Symptoms Of Mesenteric Ischemia Research Articles

Chronic Mesenteric Ischemia: Differential Vascularsurgical Therapy and Its Outcome in a Single-Center Observational Study

Aim: The aim of this study was to investigate short-/long-term vascularsurgical patency and the outcome in chronic mesenteric ischemia (CMI) depending on the mesenteric revascularization technique and reflecting real-world data. Methods: This retrospective single-center observational study registered all patients who had undergone open vascularsurgical reconstruction because of CMI at a tertiary German university hospital comparing 1-versus (vs.) 2-vessel as well as antegrade versus retrograde reconstructions. Results: In total, 35 patients were enrolled (mean [± SD] age, 64 ± 13 [range, 45–83] years; sex ratio [m:f], 16:19 [46:54]) over 12 years. Three patients with symptoms of mesenteric ischemia because of rare causes (radiation-induced and median arcuate ligament syndrome) have been excluded. While 51% of patients underwent 1-vessel reconstruction, 49% underwent 2-vessel reconstruction. There was a trend of (i) more perioperative complications in the 2-vessel group (88.2% vs. 55.6%, p = 0.06) and (ii) higher morbidity at 1 year in the 2-vessel versus 1-vessel group (57.1% and 42.9%, respectively; p = 0.466), while the morbidity of the 2-vessel versus 1-vessel group at 5 years (100% vs. 33.3%) was significantly different (p = 0.009). The mortality was greater in the 2-vessel versus 1-vessel group as it was significantly different in the early postoperative period (31.3% vs. 0, p = 0.016) and at 1 year (50% vs. 0, p = 0.005) and 5 years (100% vs. 11%, p = 0.003). Regarding overall survival, the 1-vessel group showed a significant superiority above the 2-vessel group (p = 0.004). Actually, there was no significant difference of early postoperative morbidity comparing the retrograde and antegrade group (p = 0.285) as well as at 1 year and 5 years (p = 0.715 and p = 0.620, respectively). In addition, there was no significantly different postoperative mortality in antegrade versus retrograde group at each time. Specific and general complication rates were 62.9% and 57.1%, respectively, resulting in an overall morbidity of 77.1% (mortality, 20%). Conclusion: The vascular surgeon should be prepared to perform various procedures of mesenteric reconstruction to tailor the operative strategy to the specific needs of the individual patient.

Mesenteric Ischemia

Audience: This simulation session is appropriate for emergency medicine residents at any level or medical students. Introduction: Mesenteric ischemia is a rare, but serious cause of abdominal pain. Practitioners must recognize the diagnosis quickly. The clinical course rapidly advances from bowel ischemia to infarction, sepsis, and frequently death. Mesenteric ischemia accounts for approximately 1% of all ED cases of abdominal pain in the elderly, but the mortality is as high as 93%. Objectives: At the end of this simulation session, the learner will: 1) Recognize signs and symptoms of mesenteric ischemia; 2) order appropriate imaging and labs in the workup of an elderly patient with abdominal pain; 3) manage a patient with mesenteric ischemia, a rare, but serious cause of abdominal pain in the elderly; 4) discuss anchoring bias, specifically related to patients referred to the ED with an established diagnosis by outside specialists. Methods: This educational session is a high-fidelity simulation.Topics: Mesenteric ischemia, simulation, abdominal pain in the elderly, SIRS, lactic acidosis, anchoring bias.

The celiac axis revisited: anatomic variants, pathologic features, and implications for modern endovascular management.

