Management Of Chronic Mesenteric Ischemia Research Articles

Retrospective evaluation of interventional radiological treatments for chronic mesenteric ischemia in Germany based on a four-year period of the DeGIR Registry: comparison of outcomes with international quality standards.

Endovascular treatment has emerged as the gold standard for managing chronic mesenteric ischemia (CMI) resulting from arterial stenosis or occlusion. This study aimed to assess the efficacy and complication rates of continuous interventional radiology treatment for CMI in Germany between 2018 and 2021, comparing these findings with international quality standards. Data for CMI therapy with stenting and percutaneous transluminal angioplasty (PTA) was obtained from the quality management system of the German Interventional Radiological Society (DeGIR). A total of 3752 endovascular procedures for CMI performed from 2018 to 2021 were documented (PTA: n = 675; stenting: n = 3077). Data was analyzed for technical and clinical success rates, as well as major complication rates. Overall technical and clinical success rates for PTA and stenting procedures were 92.03 %/85.9 % and 98.76 %/96.62 %, respectively. The most common major complications were: arterial occlusion (PTA: 0.73 %; stenting: 0.63), major bleeding (PTA: 1.05 %; stenting: 0.68 %), aneurysm formation (PTA: 0.29 %; stenting: 0.72 %), stent dislodgment (PTA: 0 %; stenting: 0.06 %), and organ failure (PTA: 0.43 %; stenting: 0.96 %). Technical and clinical success rates were higher, while complication rates were lower than the corresponding threshold recommended by the Society of Interventional Radiology for the percutaneous management of chronic mesenteric ischemia. Treatment of CMI performed by interventional radiologists in Germany is safe and effective during daily and on-call shifts with results exceeding internationally accepted standards. · Treatment of CMI by interventional radiologists in Germany is effective and safe.. · The interventions are safe and effective regardless of whether they are performed during on-call shifts or the daily routine.. · The clinical and technical success rates favorably surpass the thresholds presented by SIR.. · Different major complications occurred in under 1.1 % of CMI interventions..

Role of Endovascular Intervention in Management of Chronic Mesenteric Ischemia

Abstract Background Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization (SR) or endovascular revascularization (ER). - The management of symptomatic atherosclerotic chronic mesenteric ischemia which is an uncommon disorder is challenging. Although surgical revascularization (SR) has been considered as the gold standard since its introduction based on observational data published over the last 25 years, there has been increased use of endovascular revascularization (ER) in treating CMI. This review seeks to assess, through the available literature, the role of endovascular intervention in management of chronic mesenteric ischemia and determine the benefits as well as the withdraws of the intervention. Objective to assess the role of endovascular intervention in management of chronic mesenteric ischemia and determine the efficacy (in terms of patency), and safety, (in terms of perioperative morbidity and mortality) of endovascular revascularization (ER) in treating patients with CMI, using the currently available literature and applying a systematic review and meta-analysis. Methods The review is a meta-analysis and systematic review that included randomized controlled trials (RCT), case series and retrospective studies which studied the role on endovascular techniques of management of chronic mesenteric ischemia. Results Abstracts of articles that were published from 2000-2020 identified using the search strategy were reviewed and articles that appear to fulfill the inclusion criteria were retrieved in full text. Data on at least one of the outcome measures was included in the study. This study included published papers and research written in English language that published from 2000-2020. We excluded papers not written in English, studies before 2000 and case report study. Conclusion Endovascular management of chronic mesenteric ischemia is a feasible strategy associated with increased technical and clinical success rate and patency rates. It also associated with low rate of mortality and complications. Restenosis and symptom recurrence were reported in more than 20% of the patients which necessitating preoperative assessment of abdominal pain, good selection of patients and improving the endovascular technique.

