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Endovascular Treatment of Acute on Chronic Mesenteric Ischaemia

Authors:
Colin D Bicknell at Imperial College London
Colin D Bicknell
A. H Al-Jeroudi
A. H Al-Jeroudi
A. H Al-Jeroudi
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Andrew Ramwell at St George's, University of London
Andrew Ramwell
M. W Clark
M. W Clark
M. W Clark
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SHORT REPORT
Endovascular Treatment of Acute on Chronic Mesenteric Ischaemia
C. D. Bicknell
1
, A. H. Al-Jeroudi
2
, A. P. Ramwell
1
, M. W. Clark
2
, N. J. W. Cheshire
1
and M. G. Cowling
2
Departments of
1
Vascular Surgery, and
2
Vascular Radiology, St Mary's Hospital,
London, W2 1NY, U.K.
Key Words: Mesenteric ischaemia; Angioplasty; Stenting; Aortic aneurysm.
Introduction
Chronic mesenteric ischaemia is a condition caused
by occlusion or stenosis of the cúliac axis, superior
mesenteric artery (SMA) or inferior mesenteric artery.
Multiple collaterals throughout the mesenteric vascu-
lar tree dictate that disease of multiple vessels is
usually required before symptoms become apparent.
Operative treatment of mesenteric ischaemia is
technically demanding and patients with this condi-
tion are often elderly, malnourished and have wide-
spread vascular disease, which can result in a poor
outcome. Many have reported success with endovas-
cular techniques in patients with chronic, longstand-
ing mesenteric angina. We report a case of acute on
chronic mesenteric ischaemia presenting with bowel
ischaemia at a clinically critical stage.
Case History
A 63-year-old lady presented with a three-week his-
tory of epigastric pain radiating to the back, associated
with anorexia, weight loss and a raised leukocyte
count (20.7 10
9
/L). She went on to develop bloody
diarrhoea three days after admission. Her past history
included peptic ulcer disease, appendicectomy and
cholecystectomy. She was a heavy smoker, hyperten-
sive and hypercholestrolaemic.
Computerised Tomography (CT) examination
demonstrated aneurysmal change of the descending
thoracic aorta and abdominal aorta to a maximum
anteroposterior diameter of 4.0 cm at the hiatus
with extensive thrombus lining the aortic lumen.
The coeliac axis was occluded and there was a tight
stenosis at the origin of the SMA.
Oesophagogastroduodenoscopy showed appear-
ances of pan-gastritis and oesophagitis. Sigmoido-
scopy demonstrated similar inflammatory changes of
active colitis with granular, friable mucosa and one
area of ulceration. Biopsy specimens showed changes
suggestive of ischaemia.
Mesenteric angiography confirmed coeliac and
inferior mesenteric artery occlusion with a severe
stenosis (80%) at the origin of the SMA and a further,
one-centimeter long, stenosed segment, two centi-
metres from the origin (Fig. 1).
Through a femoral approach using a 7 French long
sheath and a guide wire (TAD II), the origin of the
SMA was primarily stented using a 6 16 mm balloon
expandable AVE stent. The distal stenosis was then
angioplastied using a 6 20 mm balloon. Three thou-
sand units of heparin and three hundred micrograms
of isosorbide dinitrate were administered intra-
arterially during the procedure. There was an excel-
lent immediate angiographic result, with filling of the
coeliac axis via collaterals (Fig. 2).
Following angioplasty and stent placement
this patient was pain free. Oral feeding was com-
menced on day 1. She made an uneventful
recovery and was discharged home on the 11th post-
operative day.
Please address all correspondence to: C. Bicknell, Vascular Secre-
taries Office, Waller Cardiac Building, St Mary's Hospital, Praed
Street, London, W2 1NY, U.K.
EJVES Extra 4, 76±78 (2002)
doi:10.1053/ejvx.2002.0179, available online at http://www.sciencedirect.com on
1533±3167/03/050076 03 $35.00/0 #2003 Elsevier Science Ltd. All rights reserved.
Discussion
Surgical correction of chronic mesenteric ischaemia is
well reported in the medical literature. Many opera-
tive approaches have been described in operative
series including multiple vessel revascularisation,
1±5
single vessel SMA revascularisation
6
and transaortic
endarterectomy.