The celiac axis (CA) and its branches are critically important arteries that supply blood to the vital solid and hollow abdominal viscera of the foregut. There are many potential anatomic configurations, with up to half the population having a variation from the classic pattern of the CA bifurcating into the hepatosplenic trunk and left gastric artery. These configurations result from permutations in the fusion of the paired dorsal aortas during the first trimester. Despite the short length of the CA, it is affected by a wide range of pathologic conditions, including mesenteric ischemia due to intrinsic occlusion (secondary to causes such as atherosclerosis or thromboembolic events) and extrinsic compression from masses or the median arcuate ligament. Symptoms of mesenteric ischemia are nonspecific and include postprandial abdominal pain and weight loss; thus, the underlying pathologic condition may be found only when being sought specifically. More unusual pathologic conditions include dissection, aneurysms, and vascular malformations. Awareness of the pathologic conditions that affect the CA is important for both diagnostic and interventional radiologists. Early recognition and treatment of CA disease may prevent catastrophic hemorrhage and bowel infarction. Both endovascular and surgical approaches to treatment are greatly enhanced by correct identification of arterial anatomic variants; catheter angiography, computed tomographic angiography, and magnetic resonance angiography can facilitate detection of these variants. Knowledge of the different anatomic permutations is essential to guide endovascular procedures, such as hemorrhage control, transarterial interventional oncologic therapy, and treatment of visceral artery aneurysms. Online supplemental material is available for this article.

A Case of Polyarteritis Nodosa Manifesting as a Neuropathy Following Influenza Infection

Polyarteritis nodosa (PAN) is a necrotizing vasculitis of the medium-sized arteries. The symptoms and signs of PAN include purpuric skin lesions, mononeuritis multiplex, symptoms of mesenteric ischemia, and renal involvement. We report the first case of PAN manifesting as a neuropathy after influenza infection in Korea. A 68-year-old woman had fever, myalgia, hyperesthesia of both hand and foot, and lower extremity weakness. EMG findings showed severe sensorimotor polyneuropathy, such as multiple mononeuritis. A sural nerve biopsy showed vasculitis and Influenza A (H1N1) were positive. Our patient was treated by glucocorticoid and oral cyclophosphamide, thereafter, symptoms and signs improved. No recurrence has been observed for five months.

Diagnostic et prise en charge des ischémies mésentériques aiguës

The prevalence of significant splanchnic arterial stenoses is increasing, but remains mostly asymptomatic due to abundant collateral circulation. Acute insufficiency of mesenteric arterial blood flow accounts for 60 to 70% of cases of mesenteric ischemia and results mostly from a superior mesenteric embolus. Despite major advances have been achieved in understanding the pathogenic mechanisms of bowel ischemia, its prognosis remains dismal with mortality rates about 60%. The diagnosis of acute mesenteric ischemia depends upon a high clinical suspicion, especially in patients with known risk factors. Rapid diagnosis is essential to prevent intestinal infarction. However, early signs and symptoms of mesenteric ischemia are non specific, and definitive diagnosis often requires radiologic examinations. Early and liberal implementation of angiography has been the major advance over the past 30 years which allowed increasing diagnostic accuracy of acute mesenteric ischemia. CT and MR-based angiographic techniques have emerged as alternatives less invasive and more accurate to analyse splanchnic vessels and evaluate bowel infarction. The goal of treatment of patients with acute mesenteric ischemia is to restore intestinal oxygenation as quickly as possible after initial management that includes rapid hemodynamic monitoring and support. Surgery should not be delayed in patients suspected of having intestinal necrosis.

Mid-abdominal Coarctation Exacerbated by Pre-eclampsia: A Case Report of Thoracoabdominal Reconstruction in a Woman who Suffered Hypertension Induced Premature Childbirth

