Role for Endovascular Therapy in Chronic Mesenteric Ischemia

Abstract

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

“…Multisliced CT is a noninvasive technique, which can play a pivotal role in diagnosing vascular disease of the celiac trunk and SMA in chronic ischemia. In addition, MRI and MRA are very promising diagnostic modalities when combined with fast contrastenhanced (CE) techniques [5,35] . While AMI is an emergency where CT scanning is the most appropriate diagnostic tool, CMI is best examined with CEMRA, coupled with measurements of flow.…”

“…ER appears to have lower postoperative mortality and morbidity rates and shorter intensive care unit and hospital stay. Therefore, ER has been proposed for high risk surgical candidates or those with short life expectancy due to its minimally invasive nature [35,52,53] . In ER, a short stump of the patent artery is necessary to gain wire access.…”

Percutaneous Angioplasty and Stenting for Mesenteric Ischaemia

“…Despite its prevalence, the majority of these patients are asymptomatic as a result of the extensive collateral circulation between the celiac trunk, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Whether or not ischaemia ensues depends on the site of the stenosis or occlusion and the development or otherwise of collateral vessels (Loffroy et al, 2009). CMI typically occurs in patients who have SMA lesions in conjunction with lesions in either the celiac trunk or IMA.…”

“…Balloon-expandable stents are preferred because of their accuracy and ability to generate considerable radial force. More distal or long lesions may be better suited to self-expandable stents given their flexibility (Loffroy et al, 2009). Kougias et al (2007) reported that technical success was significantly higher with stenting compared with angioplasty alone (95% vs 83%, p=0.007), although the rate of restenosis was also higher in the stented subgroup, a finding that may have been biased by the inclusion of earlier studies where more primitive stents were used and peri-procedural anticoagulant and antiplatelet treatment regimens were not standardized.…”

“…Prompt diagnosis and institution of revascularisation therapy are crucial for a successful outcome. Endovascular treatment for AMI was traditionally reserved for selected patients who have prohibitive operative risk, no clinical signs of peritoneal inflammation, or those with a contaminated peritoneal cavity and no autogenous vessel available for grafting (Loffroy et al, 2009). With evolving expertise and technological advancements in endovascular therapy, there has been an increase in the use of endovascular revascularisation for treatment of AMI.…”