3
Patients with this condition, how-
ever, are invariably poor surgical candidates who are
elderly with severe multisystem vascular disease and
malnutrition from long term ``fear of food''. For all
procedures the in-hospital operative mortality is
between 4.5 and 12.2%, with a post-operative compli-
cation rate of 45±54%.
1±6
High peri-operative mortality rates mean that
endovascular treatments are an attractive option in
the treatment of chronic mesenteric ischaemia, most
clearly in high-risk patients with short occlusions.
Early and long-term results have been favourable in
limited series.
7
The presence of aneurysmal disease at the level of
the superior mesenteric artery and thrombus within
the lumen of the aorta, with potential for embolisation,
rendered this lady a high-risk for surgical revascular-
isation. An endovascular procedure was thought to be
the treatment option with least risk and the patient
proceeded to angioplasty and stenting.
It is important to stress the need for appropriate
patient selection. Mesenteric ischaemia that has
progressed to bowel infarction must be operatively
managed after appropriate resuscitation. In addition,
careful vigilance during the post-operative period is
vital in the successful management of these patients.
Failure or thrombosis of the artery or stent may lead to
a sudden deterioration of the patient and bowel
infarction.
This case illustrates that in a high-risk surgical
patient with atherosclerotic chronic mesenteric ischae-
mia that has progressed to a critical stage, endovascu-
lar treatment of multiple stenoses within the SMA can
be carried out safely with a good angiographic result.
References
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Krajewski LP. Elective surgical treatment of symptomatic chronic
mesenteric occlusive disease: Early results and late outcomes.
J Vasc Surg 1999; 29: 821±832.
Fig. 1. Lateral angiographic image of the abdominal aorta. There is a
stenosis at the origin of the SMA and another stenosis distally. The
coeliac axis is occluded.
Fig. 2. The catheter can be seen within the distal SMA. A stent has
been placed at the origin of the SMA and the distal stenosis has been
angioplastied with a good angiographic result.
Endovascular Treatment of Mesenteric Ischaemia 77
EJVES Extra, 2002
2 Johnston KW, Linsay TF, Walker PM, Kalman PG. Mesenteric
arterial bypass grafts: early and late results suggested surgical
approach for chronic and acute mesenteric ischaemia. Surgery
1995; 118: 1±7.
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Stoney RJ. Chronic visceral ischaemia. Ann Surg 1991; 214:
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4 Rheudasil JM, Stewart MT, Schellack JV, Smith RB III,
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Surg 1992; 164: 220±224.
6 Gentile AT, Moneta GL, Taylor LM Jr, Park TC,
McConnell DB, Porter JM. Isolated bypass to the superior
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EJVES Extra, 2002
ResearchGate has not been able to resolve any citations for this publication.
Influence of complete revascularization on chronic mesenteric ischemia
Article
  • Oct 1992
  • AM J SURG
Complete revascularization for chronic intestinal ischemia is controversial. Fifty-eight patients (119 arteries) underwent mesenteric revascularization between 1981 and 1988. There were 46 women and 12 men (mean age: 63 years). Sixty percent of patients had three-vessel disease. Twenty-one patients underwent concomitant aortic reconstruction. Operative mortality was 10%. Four of the six deaths occurred in patients undergoing aortic surgery. Late graft failure occurred in five patients (10%). Five-year survival for patients with three-vessel involvement who underwent three-vessel repair was 73%, compared with 57% for two-vessel repair and 0% for one-vessel repair (p = NS). Similarly, graft patency in patients with three-vessel disease was highest in those patients who had complete revascularization (90%, 54%, and 0%, respectively) (p = NS). We conclude that increased graft patency and survival in patients with three-vessel disease was most frequent with complete revascularization. Diseased inferior mesenteric arteries should be repaired if feasible. Concomitant aortic operations should be avoided if possible.
