Le ischemie gastrointestinali
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1 Le ischemie gastrointestinali La Radiologia Interventistica nell Emergenza-Urgenza Andrea Discalzi / Torino UNIVERSITÀ DEGLI STUDI DI TORINO Scuola di Medicina Dipartimento di Scienze Chirurgiche A.O.U Città della Salute e della Scienza di Torino Dipartimento di Diagnostica per Immagini e Radioterapia Radiologia 1 Universitaria UNIVERSITA DEGLI STUDI DI TORINO Dipartimento di Scienze Chirurgiche
2 Introduction Overall incidence 0.63/ person years Autopsy rate incidence more than twenty times higher 12.9/ person years M=F Meanage70 y.o. Mortality rates 50-70%
3 Pathophysiology Acute Mesenteric Ischaemia Arterial occlusion Venous occlusion Non-occlusive Embolism 20-30% Thrombosis 50% Mesenteric Venous thrombosis 15% Non-occlusive Mesenteric ischaemia 15% 54% 77% 32% 73% Mortality rates Bradbury AW, et al. Br J Surg 1995;82: SchootsIG, (2004). "Systematic review of survival after acute mesenteric ischaemia according to disease aetiology". The British journal of surgery 91 (1): 17 27
4 Clinical suspicion Most symptoms and signs are non-specific and need to exclude other non-vascular emergencies Past history of atherosclerotic diseases, hypertension and FA are the principal risk factor Symptoms and signs Abdominal pain 95% Pain out of proportion of signs Nausea 44% Vomiting 35% Bloody Diarrhea 35% PR bleeding 16% Fever 46% Tachycardia 58% Abd distension 66% Laboratory tests Leukocytosis Elevated urea Elevated creatinine Elevated lactate Metabolic acidosis DIC Endean ED, et al. Ann Surg 2001;233: Park WM, et al. J Vasc Surg2002;35: Sreedharan S, et al. Singapore Med J 2007;48:319-23
5 Time critical 15 mins Structural changes to intestinal villi 3 hours - Mucosal sloughing - Still reversible 6 hours - Transmural necrosis - Gangrene - Perforation 15 mins 3 hours 6 hours UdassinR, et al. J Surg Res1994;56:221-5
6 Time critical SPASTIC PHASE Widespread cramping pain, diarrhea nausea and vomiting. No signs of acute abdomen Persisting Ische emia PARALYTIC PHASE PERITONITIS PHASE Severe ischemic pain, stopping diarrhea and cramping. Initial signs of acute abdomen Acute abdomen associated to rapid worsening of general condition and shock Gaspariniet al. CIRSE 2010 Workshop: acute mesenteric ischemia, all you need to know
7 CT scan SMA thrombus Bowel wall thickening Non-enhanced bowel wall Pneumatosis intestinalis Portal venous gas Fluid collection Wiesner W, et al. Radiology 2003;226:635-50
8 Injury Severity Life threatening transmural bowel wall necrosis Wallthikness 2-3 mm Persisting ischemia Gaspariniet al. CIRSE 2010 Workshop: acute mesenteric ischemia, all you need to know
9 Acute SMA occlusion SMA Embolism Aortic ostium ~15% SMA Thrombosis Aortic ostium ~60-80% Around Middle colic artery ~40% Around Middle colic artery ~15% Distal branches ~45% Distal branches ~5% Acosta S, et al. Ann Surg 2005;241:516-22
10 Vascular anastomosis RIOLANO S ARCH DUODENAL PANCREATIC ARCHES HEMORRHOID ARTERY DRUMMOND SARCH (Marginal artery) Gasparini et al. CIRSE 2010 Workshop: acute mesenteric ischemia, all you need to know
11 Weakpoints The splenic flexure (Griffith Point) The rectosigmoid junction(sudek s point)
12 Reiner scritical Segment The point of Reiner is a segment of the superior mesenteric artery between the point before the origin of the second intestinal artery and middle colic and a point downstream dell'ileocolic artery. The occlusion is frequent in case of emboli ischemia and this event undermine the Drumond arch.
13 Reiner scritical Segment Injury extension in case of obstruction of the Reiner segment. The ischemia is extended from the Traiz legament to the splenic colon flexure.