Association between Statin Medications and Primary Patency and All-cause Mortality Rates in Patients with Chronic Mesenteric Ischemia

The recent guidelines from the Society for Vascular Surgery recommend the use of statins following endovascular management of chronic mesenteric ischemia (CMI). These recommendations were extrapolated from the American Heart Association guidance for the treatment of atherosclerotic equivalent conditions such as coronary artery disease. No published evidence is available specifically for CMI. This study aims to investigate the impact of statins on primary patency rates and all-cause mortality following endovascular management for CMI. A single-center retrospective review of all patients who underwent endovascular interventions for CMI from 2003 to 2019 was performed. All patients underwent The patients were divided into two groups based upon the postintervention use of a statin. The no statin group includes patients documented to be on no statin or with adherence <50%. Patients in whom statin compliance could not be assessed were excluded. Kaplan-Meier estimation and Cox proportional hazards models were calculated. A total of 156 patients were included with a mean age of 71.0 ± 12.3 years and 109 (69.9%) were female. Sixty-eight (43.6%) patients were included in the statins group and 88 (56.4%) in the no statin group. Patients on statins had higher rates of coronary artery disease, congestive heart failure, hyperlipidemia, peripheral artery disease, and diabetes mellitus (P < .05 in all). In the statin group, 28 (41.8%) patients took high-intensity statins, with atorvastatin and simvastatin being the most commonly prescribed medications. The multivariate model showed that statin use was a protective factor from primary patency loss (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.21-0.97; P = .041) (Table), but not from all-cause mortality (HR, 1.40; 95% CI, 0.77-2.56; P = .27). Similarly, the Kaplan-Meier curve showed higher primary patency rate in the statin group compared to the no statin cohort (Figure). Active smoking and gender were not associated with loss of primary patency in this analysis (HR, 0.80; 95% CI, 0.38-1.69; P = .56) and (HR, 1.51; 95% CI, 0.73-3.12; P = .26), respectively. The use of statins following endovascular interventions for CMI is associated with improved primary patency. This finding provides the first CMI-specific evidence to support the current Society for Vascular Surgery recommendations on statin use post procedurally. The finding represents the foundation for a multicenter investigation to confirm our observation.TablePrimary patency loss: All, multivariable, and overallVariableLevelsNo.HR (95% CI)P valueStatin groupNonstatin921.00Statin880.45 (0.21-0.97).041Coronary artery diseaseNo931.00Yes870.58 (0.26-1.28).18Congestive heart failureNo1521.00Yes281.02 (0.35-3.01).97HyperlipidemiaNo751.00Yes1051.43 (0.67-3.02).35Peripheral arterial diseaseNo921.00Yes880.60 (0.30-1.20).15Diabetes mellitusNo1301.00Yes501.58 (0.74-3.35).23Preoperative medications: aspirinNo681.00Yes1121.18 (0.54-2.57).68Postoperative medications: aspirinNo561.00Yes1241.24 (0.53-2.87).62CI, Confidence interval; HR, hazard ratio.n = 180 vessels. Open table in a new tab

Covered Versus Bare Metal Stents for Chronic Mesenteric Ischemia: Systematic Review and Meta-analysis

