operative complications, and in-hospital mortality. Seventy consecutive patients were identified with AMI (mean age, 64 ± 13 years). Etiology of mesenteric ischemia was 65% thrombotic and 35% embolic occlusions. Endovascular revascularization was the preferred treatment (81%) vs operative therapy (19%). Successful endovascular treatment was achieved in 87%. Endovascular therapy required laparotomy in 69% vs traditional therapy in 100% (P < .05), with a median 52-cm necrotic bowel resected (interquartile range [IQR], 11-140 cm) vs 160 cm (IQR, 90-250 cm; P < .05), respectively. Acute renal failure and pulmonary failure occurred less frequently with endovascular therapy (27% vs 50%; P < .05 and 27% vs 64%; P < .05). Successful endovascular treatment resulted in a mortality rate of 36% compared with 50% (P < .05) with traditional therapy, whereas the mortality rate for endovascular failures was 50%. Endovascular therapy was associated with improved mortality in thrombotic AMI (odds ratio, 0.10; 95% confidence interval, 0.10-0.76; P < .05). Endovascular therapy has altered the management of AMI, and there are measurable advantages to this approach. Using endovascular therapy as the primary modality for AMI reduces complications and improves outcomes.

Trauma‐associated acute mesenteric ischemia in a dog

To describe the successful management of acute mesenteric ischemia (AMI) in a dog. An 11-year-old, 21.4kg, male castrated Rough-Coated Collie was referred for evaluation of an acute abdomen following sustaining injuries in a vehicular accident. On presentation to the hospital, clinicopathologic assessments were within normal limits and distended intestinal loops were evident on abdominal palpation. Plain and contrast radiography demonstrated diffusely distended gas-filled intestinal loops with a delayed barium transit time. Emergency surgical exploration was performed. The cecum and the proximal two-thirds of the colon were dark purple to black in color and there were no palpable pulses in the mesenteric arteries associated with the cecum and colon. The cecum and proximal two-thirds of the colon were resected and an ileocolic anastomosis was performed. The dog recovered well from surgery and was discharged 2 days later. Histopathologic examination was consistent with AMI. AMI is uncommonly reported in human medicine and is a rare complication from even minor blunt abdominal trauma. This is the first reported case of trauma-associated AMI in a dog.

Acute mesenteric ischemia

Management of acute mesenteric ischemia is still a matter of concern for physicians. This disorder has been associated to an increased mortality mainly because of a late diagnosis and controversial treatment options. We describe the case of a multidisciplinary approach to a cardiogenic thrombotic occlusion of superior mesenteric artery resulting in acute mesenteric ischemia. After rapid diagnosis with Duplex scan, we brought the patient to our catheterization laboratory and managed it with the common tools used for primary percutaneous coronary intervention. Among the specific issues of this case report, we observed some of the common complications of the acute myocardial infarction managed in the catheterization laboratory and treated them with the same tools used in the "myocardial area." We showed how an "interventional cardiologist's" approach to acute mesenteric ischemia was effective in restoring superior mesenteric artery patency and in aborting a mesenteric infarction.

Planned second-look laparoscopy in the management of acute mesenteric ischemia

To investigate the role of second-look laparoscopy in patients with acute mesenteric ischemia (AMI). Between January 2000 and November 2005, 71 patients were operated for the treatment of AMI. The indications for a second-look were low flow state, bowel resection and anastomosis or mesenteric thromboembolectomy performed during the first operation. Regardless of the clinical course of patients, the second-look laparoscopic examination was performed 72 h post-operatively at the bed side in the ICU or operating room. The average time of admission to the hospital after the initiation of symptoms was 3 d (range, 5 h-9 d). In 14 patients, laparotomy was performed. In 11 patients, small and/or large bowel necrosis was detected and initial resection and anastomosis were conducted. A low flow state was observed in two patients and superior mesenteric artery thromboembolectomy with small bowel resection was performed in one patient. In 13 patients, a second-look laparoscopic examination revealed normal bowel viability, but in one patient, intestinal necrosis was detected. In two of the patients, a third operation was necessary to correct anastomotic leakage. The overall complication rate was 42.8%, and in-hospital mortality rate was 57.1% (n = 6). Second-look laparoscopy is a minimally invasive, technically simple procedure that is performed for diagnostic as well as therapeutic purposes. The simplicity and ease of this method may encourage wider application to benefit more patients. However, the timing of a second-look procedure is unclear particularly in a patient with anastomosis.