View
Chronic Visceral Ischemia
Article
  • Mar 1992
  • SURG CLIN N AM
Visceral ischemic syndromes constitute a spectrum of diseases that may, if not detected and treated, culminate in fatal intestinal gangrene. Symptomatic chronic visceral ischemia may run a prolonged course before diagnosis and effective surgical revascularization is employed. The internist or general practitioner plays an important role in the management of all patients with chronic visceral ischemia, usually being the first physician to evaluate the patient and often being able to direct the efforts to diagnose the problem effectively. An awareness of the disease and a high index of suspicion will lead to the confirmatory arteriogram, after which appropriate consultation will ensure that treatment which becomes readily apparent. The vascular surgeon who possesses the skill to execute transaortic extraction endarterectomy and antegrade aortovisceral bypass can realistically meet the therapeutic challenge of this disease, relieving the patients' symptoms and, more importantly, preventing fatal intestinal gangrene.
View
Surgical treatment of chronic mesenteric arterial insufficiency
Article
  • Nov 1988
  • J VASC SURG
The treatment of 41 patients with chronic mesenteric insufficiency is reviewed: 20 men and 21 women with a mean age of 59 years were treated and observed for an average of 42 months. Thirty-one patients had symptoms of intestinal angina whereas 10 patients underwent prophylactic revascularization during other aortic operations. All but one patient had revascularization of the superior mesenteric artery, alone or in combination with another revascularization. Various surgical techniques were used, including retrograde bypass in 24 patients, antegrade bypass in 11 patients, and endarterectomy in the remaining six patients. Seven patients had acute abdominal symptoms and required emergency operation while in the hospital awaiting elective revascularization. There were two deaths in the perioperative period (4.9%), both caused by bowel necrosis. Six patients are known to have had late revascularization failure, resulting in recurrent symptoms in three patients and two subsequent deaths. All patients who remained asymptomatic after late graft failure had undergone multiple vessel revascularization; no patient revascularized prophylactically had symptoms of intestinal angina during the follow-up period. Early mesenteric revascularization is a safe and effective method of relieving the symptoms of chronic visceral ischemia and may prevent the development of fatal bowel necrosis.
View
Mesenteric arterial bypass grafts: Early and late results and suggested surgical approach for chronic and acute mesenteric ischemia
Article
  • Aug 1995
  • SURGERY
The purposes of this study were to determine the early and late results of placement of arterial bypass grafts in the treatment of chronic and acute intestinal ischemia and to ascertain whether multiple grafts provide better late results than a single graft. Records of 34 patients who underwent mesenteric vascular graft placement were retrospectively reviewed. All 21 patients with chronic ischemia had a history of intestinal angina and weight loss. Food fear was reported by 33% of patients; also, diarrhea in 57%, constipation in 29%, acalculous cholecystitis in 19%, ischemic gastritis or peptic ulcer in 19%, and elevation of liver enzymes in 22% were reported. Angiogram showed more than 50% stenosis or occlusion of the superior mesenteric artery (SMA) in 100% of patients, celiac artery in 90%, and inferior mesenteric artery in 90%. Although not described previously, a reduction in collateral flow from the internal iliac arteries was caused by severe pelvic disease in 56% of patients. There were no in-hospital deaths. The rate of survival at 1 year was 100%; at 2 years it was 93% +/- 6%, at 3 years 86% +/- 9%, at 5 years 79% +/- 11%, and at 10 years 50% +/- 15%. During follow-up, graft thrombosis occurred in three patients. Of the patients who underwent only a single SMA or celiac bypass, two of five died of bowel infarction; only one of 16 patients who underwent both celiac and SMA bypass had to undergo a repeat surgical procedure because of graft occlusion. Three of 16 retrograde bypasses thrombosed, compared with zero of five prograde bypasses. In nine patients who underwent placement of mesenteric bypass grafts because of acute ischemia caused by acute mesenteric thrombosis, the early mortality rate was 22%; the two deaths were the result of bowel ischemia. The cumulative survival rate was 78% +/- 14% at 1 month, 65% +/- 17% at 1 year, and 52% +/- 16% at 5 years. One of the two late deaths was due to graft thrombosis and bowel infarction. Three of four patients who underwent concomitant mesenteric bypass at the time of aneurysm repair or aortobifemoral bypass survived the surgical procedure. When chronic and acute mesenteric ischemia are diagnosed and treated with a bypass graft, the early and late results are good. Complete revascularization of the SMA and celiac artery or pelvis or both and prograde bypass may reduce the risk of late bowel ischemia.