Endovascular revascularization through mesenteric stenting is the preferred initial treatment strategy for symptomatic chronic mesenteric ischemia (CMI), but restenosis and symptom recurrence are common. Emerging evidence suggests that covered stents (CS) may reduce or delay the incidence of in-stent restenosis compared with traditional bare metal stents (BMS). Our study objective was to compare the performance of CS to BMS in the management of CMI. We searched PubMed and Embase databases (inception to April 27, 2021) for studies comparing CS with BMS in the management of CMI following the PRISMA guidelines. The abstract and full-text screening were done in parallel by two authors, resolving conflicts by reviewing them with a third author. Our outcomes of interest were loss of primary patency, restenosis, and symptom recurrence at the latest follow-up. Primary analysis was performed using random-effects models and heterogeneity was measured using the I2 statistic. We assessed the quality of observational studies using the Newcastle-Ottawa Scale. The predefined protocol was registered in PROSPERO. We double-screened a total of 502 articles, of which four observational studies (n = 432 patients, 511 vessels) were included (Fig 1). CS were used in 20.4% of vessels (n = 104). When compared with BMS, the use of CS was associated with lower odds of loss of primary patency (pooled odds ratio, 0.37; 95% confidence interval [CI], 0.15-0.90; P value = 0.029; I2 = 58.9%; n = 511 vessels) (Fig 2). CS were also associated with lower odds of restenosis (pooled odds ratio, 0.12; 95% CI, 0.06-0.23; P < 0.001; I2 = 0%; n = 280 patients). One study reported lower symptom recurrence associated with CS use (OR, 0.08; 95% CI, 0.02-0.23; P < 0.001; n = 189 patients). The length of follow-up varied across studies (median follow-up range, 16-31 months). Heterogeneity was high, and the overall quality of included studies was low owing to small sample sizes, single-center design, retrospective data collection, differential follow-up between treatment groups, and risk for systematic or selection bias. Available data comparing BMS with CS for use in patients with CMI are limited and of variable quality. Although endovascular treatment with CS was associated with lower odds of loss of primary patency and restenosis when compared with BMS, these results must be interpreted with caution. (PROSPERO CRD42021281294).Fig 2Pooled odds ratio (OR) for loss of patency at latest follow-up. 95%-CI, 95% confidence interval.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Outcomes Using Uncovered Stents and Covered Stents Are Similar for Management of Chronic Mesenteric Ischemia: A Single-Center Retrospective Experience

Endovascular treatment of chronic mesenteric ischemia (CMI) has been shown to have similar perioperative mortality and shorter hospitalization compared with open repair but increased reinterventions due to restenosis. Covered stents (CSs) are associated with less restenosis, recurrence of symptoms, and reinterventions than bare-metal uncovered stents (UCSs). This study intends to revisit endovascular management of CMI and to evaluate differences in patients who received CSs or UCSs. Clinical data were obtained retrospectively for CMI patients at a single center from 2010 to 2015. Patients included were treated with either UCS or CS, were diagnosed with CMI, and had radiographic evidence of mesenteric disease. Patients who were excluded had acute mesenteric ischemia or procedures performed at an outside hospital. Sixty patients with an average age of 70.7 ± 9.4 years were involved in the study. Comorbidities included type 2 diabetes (21/60), hypertension (51/60), hyperlipidemia (51/60), and smoking history (52/60; Table I). Fisher exact test was performed, and there was a difference between the specific mesenteric vessel intervention completed and the number of diseased mesenteric vessels (P < .001). No difference was seen between UCS and CS with vessel intervened on (P = .290). There was no significant difference in symptom recurrence (48.8% vs 42.1%), reintervention rates (34.2% vs 26.3%), number of reinterventions (1 [1-4] vs 1 [1-2], median [range]), or hospital length of stay (1 [0-28] days vs 1 [0-8] days) between UCS and CS interventions, respectively (P > .05). Reintervention rates were similar despite antiplatelet regimen (no antiplatelet, 40%; single antiplatelet, 48.4%; or dual antiplatelet, 47.4%; P > .05). No significant difference in death rate (43.9% vs 68.4%) was seen, and all-cause mortality from index operation was 2.6 years (0.1-7.2 years; Table II). In this retrospective review, there was no significant difference in success rate for revascularization, recurrence, or complications with the use of CSs or UCSs. Larger randomized studies may be needed to determine the superiority of one stent type over another.Table IDemographics of patients receiving uncovered stents (UCSs) and covered stents (CSs) for chronic mesenteric ischemia (CMI)Age, years70.7 ± 9.4Type 2 diabetes35%Sex63.3% MHypertension85%36.7% FHyperlipidemia85%Total patients60Smoking86.70% Open table in a new tab Table IIDifferences in outcomes between interventions completed for uncovered stents (UCSs) and covered stents (CSs)UCSsCSsSymptom recurrence48.8042.10Incidence of reintervention34.2026.30Total No. of reinterventions1 (1-4)1 (1-2)Hospital length of stay, days1 (0-28)1 (0-8)Death rate43.9068.40Categorical variables are presented as percentage. Continuous variables are presented as median (range). Open table in a new tab

Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era

Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Endovascular treatment of chronic mesenteric ischemia

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.

