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Description : A brief review of mesenteric arterial diseases and surgical treatments of them

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Published on : Jul 25, 2020 | Views : 2714 | Downloads : 26

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MESENTERIC ARTERY DISEASE Gathered and presented by: Mehrdad Farahmanesh Ali Bahari parham Irandoost
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preview Vascular occlusive disease of the mesenteric vessels is a relatively uncommon but potentially devastating condition that generally presents in patients over 60 years of age, is three times more frequent in women, and has been recognized as an entity since 1936.
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Chronic mesenteric ischemia Chronic mesenteric ischemia is related to a lack of blood supply in the splanchnic region and is caused by disease in one or more visceral arteries: the celiac trunk, the superior mesenteric artery, and the IMA.
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Chronic mesenteric ischemia Mesenteric ischemia is thought to occur when two of the three visceral vessels are affected with severe stenosis or occlusion; however, in as many as 9% of cases, only a single vessel is involved This disease process may evolve in a chronic fashion, as in the case of progressive luminal obliteration due to atherosclerosis.
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Prognosis mesenteric ischemia is considered one of the most catastrophic vascular disorders with mortality rates ranging from 50% to 75%. Early recognition and prompt treatment before the onset of irreversible intestinal ischemia are essential to improve the outcome.
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Anatomy
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Anatomy Mesenteric arterial circulation is remarkable for its rich collateral network. Three main mesenteric arteries provide the arterial perfusion to the gastrointestinal system: the celiac artery (CA), the superior mesenteric artery (SMA), and the IMA.
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Anatomy the CA provides arterial circulation to the foregut (distal esophagus to duodenum), hepatobiliary system, and spleen; the SMA supplies the midgut (jejunum to mid-colon); and the IMA supplies the hindgut (mid-colon to rectum).
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Anatomy The CA and SMA arise from the ventral surface of the infradiaphragmatic suprarenal abdominal aorta the IMA originates from the left lateral portion of the infrarenal aorta.
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Anatomy Because of the abundant collateral flow between these mesenteric arteries, progressive diminution of flow in one or even two of the main mesenteric trunks is usually tolerated, provided that uninvolved mesenteric branches can enlarge over time to provide sufficient compensatory collateral flow. In contrast, acute occlusion of a main mesenteric trunk may result in profound ischemia due to lack of sufficient collateral flow.
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Anatomy
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Pathophysiology
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Pathophysiology Clinical manifestation of mesenteric ischemia is predominantly postprandial abdominal pain, which signifies that the increased oxygen demand of digestion is not met by the gastrointestinal collateral circulation.
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transient anaerobic metabolism and acidosis. Persistent or profound mesenteric ischemia mucosal compromise unimpeded influx of toxic substances from the bowel lumen with systemic consequences. full-thickness necrosis intestinal perforation peritonitis
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Types of Mesenteric Artery Occlusive Disease
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There are three major mechanisms of visceral ischemia involving the mesenteric arteries: (a) acute mesenteric ischemia, which can be either embolic or thrombotic in origin (b) chronic mesenteric ischemia (c) nonocclusive mesenteric ischemia
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acute mesenteric ischemia The superior mesenteric artery (SMA) is the most commonly involved vessel in acute mesenteric ischemia. Acute thrombosis occurs in patients with underlying mesenteric atherosclerosis, which typically involves the origin of the mesenteric arteries while sparing the collateral branches.
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acute mesenteric ischemia In acute embolic mesenteric ischemia, the emboli typically originate from a cardiac source and frequently occur in patients with atrial fibrillation or following myocardial infarction
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A lateral mesenteric angiogram showing an abrupt cutoff of the proximal superior mesenteric artery (SMA), which is consistent with SMA embolism (arrow).
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An anteroposterior view of a selective superior mesenteric artery angiogram shows an abrupt cutoff of the middle colic artery, which was caused by emboli (arrow) due to atrial fibrillation.
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nonocclusive mesenteric ischemia Nonocclusive mesenteric ischemia is characterized by a low flow state in otherwise normal mesenteric arteries and most frequently occurs in critically ill patients on vasopressors.
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chronic mesenteric ischemia chronic mesenteric ischemia is a functional consequence of a long-standing atherosclerotic process that typically involves at least two of the three main mesenteric vessels.
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chronic mesenteric ischemia The gradual development of the occlusive process allows the development of collateral vessels that prevent the manifestations of acute ischemia, but are not sufficient to meet the high postprandial intestinal oxygen requirements, giving rise to the classical symptoms of postprandial abdominal pain and the resultant food fear.