14 Treatment Traditional management of AMI was open surgery especially for acute abdomen. Embolectomy Thrombo-endarterectomy Aorto-mesenteric bypass +/- Bowel resection of necrotic parts Mortality and intestinal resection rate remains high (37%-59%) Alternative treatment: Endovascular Raupachet al. CIRSE 2016 Workshop: acute mesenteric ischemia
15 Endovascular treatment PTA and stenting Primary stenting Mechanical aspiration (manual or automated sistems) Pharmacological therapy (urokinasis, rtpa, 2b 3a antagonists ) Combined tecnique
16 ET: SMA stenting Brachial vs femoral Occlusions stump Lateral view Heparin 2500 U.I. Vasodilators Long sheath Occasionally, a.014 and low-profile balloons are needed to cross and predilate the lesion Balloon-expandable stents should be preferred for proximal lesions and self-expandable to compliance better to SMA angulations for distal ones dual anti-platelets (aspirin for life/clopidogrel 3-6 months) restenosis/occlusion 16-20%/1 year Raupach et al. CIRSE 2016 Workshop: acute mesenteric ischemia Acosta S, Sonesson B, Resch T (2009) Endovascular therapeutic approaches for acute superior mesenteric artery occlusion. Cardiovasc Intervent Radiol 32:
17 Aspirationembolectomy 7F angled guiding catheter, (Destinaton, RDC, Terumo) removable haemostatic valve 5-7F aspiration catheter manual aspiration 20 ml/60 ml syringe Automatic thromboaspiration Penumbra Indigo System (CAT5- CAT6 ) Raupachet al. CIRSE 2016 Workshop: acute mesenteric ischemia
18 Tromboembolectomy Thrombectomy by AngioJet (Boston Scientific) Thrombectomy by Rotarex (Straub Medical AG) Thrombectomy with carotid filter Thrombectomy with stent retriever 7-8F guiding cath for treatby mechanical fragmentation (e.g. Aspirex, Straub) or aspiration by several passes Raupachet al. CIRSE 2016 Workshop: acute mesenteric ischemia S.Acosta, Cardiovasc Intervent Radiol(2009) 32:
19 Thrombolysisinfusion Femoral access with a 6-8F introducer. Heparin up to ACT The SMA must be deeply engaged and a 7F 60cm introducer with removable hub (Destination, Terumo). Local thrombolysis should be performed with rtpa at a rate of 0.25 to 1 mg/h or mg/kg/h. Angiographic control of cath position and thrombolytic effect should carried out every 12 hours. Raupach et al. CIRSE 2016 Workshop: acute mesenteric ischemia S.Acosta, Cardiovasc Intervent Radiol(2009) 32: Nileshet al CIRSE Quality Improvement Guidelines for PercutaneousManagementof Acute Lower-extremity Ischemia
20 Evidence No randomized controlledtrials to guide treatment High ratio of case reports and small retrospective series
21 Morbidity Zhao Y, Management of acute mesenteric ischemia, Vascular and Endovascular Surgery, 2016
22 Zhao Y, Management of acute mesenteric ischemia, Vascular and Endovascular Surgery, 2016
23 Mortality In hospital mortality ET 27% vsos 40% 5-year Mortality 1 yearet 90% vsos 65% 2 yearset 56% vsos 50 e 55% But selection bias... Zhao Y, Management of acute mesenteric ischemia, Vascular and Endovascular Surgery, 2016
24 Time critical No presence of peritonitis or suspicions of intestinal necrosis! SPASTIC PHASE Widespread cramping pain, diarrhea nausea and vomiting. No signs of acute abdomen Persisting Ischemia PARALYTIC PHASE PERITONITIS PHASE Severe ischemic pain, stopping diarrhea and cramping. Initial signs of acute abdomen REVASCULARIZATION CUT OFF Acute abdomen associated to rapid worsening of general condition and shock Gaspariniet al. CIRSE 2010 Workshop: acute mesenteric ischemia, all you need to know
25 Time critical Injury Severity Life threatening transmural bowel wall necrosis Wallthikness 2-3 mm Persisting ischemia Gaspariniet al. CIRSE 2010 Workshop: acute mesenteric ischemia, all you need to know
26 Anatomicalsuitability Anatomicsuitabilityisoneof the mostimportantfactorsfor determining choice of endovascular intervention Maintrunkof SMA isnotangularor tortuous Proximaland distallandingzonesare 10 mm No mainbrancheslocatedwithinthe sectionof proximalor distallandingzone Zhao Y, Management of acute mesenteric ischemia, Vascular and Endovascular Surgery, 2016
27 Guidelines? Tilsed et al. ESTES guidelines: acute mesenteric ischaemia EurJtrauma Emerg Surg2016
28 Guidelines? Tilsed et al. ESTES guidelines: acute mesenteric ischaemia EurJtrauma Emerg Surg2016
29 Treatment algorithm Peritoneal irritation Emergency OS OS Suitable anatomy ET Life expectancy >5y ET/ET to OS Good Nutrition status OS/HT Zhao Y, Management of acute mesenteric ischemia, Vascular and Endovascular Surgery, 2016
30 MesentericVenous Thrombosis Younger patients Primary MVT (40%) any hypercoagulable states Secondary MVT (60%) Portal hypertension Intraabdominal sepsis Intraabdominal neoplasia Pancreatitis Trauma Symptoms Less severe Slower onset[weeks] Mainstay therapy Anti-coagulation Surgical resection Bradbury AW, et al. Br J Surg 1995;82:
31 Endovascular treatment SMA thrombolytic infusion Portal vein or SMV: Percutaneous hepatic/splenic Trans-jugular trans-hepatic Thrombolysis Mechanical When? Anti-coagulation failure Severe pain without infarction Infarction/surgery excludes thrombolysis Options discussion Raupach et al. CIRSE 2016 Workshop: acute mesenteric ischemia
32 Guidelines? Tilsed et al. ESTES guidelines: acute mesenteric ischaemia EurJtrauma Emerg Surg2016
33 Non-occlusive MesentericIschaemia Conditions resulting in splanchnic vasoconstriction ICU elderly Septic or cardiogenic shock Vasoconstrictivedrugs/poisoning Infarctionestablished Exclude SMV thrombosis Management Treatshock Spasm-local vasodilators[poisoning] Laparotomy/laparoscopy Raupachet al. CIRSE 2016 Workshop: acute mesenteric ischemia
34 Guidelines? Tilsed et al. ESTES guidelines: acute mesenteric ischaemia EurJtrauma Emerg Surg2016
35 Occlusion of the mesenteric vessels is apt to be regarded as one of those condition of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost useless A.J. Cokkinis 1926 Grazie! Cokkinis AJ. Mesenteric vascular occlusion. London, Bailliere, Tindall and Cox. 1926pp1-93
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