The radiologist's guide to duplex ultrasound assessment of chronic mesenteric ischemia.

This article reviews the relevant anatomy and physiology of the mesenteric vasculature, familiarizes the radiologist with the accepted diagnostic criteria for mesenteric artery stenosis and its role in the diagnosis of chronic mesenteric ischemia, describes Doppler imaging techniques, and provides protocols for the assessment and surveillance of the mesenteric vasculature before and after revascularization. It also discusses expected changes following revascularization and reviews common post-procedural complications. Duplex sonography plays an important role in the diagnosis and management of chronic mesenteric ischemia (CMI). Establishing a successful diagnosis is dependent upon knowledge of mesenteric arterial anatomy and physiology as well as sufficient expertise in image optimization and scanning techniques. Although there has been a trend toward utilization of other noninvasive [computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and invasive (digital subtraction angiography (DSA)] imaging modalities for assessment of the mesenteric vasculature, a new era of "imaging wisely" raises legitimate concerns about the effects of ionizing radiation as well as potential effects of CT and MR contrast agents. These concerns are obviated by the use of ultrasound, and recently developed techniques, such as contrast-enhanced ultrasound and vascular applications focused on the evaluation of slow flow, have revealed the vast potential of vascular ultrasound in the evaluation of chronic mesenteric ischemia. Duplex sonography is a cost-effective and powerful tool that can be utilized for the accurate assessment of mesenteric vascular pathology, specifically mesenteric arterial stenosis, and for the evaluation of mesenteric arterial system post revascularization.

PC170. Impact of National Adoption of Endovascular Revascularization on a Regional Referral Center Specializing in Management of Chronic Mesenteric Ischemia

A dramatic increase in the national rates of endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) has occurred; however, the incidence of open mesenteric bypass (OMB) has remained largely unchanged. The impact of ER adoption on referral hospitals specializing in CMI management that may be disproportionately affected by features precluding ability to use ER remains poorly defined. The purpose of this analysis was to determine the temporal variation in management and outcomes within a center with regional specialization for CMI management. A single, large tertiary academic referral institution’s prospectively collected database was queried retrospectively to identify all patients treated for CMI (2002-2018). The primary end point was temporal change in revascularization strategy (ER vs OMB; eras for analysis: 2002-2007, 2008-2013, 2014-2018). Secondary end points included temporal change in complications, reintervention, and survival. Life tables were used to estimate end points. The incidence of organ dysfunction (hepatic, renal, pulmonary, coagulopathy) was examined, and its relationship to outcomes was determined. There were 189 patients identified (OMB, n = 109 [antegrade, 91%; retrograde, 8%]; ER, n = 80 [mesenteric stent, 91%; angioplasty alone, 9%]. There was a significant difference in use of ER and OMB (most recent era, 84% OMB; P < .0001). For either ER or OMB, incidence of in-hospital complications or 30-day mortality was similar over time. OMB patients were significantly younger (66 ± 11 years vs ER, 71 ± 11 years; P = .006) and more likely to have undergone prior ER (OMB, 36%; ER, 17%; P = .005). No significant difference in presenting symptoms (postprandial pain > unintentional weight loss) or comorbidities was present. Major complications were more frequent with OMB (OMB, 54%; ER, 20%; P < .0001); however, 30-day mortality was similar (OMB, 6% [n = 6]; ER, 1% [n = 1]; P = .012). ER had a negligible incidence of postoperative organ dysfunction, whereas OMB was associated with a 75% incidence (threefold or higher transaminitis, 72%; thrombocytopenia [platelet count <40,000], 35%; renal injury, 9%; respiratory failure, 13%). Two-year symptom resolution overall was 69%; however, there was greater frequency of restenosis or recurrent symptoms after ER (50% vs OMB, 9%; P < .0001). Five-year freedom from reintervention or restenosis was significantly higher for OMB (77% ± 7% vs ER, 33% ± 6%; log-rank, P < .0001). There was a nonsignificant trend toward improved 5-year survival after OMB (70% ± 5% vs ER, 60% ± 6%; Cox model, P = .06; Fig). Centers focused on CMI management may not reflect national trends in revascularization strategies as evidenced by the increasing use of OMB. This selection pressure is predominantly due to a significant proportion of prior mesenteric revascularization failures or nonanatomic suitability for ER. Despite specialization and a high-volume referral pattern, complication rates, including frequency of postoperative organ dysfunction, remained similar over time, probably reflecting a cohort of complex patients with significant comorbidities. These findings highlight the significant challenges and resource utilization faced by regional referral centers and provide contemporary benchmarks for outcomes, especially when elective OMB occurs.

