Nonocclusive Mesenteric Ischemia and Interventional Local Vasodilatory Therapy: A Meta-Analysis and Systematic Review of the Literature

Abstract

Background: Intensive care patients with nonocclusive mesenteric ischemia (NOMI) show mortality rates of 70% to 90%. Besides emergency surgery, different interventional local vasodilatory treatment (LVT) attempts have been described. We performed a systematic review and a meta-analysis to evaluate feasibility, efficacy, and tolerability of LVT in patients with life-threatening NOMI. Methods: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed until February 2019. Measured outcomes included immediate technical success rates (as indicated by mesenteric vasodilation on angiography or clinical improvement) and adverse events (AEs). Therapeutic efficacy was measured by the assessment of overall mortality. Results: Twelve studies (335 patients, 245 received LVT) from 1977 to 2018 were included. All studies were retrospective (4 comparative and 8 noncomparative). Different intra-arterial vasodilators (4× papaverine, 6× prostaglandin E1, 1× tolazoline/heparin, 1× tolazoline + iloprost) were reported. Initial technical success rate was 75.9% (95% confidence interval [CI], 55.1%-89%, P = .017) with an AE rate of 2.9% (95% CI: 1.3%-6.6%; P = .983). Overall mortality in LVT patients was 40.3% (95% CI: 28.7%-53%, P = .134). In 4 studies, outcomes were compared between patients receiving LVT to those who received standard of care (odds ratio for death in LVT patients was 0.261 [95% CI: 0.095-0.712, P = .009]). Conclusions: Local vasodilatory treatment appears to be safe in patients with NOMI and might have the potential to at least partially reverse mesenteric vasoconstriction features in control angiographies. However, with no randomized and prospective studies available yet, the overall quality of published studies has to be considered as low; therefore, it is not possible to draw generalizable conclusions from the present data concerning clinical end points. Its application might hold promise as a rescue treatment strategy and deserves further evaluation in randomized controlled trials.

Acute Mesenteric Ischemia: A Challenge for the Acute Care Surgeon

“…Recently, a systematic review of 12 retrospective studies of interventional local vasodilatory treatment in NOMI reported 40% overall mortality and low treatment-related complication rate of less than 3%. In four comparative studies between patients receiving intra-arterial vasodilator therapy and those who received standard care, the pooled odds of death was significantly lower for those receiving the experimental therapy ( 20 ). Another interesting experimental treatment that may be worth studying further is the administration of prostaglandin or iloprost intravenously to improve the hepato-splanchnic blood flow and oxygen intake in NOMI ( 21 , 22 ).…”

Nonocclusive Mesenteric Ischemia Is a Potentially Lethal Complication Just after Stroke Onset: Report of Six Case Studies

“…Papaverine and prostaglandin E1 are the most commonly used agents, but their availability is limited. 14) Winzer et al reported that local intra-arterial infusion of papaverine in patients with NOMI significantly increased survival in comparison with conservative treatment. However, this study also reported that high lactate levels, low pH and high base excess, and high demand for catecholamines were associated with poor outcome.…”

Predictors of Response To Intra-Arterial Vasodilatory Therapy of Non-Occlusive Mesenteric Ischemia In Patients With Severe Shock - Results From A Prospective Observational Study

“…The mortality associated with NOMI remains unchanged exceedingly high up to above 90% (3,4). NOMI accounts for up to 15% of acute mesenteric ischemia cases (5) and is characterized by functional vasoconstriction of the superior mesenteric artery (SMA) and its smaller branches in the absence of an intraluminal obstruction (2,4,5). Spasm of these mesenteric vessels leads to signi cantly reduced perfusion of the intestine and consequently, mesenteric ischemia, which may result in transmural necrosis.…”

“…This process triggers a secondary systemic in ammatory response that may result in remote organ failure (7). NOMI occurs typically in the context of shock, especially following cardiac surgery (1)(2)(3)(4), in low output heart failure (1,2,4), and a variety of heterogeneous acute critical illnesses all requiring high dose vasopressor therapy such as septic shock (2)(3)(4)8). Various preexisting comorbidities, i.e.…”

“…Various preexisting comorbidities, i.e. heart diseases, chronic or acute kidney disease but also older age and diabetes mellitus increase the risk of developing NOMI (2,4,8,9). Since emergency surgical intestinal resection has repeatedly shown poor survival and even tends to worsen the underlying pathological processes of NOMI (4,9), current treatment recommendations aim at rapid reestablishment of intestinal perfusion including uid resuscitation and reduction of vasoconstrictors (10).…”