View
Isolated Bypass to the Superior Mesenteric Artery for Intestinal Ischemia
Article
  • Oct 1994
  • ARCH SURG-CHICAGO
A number of reports indicate revascularization for intestinal ischemia should include the superior mesenteric artery (SMA) and the celiac artery. However, no controlled or randomized studies have proven this approach superior to SMA bypass alone. We report our results using bypass to only the SMA for intestinal ischemia. Retrospective review with mean follow-up of 40 months (range, 2 to 110 months). University medical center and Veterans Affairs hospital. The records of patients who underwent intestinal revascularization of the SMA alone from 1982 through 1993 were reviewed. Patients were assessed for indication for operation, operative technique, perioperative mortality, and long-term outcome. The SMA grafts were examined for patency within the last 6 months using duplex scanning or arteriography. Patient survival and graft patency rates were calculated using life-table methods. Twenty-nine bypasses to only the SMA were performed in 26 patients (16 female and 10 male; mean age, 59 years; age range, 13 to 81 years). Indication for operation was symptomatic chronic mesenteric ischemia in 23 cases and acute intestinal ischemia in five cases. One bypass was performed for asymptomatic SMA occlusion. There were three perioperative deaths (10% mortality rate), all in patients with acute intestinal ischemia and previous mesenteric arterial surgery. Life-table 4-year primary graft patency and patient survival rates were 89% and 82%, respectively. Symptomatic improvement was maintained in all patients available for follow-up. Revascularization of only the SMA for intestinal ischemia provides excellent graft patency with acceptable perioperative mortality and long-term patient survival. The SMA bypass alone for intestinal ischemia appears as successful as bypasses to multiple visceral vessels.
View
Endovascular Treatment of Chronic Mesenteric Ischemia: Report of Five Cases
Article
  • Jul 1998
To evaluate the midterm results of percutaneous transluminal angioplasty (PTA) and stent placement in stenotic and occluded mesentesic arteries in five consecutive patients with chronic mesenteric ischemia. Five patients with 70%-100% obliterations of all mesenteric vessels resulting in chronic mesenteric ischemia (n = 4) and as a prophylactic measure prior to abdominal aortic aneurysm repair (n = 1) underwent PTA of celiac and/or superior mesenteric artery (SMA) stenoses (n = 2), primary stenting of ostial celiac occlusions (n = 2), and secondary stenting of a SMA occlusion (n = 1; recoil after initial PTA). All patients underwent duplex ultrasonography (US) (n = 3) and/or angiography (n = 5) during a median follow-up of 21 months (range 8-42 months). Clinical success was obtained in all five patients. Asymptomatic significant late restenoses (n = 3) were successfully treated with repeat PTA (n = 2) and stenting of an SMA occlusion (n = 1; celiac stent restenosis). Recurrent pain in one patient was interpreted as secondary to postsurgical abdominal adhesions. Two puncture-site complications occurred requiring local surgical treatment. Endovascular techniques may be attempted prior to surgery in cases of stenotic or short occlusive lesions in patients with chronic mesenteric ischemia. Surgery may still be preferred in patients with long occlusions and a low operative risk.