Endovascular Management of Chronic Mesenteric Ischemia

Aim:The purpose of this study was to review the effectiveness and feasibility of endovascular intervention for chronic mesenteric ischemia and its effect on morbidity and mortality. Patients and methods: Between march 2014, and October 2016, 7 patients diagnosed with chronic mesenteric ischemia had endovascular treatment. Demographic, clinical, diagnostic and procedure-related data were recorded, and strict follow up was done for 24 month postoperative. Results: Data was obtained for 7 patients who underwent endovascular procedures during the study period. Superior mesenteric artery (SMA) was affected in all patients, inferior mesenteric in 3 patients (42.9%) and celiac artery was affected in 2 patients (28.6%)Technical success was achieved in 6 patients. SMA was the main target for revascularization. Technical success was achieved in 6 patients (85.7%). 24 month Primary assisted patency was 71.4%. There were no major complications, minor complications occurred in 2 patients (28.6%). Conclusion: Endovascular management of chronic mesenteric ischemia has comparable outcome to surgical solutions but with less morbidity and mortality. However strict follow up and timely secondary intervention is mandatory.

3:00 PM Abstract No. 399 Percutaneous revascularization for chronic mesenteric ischemia: does a residual pressure gradient affect clinical outcomes?

Percutaneous revascularization has become a reliable option in the management of chronic mesenteric ischemia with much lower associated morbidity and mortality than surgical methods. Unlike peripheral arterial interventions, there are no quantitiative endpoints for to determine the success of mesenteric angioplasty. Complete angiographic patency or alleviation of an arterial pressure gradient across the stenosis are often not feasible. Furthermore, aggressive angioplasty is typicall avoided as the consequences of a dissection or acute occlusion can be catastrophic. Our purpose is to examine whether a residual arterial pressure gradient after percutaneous revascularization affects clinical outcomes and patient symptomatology. We present a single-institution retrospective observational study involving patients who underwent mesenteric revascularization between January 2009 and June 2017 for chronic mesenteric ischemia. Simultaneous intra-arterial pressures were obtained in the aorta and SMA or celiac trunk using an end-hole catheter with a pressure transducer. Patients who did not have post-angioplasty intra-arterial pressures recorded were excluded. Postprocedural vascular surgery clinic notes were reviewed to determine whether or not symptoms had improved. There were 20 revascularization procedures for which post-angioplasty arterial pressures are available: 14 SMA and 6 celiac trunk. Mean patient age was 69.3 years. All patients experienced post-prandial abdominal pain and most reported weight loss. All patients had at least one risk factor: hypertension, type 2 diabetes, coronary artery disease or stroke and smoking. Mean follow-up was 90.2 days (range, 33-218 days) Post-angioplasty gradients (systolic/mean) ranged from 4/0 - 65/28 mm Hg (mean 34.2/12.6 mm Hg). Minor complication rate was 8.6%. There were no deaths. Clinical improvement was reported in 100% of patients in follow-up. Three procedures were done prophylactically as the patients were asymptomatic but young with rising PSV on routine ultrasound. Percutaneous mesenteric revascularization can improve symptoms of chronic mesenteric ischemia despite a residual arterial pressure gradient.