This is a case report of a 23-year-old woman diagnosed with coarctation of the mid-abdominal aorta. She was on three anti-hypertensive medications with poorly controlled hypertension (HTN) when she developed pre-eclampsia, resulting in the premature birth of her 28-week-old baby. After childbirth, she continued to have uncontrolled HTN, symptoms of mesenteric ischemia and lower extremity claudication. A computed tomography (CT) angiogram showed approximately 50% focal narrowing of the aorta at the origin of the renal arteries, extending distally approximately 4 cm in length, near occlusion at the origin of the celiac artery with multiple collateral vessels including a patent arc of Buehler, severe stenosis of the superior mesenteric artery (SMA), and bilateral focal stenosis of the renal ostium. She underwent thoracoabdominal aortic repair with 14 mm Dacron end-to-side tube graft placement extending from the descending thoracic to the infrarenal aorta. A 12 mm x 7 mm bifurcated graft was used to complete the aorto-common hepatic artery and aorto-SMA bypasses. A third graft limb was sewn from the aortic graft to revascularize the left renal artery. Postoperatively, blood pressure was stringently monitored with goal pressures of <140/90. On postoperative day 10, she was discharged home with stable renal function and acceptable blood pressures. At one year follow up, her hypertension has completely resolved with systolic ranges from 120 s to 140 s and she has stopped taking her blood pressure medications. Her mesenteric ischemic and claudication symptoms have also resolved. Follow up CT angiogram at one year confirms patency of the aorto-aorto graft, aorto-hepatic, aorto-SMA, and aorto-left renal bypasses. This is an interesting patient with mid-abdominal coarctation syndrome whose clinical severity exacerbated with the presence of pre-eclampsia. Subsequent thoracoabdominal reconstruction appears to have been an excellent option for her.

Analysis of association between carcinoid heart disease and mesenteric fibrosis in patients with midgut carcinoid tumour

e15650 Background: Valvular heart disease in patients with carcinoid syndrome is due to development of fibrosis and endocardial thickening in the heart. The most accepted theory relating to development of heart disease is secretion of serotonin (5- hydroxy tryptamine) by the tumour or metastases. Mesenteric fibrosis develops as a result of peptides e.g.TGF beta released by local metastases. Both complications cause significant morbidity and mortality in patients with carcinoid syndrome. Aim: to evaluate the relationship of carcinoid heart disease and mesenteric fibrosis. Methods: We analysed retrospectively all patients (n=200) who had metastatic (liver metatstasis) neuroendocrine tumour and carcinoid syndrome with the primary clearly identified within the small bowel or caecum. We aimed to evaluate clinically symptoms of mesenteric ischemia and small bowel obstruction and also radiological presence of desmoplasia and small bowel dilatation. All patients underwent clinical and echocardiographic cardiovascular assessment to determine the presence of carcinoid heart disease. Results: Of 200 patients 42 had echocardiographic evidence of carcinoid heart disease. 4 patients had evidence of both mesenteric desmoplasia and carcinoid heart disease. 38 patients had carcinoid heart disease alone. Of the remaining 158 patients who had no evidence of carcinoid heart disease, 24 of them had evidence of desmoplasia and/or clinical evidence of sub-acute bowel obstruction where no other cause could be found. The remaining 134 patients had none of these complications. Comparing the relationship of Carcinoid heart disease and mesenteric fibrosis using two tailed exact Fisher's test, p value is 0.45, demonstrating they are statistically independent. We are currently assessing the effect on mortality. Conclusions: Carcinoid heart disease and mesenteric fibrosis (and its effects) are important determinants in morbidity and mortality of patients with midgut neuroendocrine tumour. Although carcinoid heart disease and mesenteric fibrosis are part of the same patho-physiologic process affecting patients with midgut neuroendocrine tumour, the results suggest that progression of these complications is independent of each other. No significant financial relationships to disclose.

Laparoscopic Treatment of Celiac Artery Compression Syndrome: Case Series and Review of Current Treatment Modalities

IntroductionCompression of the celiac artery by the diaphragmatic crura, the median arcuate ligament, or the fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). AnatomyFirst described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. Clinical PresentationPatients commonly present with a wide variety of symptoms resulting in multiple diagnostic tests. DiagnosisA firm diagnosis is difficult to establish, and treatment is equally challenging. These challenges are illustrated by the following case series, and evidence supporting current treatment modalities is reviewed. TreatmentWe describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.

Intestinale Ischämie – Internistische Sicht

Prognosis of acute mesenteric ischemia depends on the quality of the initial management of the treating physician. To reduce the still appallingly high mortality rate of this disease a rapid, invasive and aggressive diagnosis and treatment is necessary. However, early signs and symptoms of mesenteric ischemia as well as laboratory studies are nonspecific. Therefore, definitive diagnosis requires invasive testing using mesenteric angiography. Surgery should not be delayed in patients with peritoneal signs and suspected of having intestinal perforation or gangrene.