View
Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: Early results and late outcomes
Article
  • May 1999
  • J VASC SURG
The purpose of this study was to determine the safety and efficacy of the elective surgical treatment of symptomatic chronic mesenteric occlusive disease (SCMOD) and to identify the factors that influence the results of this procedure. From 1977 to 1997, 85 patients (mean age, 62 years) underwent elective surgical treatment of SCMOD. The presenting symptoms were abdominal pain in 78 patients (92%) and weight loss in 74 patients (87%). The surgical procedures included retrograde bypass grafting in 34 patients (40%), antegrade bypass grafting in 24 patients (28%), transaortic endarterectomy in 19 patients (22%), local arterial endarterectomy with patch angioplasty in six patients (7%), thrombectomy alone in one patient (1%), and superior mesenteric artery reimplantation in one patient (1%). Thirty-five patients (41%) underwent concomitant aortic replacement. All the involved mesenteric vessels were revascularized in 21 patients (25%), whereas revascularization was incomplete for the remaining 64 patients (75%). Late information was available for all 85 patients at a mean interval of 4.8 years. There were seven early (<35 days) postoperative deaths (8%). The cumulative 5-year survival rate was 64% (95% confidence interval [CI], 53% to 75%), and the 3-year symptom-free survival rate was 81% (95% CI, 72% to 90%). Serious complications occurred in 28 patients (33%). The results of univariate analysis identified advancing age at operation (P <.001), cardiac disease (P =.03), hypertension (P =.03), and additional occlusive disease (P =.05) as variables associated with mortality. Concomitant aortic replacement (P =.037), renal disease (P =.011), advancing age ( P =.035), and complete revascularization ( P =.032) were associated with postoperative morbidity including mortality. Late recurrent mesenteric occlusive disease was seen in 21 patients (16 symptomatic and five asymptomatic). Nine patients (43%) died, and 8 patients (38%) required subsequent surgical or endovascular procedures to treat their recurrent lesions. The 3-year survival rate from recurrent mesenteric occlusive disease was 76% (95% CI, 66% to 86%). We conclude that the elective surgical treatment of SCMOD may be performed with reasonable early and late mortality rates and that most of the patients remain free from recurrent symptoms of mesenteric ischemia. Advancing age, cardiac disease, hypertension, and additional occlusive disease significantly influenced the overall mortality rates, and concomitant aortic replacement, renal disease, and complete revascularization were significantly associated with postoperative morbidity rates. Surveillance and appropriate correction of recurrent disease appear to be necessary for optimal long-term results.
View
Surgical treatment of chronic mitral insufficiency
Article
  • May 1999
  • Giorn Ital Cardiol
Operative correction of chronic ischemic mitral regurgitation (CIMR) is associated with a high-risk approach. The objective of this retrospective study was to evaluate the short- and long-term results of surgical treatment of CIMR. From 1989 to 1997, mitral valve replacement or repair was performed on 46 patients with CIMR. The average age range was 63.7 +/- 6.9; 8 patients were females; 30 patients (65.2%) were in New York Heart Association (NYHA) functional class III or IV; 4 patients (8.6%) were in chronic atrial fibrillation and preoperative myocardial infarction was lower in 23 patients (50%). Preoperative echo-Doppler analysis showed severe mitral insufficiency in 15 patients (32.6%). Preoperative mean pulmonary artery pressure (PAP) was 33.6 +/- 13.6 mmHg, mean ejection fraction (EF) 37.8 +/- 13.5%. Mitral valve replacement was performed in 12 patients (26%). Mitral valve repair was performed in 34 patients (73.9%). Myocardial revascularization was performed in 42 patients (91.3%) (mean graft/patient 2.2 +/- 0.8); aneurysmectomy was performed in 5 patients (10.8%), and in 2 patients (4.3%) tricuspid insufficiency was corrected by performing annuloplasty. The overall operative mortality was 8.6% (4 patients). The operative mortality for repair was 5.8% (2 patients) and for replacement was 16.6% (2 patients). One patient was reoperated three days after first operation due to annuloplasty dehiscence. Postoperative morbidity included low output syndrome in 7 patients (15.2%), bleeding in 2 patients (4.3%), and cerebral embolism in 2 patients (4.3%). The mean length of stay in intensive care was 6.5 +/- 10.5 days. Follow-up (mean 27.6 +/- 3.3 months) was 88% complete and revealed good functional and clinical results: 86.4% of the patients in I-II NYHA class. One patient was reoperated due to mitral insufficiency progression. Two late deaths occurred, one due to acute myocardial infarction and the other to lung cancer. While long-term follow-up is mandatory, our results suggest that: a) surgical treatment of CIMI is feasible with acceptable operative risks; b) mid-term functional and clinical results are favorable; c) the choice of treatment--valve replacement or repair--is still debatable.
View
Influence of complete revascularization on chronic mesenteric ischemia Isolated bypass to the superior mesenteric artery for intestinal ischaemia
  • Jan 1992
  • 926-932
  • Mk Mcaffee
  • Kj Cherry
  • Jr
  • Jm Naessens
McAffee MK, Cherry KJ Jr, Naessens JM et al. Influence of complete revascularization on chronic mesenteric ischemia. Am J Surg 1992; 164: 220±224. 6 Gentile AT, Moneta GL, Taylor LM Jr, Park TC, McConnell DB, Porter JM. Isolated bypass to the superior mesenteric artery for intestinal ischaemia. Arch Surg 1994; 129: 926±932.