Chronic Mesenteric Ischemia

Endovascular management and treatment of chronic mesenteric ischemia has taken on an increasing role in recent years. The safety, efficacy, and cost-effectiveness have been validated in several studies. The procedure is best performed by an operator with a complete understanding of the pertinent imaging findings; a thorough knowledge of the risks, benefits, limitations, and technical challenges of the procedure; and understanding of the importance and necessity of long-term clinical management. This article outlines a general approach to endovascular management of chronic mesenteric ischemia and discusses indications, potential complications, and technical aspects of the procedure.

Inferior Mesenteric Artery Stenting as a Novel Treatment for Chronic Mesenteric Ischemia in Patients with an Occluded Superior Mesenteric Artery and Celiac Trunk

Introduction: Chronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions. Report: We report a case series of four patients with chronic mesenteric ischemia who were not candidates for CA or SMA revascularization who were successfully treated with inferior mesenteric artery (IMA) angioplasty and stent placement to improve collateral circulation and palliate symptoms. Discussion: To our knowledge, this is the largest case series to date reporting the use of an IMA stent to improve collateral circulation in patients with CMI. Inferior Mesenteric Artery Stenting as a Novel Treatment for Chronic Mesenteric Ischemia in Patients with an Occluded Superior Mesenteric Artery and Celiac TrunkEJVES ExtraVol. 27Issue 3PreviewChronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions. Full-Text PDF Open Access

Inferior Mesenteric Artery Stenting as a Novel Treatment for Chronic Mesenteric Ischemia in Patients with an Occluded Superior Mesenteric Artery and Celiac Trunk

Chronic mesenteric ischemia (CMI) is a challenging problem, with revascularization the mainstay of treatment. Management of CMI is especially challenging in the patient with superior mesenteric artery (SMA) and celiac artery (CA) occlusions. We report a case series of four patients with chronic mesenteric ischemia who were not candidates for CA or SMA revascularization who were successfully treated with inferior mesenteric artery (IMA) angioplasty and stent placement to improve collateral circulation and palliate symptoms. To our knowledge, this is the largest case series to date reporting the use of an IMA stent to improve collateral circulation in patients with CMI.

Primary balloon-expandable covered stents vs. primary bare-stents for mesenteric ischemia: patency and clinical outcomes

Purpose To evaluate the anatomical and functional outcomes of primary balloon-expandable covered stents compared to primary balloon-expandable bare-stents for the endovascular management of chronic mesenteric ischemia. Materials and Methods A retrospective audit of patients undergoing primary endovascular management of mesenteric ischemia was performed (01/2006-12/2011). The cohort was divided into bare-metal stent group (BMG) and covered stent (0.035-inch platform, V-12, Atrium) group (CVG). Inferior mesenteric artery (IMA) arteries (none in CVG) and angioplasty alone (small sample size) were excluded. Patency per artery was determined by imaging follow-up and clinical success (patency by clinical response). Results 111 primary endovascular procedures were found (18 IMA excluded). Technical success of SMA and CAx arteries was 99% (n=110/111). An additional 7 arteries (2 SMA, 5 CAx) in 6 patients were excluded (angioplasty alone). The remainder was: 15 (12 SMA, 3 CAx) arteries in 14 patients (CVG) and 88 (64 SMA, 24 CAx) arteries in 75 patients (BMG). Clinical success per patient for BMG vs. CVG was 87% (n=65/75) vs. 79% (n=11/14) (P=0.3933), respectively. Primary unassisted patency at 6, 9, 12 and 24 months for CVG vs. BMG were: 100%+/-0, 100%+/-0, 100%+/-0, and 100%+/-0 vs. 93%+/-4, 81%+/-6, 74%+/-8, and 45%+/-11, respectively (P Conclusion In patients with mesenteric ischemia, balloon-expandable covered stents have improved patency compared to balloon-expandable bare stents in the celiac axis and superior mesenteric artery.