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Other causes Median arcuate ligament syndrome or celiac artery compression syndrome (extrinsic compression of the celiac artery by the diaphragm) Acute visceral ischemia may occur following an aortic operation, due to ligation of the IMA in the absence of adequate collateral vessels.
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Other causes Acute visceral ischemia may develop in aortic dissection, which involves the mesenteric arteries, or after coarctation repair. Other unusual causes of ischemia include mesenteric arteritis, radiation arteritis, and cholesterol emboli.
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Clinical Manifestations
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Clinical Manifestations(acute) Abdominal pain out of proportion to physical findings(classic presentation) sudden onset of abdominal cramps in patients with underlying cardiac or atherosclerotic disease, often associated with bloody diarrhea, as a result of mucosal sloughing secondary to ischemia.
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Clinical Manifestations(acute) Fever, nausea, vomiting, and abdominal distention(common but nonspecific) Diffuse abdominal tenderness, rebound, and rigidity(late signs and usually indicate bowel infarction and necrosis)
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Clinical Manifestations(chronic) more subtle due to the extensive collateral development. The classical symptoms include postprandial abdominal pain, food fear, and weight loss Persistent nausea and occasionally diarrhea may coexist
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Clinical Manifestations(non-occlusive) The typical patient: an elderly patient who has multiple comorbidities, such as congestive heart failure, acute myocardial infarction with cardiogenic shock, hypovolemic or hemorrhagic shock, sepsis, pancreatitis, and administration of digitalis or vasoconstrictor agents such as epinephrine.
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Clinical Manifestations(non-occlusive) Abdominal pain is only present in approximately 70% of these patients. The pain is usually severe but may vary in location, character, and intensity.
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Clinical Manifestations(non-occlusive) In the absence of abdominal pain, progressive abdominal distention with acidosis may be an early sign of ischemia and impending bowel infarction.
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Celiac artery compression syndrome Abdominal pain due to narrowing of the origin of the CA may occur as a result of extrinsic compression or impingement by the median arcuate ligament.
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Celiac artery compression syndrome Contributes to some variants of chronic mesenteric ischemia. Most patients are young females between 20 and 40 years of age. Abdominal symptoms are nonspecific, but the pain is localized in the upper abdomen, which may be precipitated by meals.
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Diagnostic Evaluation
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Differential diagnoses The differential diagnosis of acute mesenteric ischemia includes other causes of severe abdominal pain of acute onset, such as perforated viscus, intestinal obstruction, pancreatitis, cholecystitis, and nephrolithiasis
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Laboratory evaluation Laboratory evaluation is neither sensitive nor specific in distinguishing these various diagnoses.
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Laboratory evaluation complete blood count may reveal hemoconcentration and leukocytosis. Metabolic acidosis develops as a result of anaerobic metabolism.
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Laboratory evaluation Elevated serum amylase may indicate a diagnosis of pancreatitis but is also common in the setting of intestinal infarction. Finally, increased lactate levels, hyperkalemia, and azotemia may occur in the late stages of mesenteric ischemia.
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Abdominal radiographs Plain abdominal radiographs may provide helpful information to exclude other causes of abdominal pain such as intestinal obstruction, perforation, or volvulus, which may exhibit symptoms mimicking intestinal ischemia
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Abdominal radiographs Pneumoperitoneum, pneumatosis intestinalis, and gas in the portal vein may indicate infarcted bowel. In contrast, radiographic appearance of an adynamic ileus with a gasless abdomen is the most common finding in patients with acute mesenteric ischemia.
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Abdominal radiographs Upper endoscopy, colonoscopy, or barium radiography does not provide any useful information when evaluating acute mesenteric ischemia.
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Disadvantages of barium enema Barium enema is contraindicated if the diagnosis of mesenteric ischemia is being considered. The intraluminal barium can obscure accurate visualization of mesenteric circulation during angiography.
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Disadvantages of barium enema intraperitoneal leakage of barium can occur in the setting of intestinal perforation, which can lead to added therapeutic challenges during mesenteric revascularization.
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Diagnosis of chronic mesenteric ischemia Usually prior to the evaluation by a vascular service, the patients have undergone an extensive workup for the symptoms of chronic abdominal pain, weight loss, and anorexia. Rarely, the vascular surgeon is the first to encounter a patient with the above symptoms.
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Diagnosis of chronic mesenteric ischemia In this situation, it is advisable to keep in mind that mesenteric ischemia is a rare entity and that a full diagnostic workup that should include CT scan of the abdomen and evaluation by gastroenterologist should be performed.