Celiac Artery Aneurysms: A Case Report and Review of the Literature

Celiac artery aneurysms (CAA) are uncommon. Most are asymptomatic, but up to 20 per cent will present as surgical emergencies. We present a case of an asymptomatic CAA discovered in a 56-year-old male during evaluation for nephrolithiasis. Only rough estimates of the prevalence of CAA are available, ranging between 0.005 per cent and 0.05 per cent. There appears to be a slight male predominance, and atherosclerotic degeneration is the most common cause. Although most patients are asymptomatic, some will present with vague abdominal pain, nausea, vomiting, or symptoms of mesenteric ischemia. Rupture is a devastating presentation, with reported mortality rates from 35 per cent to 80 per cent. Repair is performed by ligation or reconstruction. Ligation should be considered in an urgent setting, with reconstruction preferred for elective repair. Morbidity and mortality from elective repair should not exceed 5 per cent. Repair of CAA should be undertaken unless major comorbid factors are prohibitive.

The clinical course of asymptomatic mesenteric arterial stenosis

Purpose: The incidence of subsequent symptomatic mesenteric vascular disease is unknown for patients who have asymptomatic mesenteric arterial stenosis. The purpose of this study was to determine the risk of developing acute and chronic mesenteric ischemia in patients identified by lateral aortography to have significant mesenteric artery stenosis. Methods: From 1989 through 1995, 980 consecutive aortograms with anteroposterior and lateral projections were reviewed within 1 week of arteriography to identify patients who had significant mesenteric stenosis but no symptoms of mesenteric ischemia. Eighty-two patients were found to have 50% stenosis of at least one mesenteric artery and were monitored by interview to determine if symptoms of acute or chronic mesenteric ischemia developed. Results: Ten patients were lost to follow-up, and 12 patients were withdrawn from the study because of mild mesenteric arterial disease (1% to 49% stenosis) in combination with more significant disease of other vessels. Follow-up was 1 to 6 years. The overall mortality rate was 40%, and mesenteric ischemia developed in four patients. Each of these four patients had significant (≥50%) stenosis or occlusion of the celiac artery, superior mesenteric artery, and inferior mesenteric artery. Eighty-six percent of the 15 patients with significant three-vessel arterial disease had mesenteric ischemia, had other vague abdominal symptoms, or died. Conclusions: Patients with significant three-vessel mesenteric arterial stenosis should be considered for prophylactic mesenteric arterial reconstruction. Mesenteric arterial reconstruction should be routine when these patients undergo aortic reconstruction for aneurysmal or occlusive disease. (J Vasc Surg 1998;27:840-4.)

Percutaneous Transluminal Angioplasty of Visceral Arterial Stenoses: Results and Long-term Clinical Follow-up

To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) of the visceral arteries. We retrospectively evaluated the results of PTA performed in 20 visceral arteries in 19 patients (10 men, nine women; mean age, 63 years). Eleven patients had symptoms characteristic of mesenteric ischemia, four had atypical abdominal pain, and four were undergoing prophylactic dilation before undergoing another procedure involving the abdominal aorta. Clinical follow-up was possible in all patients. PTA was technically successful in 15 of 19 patients (79%); among these 15 patients, 12 (80%) did well clinically. Of the seven PTA procedures that were immediate failures, five failed secondary to an occult malignancy or to extrinsic arterial compression by the median arcuate ligament. Ten (83%) of the 12 patients in whom the procedures were immediate clinical successes are still clinically improved at 4-73 months follow-up (mean, 25 months). PTA was successful in only one of the four patients who had symptoms atypical of mesenteric ischemia, but it was successful in 11 of the 15 patients who had symptoms of mesenteric ischemia or who underwent prophylactic dilation. Major complications occurred in three (16%) of the 19 patients. PTA of visceral artery stenoses is effective in patients with symptoms of mesenteric ischemia. It is also effective as prophylaxis in patients undergoing additional procedures in the abdominal aorta.