Superior Patency of Covered Stents Over Bare Metal Stents in Patients with Chronic Mesenteric Ischemia

Objective: Endovascular management of chronic mesenteric ischemia, usually with stent placement, has become an accepted management strategy. Unfortunately, this therapy is plagued by poor primary patency and high rates of restenosis, usually with the return of symptoms. Our hypothesis is that treatment of chronic mesenteric ischemia with covered stents is a better treatment option than bare metal stents.

Current Concepts in the Management of Chronic Mesenteric Ischemia

Treatment of chronic mesenteric ischemia has evolved during the past two decades. Endovascular treatment has emerged as an alternative to bypass in elderly and higher-risk patients and is now the primary treatment modality for most patients with suitable lesions, independent of their surgical risk. Open surgical revascularization still has an important role for patients with more extensive disease, including those with long-segment stenosis or occlusions, small vessel diameter, multiple tandem lesions, or severe calcification. This article summarizes current concepts in the epidemiology, natural history, treatment selection, and outcomes of open and endovascular mesenteric reconstruction for chronic mesenteric ischemia.

Chronic mesenteric ischemia

Clinical manifestations of chronic mesenteric ischemia (CMI) can range from vague abdominal pain to debilitating states of intestinal angina resulting in significant weight loss and morbidity. Once the condition has been diagnosed, treatment usually is elective, except in rare cases of rapid progression to acute mesenteric ischemia. Medical management of CMI is mostly supportive. However, in disorders of coagulation, antiplatelet agents and warfarin may be helpful to prevent further thrombosis, and these disorders may require lifelong therapy. For decades, the mainstay of therapy for CMI has been surgery. Extensive disease often requires complete revascularization, although bypass of the superior mesenteric artery alone also has been shown to be effective. Multiple variations of surgical bypass have been advocated but require further evaluation to determine efficacy. Transaortic endarterectomy is a viable option for limited disease. Minimally invasive vascular procedures such as percutaneous endovascular angioplasty and stenting are proving to be effective for short-segment atherosclerotic stenosis, particularly near the origin of the vessels. Although endovascular therapy has less long-term durability compared with open surgical procedures, these treatments prove simpler, with shortened hospital stays and reduced morbidity. Furthermore, angiographic therapy is a feasible alternative for patients in whom surgery is deemed precarious.

Percutaneous Management of Chronic Mesenteric Ischemia: Outcomes after Intervention

Percutaneous Management of Chronic Mesenteric Ischemia: Outcomes after Intervention

Surgical and medical management of mesenteric ischemia

Acute mesenteric ischemia frequently results in bowel necrosis, which necessitates laparotomy to assess bowel viability. Reduction in mortality requires a high index of suspicion and prompt diagnosis. Bowel resection should be preceded by visceral artery revascularization. Medical management includes the use of anticoagulation, vasodilators, and the use of inhibitors of reperfusion injury. The management of chronic mesenteric ischemia largely depends on the general condition of the patient, who is often affected by malnutrition and dehydration. Surgery, although associated with greater morbidity and mortality, is more durable and effective in relieving the symptoms of chronic mesenteric ischemia. Endovascular treatment options for chronic mesenteric ischemia include percutaneous balloon angioplasty and stenting. This treatment is more likely to be successful in dealing with stenotic rather than occlusive lesions and offers a minimal invasive approach but is associated with a smaller primary success rate and a higher recurrence rate.