‘Second-look’ laparoscopy in the management of acute mesenteric ischaemia

‘Second-look’ laparoscopy in the management of acute mesenteric ischaemia

Surgical Management of Mesenteric Ischemia

Successful management of acute mesenteric ischemia is predicated on prompt diagnosis, which still remains clinical in nature. No single radiographic test has a sensitivity or specificity reliable enough to supplant frequent and thorough physical examination and clinical judgment. Operative management requires adequate excision of clearly necrotic bowel and a high index of suspicion of borderline segments. Arterial reconstruction is best done with autogenous tissue when possible in the setting of gangrene or spillage. While diagnosis of chronic mesenteric ischemia is far more straightforward, significant controversy still remains regarding operative management with regards to the number of vessels reconstructed, direction of the graft, and choice of conduit.

Contemporary management of acute mesenteric ischemia: Factors associated with survival

Acute mesenteric ischemia (AMI) is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the results of current management and the examination of factors associated with survival, we reviewed our experience. The clinical data of all the patients who underwent operation for AMI between January 1, 1990, and December 31, 1999, were retrospectively reviewed, clinical outcome was recorded, and factors associated with survival rate were analyzed. Fifty-eight patients (22 men and 36 women; mean age, 67 years; age range, 35 to 96 years) underwent study. The cause of AMI was embolism in 16 patients (28%), thrombosis in 37 patients (64%), and nonocclusive mesenteric ischemia (NMI) in five patients (8.6%). Abdominal pain was the most frequent presenting symptom (95%). Twenty-five patients (43%) had previous symptoms of chronic mesenteric ischemia. All the patients underwent abdominal exploration, preceded with arteriography in 47 (81%) and with endovascular treatment in eight. Open mesenteric revascularization was performed in 43 patients (bypass grafting, n = 22; thromboembolectomy, n = 19; patch angioplasty, n = 11; endarterectomy, n = 5; reimplantation, n = 2). Thirty-one patients (53%) needed bowel resection at the first operation. Twenty-three patients underwent second-look procedures, 11 patients underwent bowel resections (repeat resection, n = 9), and three patients underwent exploration only. The 30-day mortality rate was 32%. The rate was 31% in patients with embolism, 32% in patients with thrombosis, and 80% in patients with NMI. Multiorgan failure (n = 18 patients) was the most frequent cause of death. The cumulative survival rates at 90 days, at 1 year, and at 3 years were 59%, 43%, and 32%, respectively, which was lower than the rate of a Midwestern white control population (P <.001). Six of the 16 late deaths (38%) occurred because of complications of mesenteric ischemia. Age less than 60 years (P <.003) and bowel resection (P =.03) were associated with improved survival rates. The contemporary management of AMI with revascularization with open surgical techniques, resection of nonviable bowel, and liberal use of second-look procedures results in the early survival of two thirds of the patients with embolism and thrombosis. Older patients, those who did not undergo bowel resection, and those with NMI have the highest mortality rates. The long-term survival rate remains dismal. Timely revascularization in patients who are symptomatic with chronic mesenteric ischemia should be considered to decrease the high mortality rate of AMI.

Operative Management of Acute Mesenteric Ischemia

Operative Management of Acute Mesenteric Ischemia

Acute Mesenteric Ischemia: A Simple and Practical Approach

The diagnosis and management of acute mesenteric ischemia (AMI) have evolved considerably since first described nearly 150 years ago. Angiography remains the gold standard for establishing a definitive diagnosis. Today, several therapeutic options—both percutaneous and surgical—are available for combatting AMI. Vasodilation, lytic, and balloon angioplastic procedures are percutaneous approaches that can be considered in a subset of patients in whom the clinical examination does not necessitate immediate laparotomy. When laparotomy is mandatory, embolectomy, thromboendarterectomy, and a variety of mesenteric revascularization procedures have enabled intestinal salvage. As a result, the morbidity and mortality of AMI have declined. The authors offer an algorithm that simplifies the approach to AMI, emphasizes rapid diagnosis and early intervention, and includes percutaneous therapy as an option to consider.