Chronic Mesenteric Ischemia
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1 Chronic Mesenteric Ischemia February 10 th, 2018 Moses Kim, MD Vascular Surgery Iowa Heart and Vascular
2 Financial Disclosures Employee-Iowa Heart Center/Mercy-Des Moines
3
4 Case 75 yo male who presented as an emergent transfer for mesenteric ischemia POD#14 after SBR for ischemia TPN dependent Post-op CTA: SMA chronic occlusion Peritonitis on exam OR
5
6 Case History 9 months of abdominal pain Post-prandial, diffuse 20 lb weight loss EGD/colonoscopy: negative US/HIDA: negative CT Scan: negative Care was withdrawn patient expired
7 CMI is not very Common Chronic mesenteric ischemia (CMI) accounts for less than 1/100,000 of hospital admissions Less than 2% of patients of all GI admissions BUT: patients older than 65, the incidence can be as high as 18% 1 Females affected more common than males (3:1) for atherosclerotic disease 1:1 ratio for non-atherosclerotic etiologies
8 CELIAC ARTERY SMA IMA
9 Natural History Not well understood Stenosis of 1 of 3 usually does not cause symptoms Complete occlusion of single artery may cause angina in 5% of patients Up to 40% of patients with ACUTE intestinal ischemia have no CMI symptoms 2 Average time to diagnosis and treatment is 15 months Depends on Etiology: Atherosclerotic vs. Non
10 Differentials: Remember Ischemia Inflammatory Infectious Anatomic Ischemic
11 Demographics Concurrent CAD (50-70%) Cerebrovascular (20-45%) PAD (20-35%) HTN/HL/Smoking (60%)
12 Clinical Symptoms/Signs Intestinal Angina Mayo Clinic 357 patients Abdominal pain 96% Post-prandial 74% Weight loss 84% Physical exam Cachexia +/- Abdominal tenderness Muscle Wasting Flat abdomen Abdominal Bruit (50%) Signs of PAD (non-palpable pulses)
13 Laboratory Findings are Non-specific Albumin, transferring, pre-albumin decreased Signs of systemic inflammation Elevated Lactic acid/d-dimer after meal challenge
14 Diagnosis: US ELEVATED PSV (>275) FASTING EXAM >70% Stenosis Validated criteria General abdominal US is also useful for Gall bladder dz Pancreatitis Hepatitis
15 Diagnosis: CTA
16 Diagnosis: Endoscopy In patients with diagnosed mesenteric ischemia: 38% can have duodenitis 57% can have ischemic colitis But this also means that a significant number will have NO specific findings on endoscopy Good test for ruling in/out other causes Gastritis GERD Ulcer Disease Infectious colitis
17 Treatment: Endovascular 70-80% of all lesions now treated with angioplasty/stenting No randomized comparisons vs open Lower morbidity Decreased patency Anatomic suitability is a must
18 Treatment: Open Surgical Large volume centers have achieved mortality rates of <3% Due to improved pre-op evaluation, ICU care, better technique Previously, OR mortality could be as high as 10% GOLD STANDARD: Antegrade bypass SECONDARY: Retrograde bypass
19 Outcomes There are no randomized trials directly comparing the two major therapies Endovascular surgery has lower rates of morbidity (11% at 3 days) 33% at 14 days with open surgery 30 day mortality rates are similar (2-6%) Stent patency on average is 60-70% at 3 years Open graft patency is 90% at 5 years
20 Celiac Artery Treatment Very unlikely that isolated celiac artery lesions cause significant symptoms Median Arcuate Ligament Syndrome some controversy exists in vascular surgery to treating this disease Retrospective studies: treatment of celiac and SMA vs SMA alone did not show any benefit 3 Increased rates of celiac artery restenosis No evidence that two-vessel stenting provides better symptoms relief Typically reserved for cases of severe UGI ischemia without collateralization
21 Conclusions Mesenteric Ischemia is uncommon, and not all patients are symptomatic Keep the ischemia differential in mind Fasting US is a great, non-invasive diagnostic tool Endovascular vs. Open therapy depends on anatomy, patient factors Isolated celiac stenosis with abdominal pain requires multi-disciplinary approach
22 THANK YOU
23 References Textbooks: [Edited by] Jack L. Cronenwett, K. Wayne Johnston. Rutherford's Vascular Surgery, Chapters 151 and 152. Philadelphia, PA :Saunders/Elsevier, Print. [Edited by] Wesley S. Moore. Vascular and Endovascular Surgery: A Comprehensive Review, Chapter 23. Philadelphia, PA: Saunders/Elsevier, Print. Articles: 1 Hansen KJ, Wilson DB, Craven TE, Pearce JD, English WP, Edwards MS, Ayerdi J, Burke GL. Mesenteric artery disease in the elderly. J Vasc Surg Jul;40(1): PubMed PMID: Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S, Bower TC. Revascularization for acute mesenteric ischemia. J Vasc Surg Jun;55(6): doi: /j.jvs Epub 2012 Apr 12. PubMed PMID: Malgor RD, Oderich GS, McKusick MA, Misra S, Kalra M, Duncan AA, Bower TC, Gloviczki P. Results of single- and two-vessel mesenteric artery stents for chronic mesenteric ischemia. Ann Vasc Surg Nov;24(8): doi: /j.avsg PubMed PMID:
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