MESENTERIC ISCHEMIA. Phillip J Bendick, PhD

Transcription

1 MESENTERIC ISCHEMIA Phillip J Bendick, PhD

2 Arterial Celiac - Hepatic - Splenic Superior Mesenteric Artery Inferior Mesenteric Artery Venous Mesenteric system Porto - hepatic system Inferior Vena Cava

3 Acute Mesenteric Ischemia Mortality Data Past 35 years 69% Past 10 years 66% Series of >40 patients 70%

4 Acute Mesenteric Ischemia Mortality Data Most recent data (2009) 40 50% Early diagnosis and treatment!!

5 Acute Mesenteric Ischemia: a surgical emergency, not an urgent ultrasound study!!

6 Chronic Mesenteric Ischemia F:M 3:1 Nausea Post-prandial pain Fear of food syndrome Weight loss Diarrhea

7 Chronic Mesenteric Ischemia Age 65 (40 85 yrs) Sx: Post-prandial pain % Weight loss (20-30 lb.) 70-80% Fear of food ~ 50%

8 Chronic Mesenteric Ischemia Vessel involvement: Celiac trunk + SMA disease Typically ostial Aortic disease often not seen

9 Chronic Mesenteric Ischemia Vessel involvement: Mean 2.5 Single vessel < 5% Two vessel 40-50% Three vessel 40-50%

10 Chronic Mesenteric Ischemia Sx onset to Dx: mos.

11 Patient preparation Morning examinations Light meal the night before NPO after midnight NOsmoking or gum chewing the morning of the examination

12 Mesenteric Artery Stenosis Technique Don t struggle and frustrate yourself Patient supine, but don t hesitate to move the patient around Optimize your controls: B-mode gain, color gain, color PRF, Doppler sample volume and gain, focal zones,...

13 Visceral arteries Breath holding technique: Stop breathing Optimize controls before breath hold

14 Scanning tips: Spectral Doppler Set scale (PRF) to fill window Use large sample volume size Use low wall filter setting Use highest Doppler frequency possible

15 Color Doppler Imaging PRF high: Differentiate arterial from venous flow Less aliasing Less color flash Increase wall filter Minimize ROI (higher frame rate)

16 Chronic Mesenteric Ischemia Technically adequate duplex ultrasound examinations in more than 95% of patients

17 ANATOMY OF THE MESENTERIC STUDY

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20 SMA

21 SMA

22 Normal Mesenteric Velocity PSV EDV Proximal aorta (cm/sec) Celiac trunk SMA - fasting SMA - postprandial 180 >45

23 Mesenteric Arterial Disease Fasting study: Sensitivity > 90% Specificity > 95% Negative predictive value ~ 99% Overall accuracy > 95% Moneta et al AmerJSurg 1995

24 Celiac Artery Disease >70% stenosis PSV > 200 cm/sec

25 Celiac Stenosis

26 Celiac Artery Stenosis: Caveats Celiac artery occlusion

27 Celiac Artery Disease >70% stenosis PSV > 200 cm/sec Total / near total occlusion Absent flow Reversed common hepatic artery flow

28 Celiac Artery Disease Hepatic artery Note reversed flow

29 Superior Mesenteric Artery Disease >70% stenosis PSV > 275 cm/sec EDV > 55 cm/sec Post -prandial Minimal or no increase in EDV

30 Stenosis Proximal SMA

31 Post-Stenotic Turbulence, Proximal SMA

32 Mesenteric Arterial Disease Management: Angioplasty/Stent vs Open Surgery In-hospital mortality In-hospital morbidity Hospital LOS NS NS NS

33 THE MESENTERIC STUDY Chronic Mesenteric Ischemia

34 Mesenteric Arterial Disease Management

35 Mesenteric Arterial Disease Management: Angioplasty/Stent vs Open Surgery In-hospital mortality NS In-hospital morbidity NS Hospital LOS NS Recurrent symptoms p =.001

36 Mesenteric Arterial Disease Management

37 Mesenteric Arterial Disease Management

38 Chronic Mesenteric Ischemia Pre-stent: Celiac

39 Pre-stent: SMA Chronic Mesenteric Ischemia

40 Chronic Mesenteric Ischemia Post-stent: stent: 8 months, recurrent symptoms

41 Miscellaneous studies -Arterial Median arcuate ligament syndrome

42 Miscellaneous studies -Arterial Median arcuate ligament syndrome

43 Miscellaneous studies -Arterial Median arcuate ligament syndrome Compression ASO

44 Miscellaneous studies -Arterial Median arcuate ligament syndrome

45 Splenic Artery Aneurysm 2.8 cm

46 Miscellaneous studies -Arterial Median arcuate ligament syndrome Splenic artery aneurysm Fibromuscular dysplasia Post -operative evaluation Miscellaneous zebras

47 Peri-aortic lymph nodes

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49 Pelvic AVM