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Diagnosis of chronic mesenteric ischemia Mesenteric occlusive disease may coexist with malignancy, and symptoms of mesenteric vessel stenosis may be the result of extrinsic compression by a tumor.
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Duplex ultrasonography Duplex ultrasonography is a valuable noninvasive means of assessing the patency of the mesenteric vessels. A peak systolic velocity in the SMA >275 cm/s demonstrated a sensitivity of 92%, specificity of 96%, and overall accuracy of 96% for detecting >70% stenosis.
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Duplex ultrasonography Duplex has been successfully used for follow-up after open surgical reconstruction or endovascular treatment of the mesenteric vessels to assess recurrence of the disease.
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What is the gold standard modality?
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biplanar mesenteric arteriography The definitive diagnosis of mesenteric vascular disease is made by biplanar mesenteric arteriography, which should be performed promptly in any patient with suspected mesenteric occlusion.
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biplanar mesenteric arteriography It typically shows occlusion or near-occlusion of the CA and SMA at or near their origins from the aorta. In most cases, the IMA has been previously occluded secondary to diffuse infrarenal aortic atherosclerosis.
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biplanar mesenteric arteriography(emboli) Mesenteric emboli typically lodge at the orifice of the middle colic artery, which creates a “meniscus sign” with an abrupt cutoff of a normal proximal SMA several centimeters from its origin on the aorta.
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biplanar mesenteric arteriography(thrombosis) Mesenteric thrombosis, in contrast, occurs at the most proximal SMA, which tapers off at 1 to 2 cm from its origin.
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biplanar mesenteric arteriography(chronic mesenteric occlusion) In the case of chronic mesenteric occlusion, the appearance of collateral circulation is typically present.
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biplanar mesenteric arteriography(Nonocclusive mesenteric ischemia ) Nonocclusive mesenteric ischemia produces an arteriographic image of segmental mesenteric vasospasm with a relatively normal-appearing main SMA trunk
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biplanar mesenteric arteriography(Nonocclusive mesenteric ischemia ) Mesenteric arteriogram showing nonocclusive mesenteric ischemia as evidenced by diffuse spasm of intestinal arcades with poor filling of intramural vessels.
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biplanar mesenteric arteriography(Nonocclusive mesenteric ischemia ) Mesenteric arteriography can also play a therapeutic role. Once the diagnosis of nonocclusive mesenteric ischemia is made on the arteriogram, an infusion catheter can be placed at the SMA orifice, and vasodilating agents, such as papaverine, can be administered intra-arterially.
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Caution Arteriography can be a time-consuming diagnostic modality. In patients with typical history of chronic intestinal angina who present with an acute abdomen and classical findings of peritoneal irritation , immediate exploration for assessment of intestinal viability and vascular reconstruction is the best choice.
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Surgical Repair
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Acute Embolic Mesenteric Ischemia The primary goal of surgical treatment in embolic mesenteric ischemia is to restore arterial perfusion with removal of the embolus from the vessel.
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Acute Embolic Mesenteric Ischemia Once the proximal SMA is identified and controlled with vascular clamps, a transverse arteriotomy is made to extract the embolus, using standard balloon embolectomy catheters.
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Acute Embolic Mesenteric Ischemia Following the restoration of SMA flow, an assessment of intestinal viability must be made, and nonviable bowel must be resected.
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Acute Embolic Mesenteric Ischemia A second-look procedure should be considered in many patients and is performed 24 to 48 hours following embolectomy. The goal of the procedure is reassessment of the extent of bowel viability, which may not be obvious immediately following the initial embolectomy. Additional resection is indicated if non-viable tissue is detected.
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Acute Thrombotic Mesenteric Ischemia Thrombotic mesenteric ischemia usually involves a severely atherosclerotic vessel, typically the proximal CA and SMA. Therefore, these patients require a reconstructive procedure to the SMA to bypass the proximal occlusive lesion and restore adequate mesenteric flow.
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Acute Thrombotic Mesenteric Ischemia The saphenous vein is the graft material of choice, and prosthetic materials should be avoided in patients with nonviable bowel, due to the risk of bacterial contamination if resection of necrotic intestine is performed.
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Acute Thrombotic Mesenteric Ischemia The bypass graft may originate from either the aorta or iliac artery. Supraceliac aorta is the best choice because: 1.less chance of kinking and 2. the absence of atherosclerotic disease in the supraceliac aortic segment.
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Chronic Mesenteric Ischemia The therapeutic goal in patients with chronic mesenteric ischemia is to revascularize mesenteric circulation and prevent the development of bowel infarction. Approaches are: transaortic endarterectomy & mesenteric artery bypass
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The end