chronic mesenteric ischemia and therapeutic paradigm

7/24/2019 Chronic Mesenteric Ischemia and Therapeutic Paradigm

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CASE SERIES

Chronic mesenteric ischemia and therapeutic paradigm

of mesenteric revascularization

Shashidhar Kallappa Parameshwarappa &Ajay Savlania &

Sidharth Viswanathan &Srinivas Gadhinglajkar &

Kapilamoorthy Tirur Raman &Madathipat Unnikrishnan

Received: 26 April 2013 /Accepted: 29 July 2013 /Published online: 31 August 2013# Indian Society of Gastroenterology 2013

Abstract Chronic mesenteric ischemia is a life-threatening

clinical problem resulting in death from inanition and/or bow-

el infarction, if left untreated, albeit low disease prevalence.

Typical presentation is postprandial abdominal pain, severeweight loss, and altered bowel habit. Surgical revasculariza-

tion of the superior mesenteric artery provides effective long-

term treatment for chronic intestinal ischemia. Eleven patients

underwent superior mesenteric artery revascularization, nine

of them with open retrograde superior mesenteric artery by-

pass and two with angioplasty and stenting. All patients

except one made a satisfactory recovery in this cohort. Major

complication included one graft thrombosis leading to bowel

ischemia and death. The rest all recovered weight in 3

6 months with a follow up period of 6 to 28 months. Two

patients had recurrence of symptoms due to failing bypass

requiring stenting for assisted primary patency. Superior mes-

enteric artery revascularization can be performed with mini-

mal morbidity and mortality, providing excellent symptom

relief and quality of life.

Keywords Gastrointestinaltract. Superiormesentericartery.

Vascular disease

Introduction

Chronic mesenteric ischemia (CMI) is a life-threatening

clinical problem resulting in death from inanition and/orbowel infarction, albeit low disease prevalence. The un-

derlying initial pathophysiology involves failure to achieve

postprandial hyperemic intestinal blood flow with insidi-

ously worsening ischemia eventually leading to bowel

gangrene. In normal individuals, intestinal blood flow

increases right from a cephalic phase, with a maximal

increase occurring in 30 to 90 min [1]. This hyperemic

response lasts between 4 and 6 h and varies with size and

composition of the meal [1, 2]. The majority of the

hyperemic blood flow goes to the small bowel and pan-

creas, with only a small proportion to the stomach and

colon [3].

Most patients develop sufficient collateral circulation to

the intestine to prevent ischemic symptoms. When the

superior mesenteric artery is occluded, the pancreatic duo-

denal arteries supply blood via the hepatic and gastroduo-

denal arteries to the bowel. When the celiac artery and

superior mesenteric artery (SMA) are occluded, the inferior

mesenteric artery supplies blood to the small bowel via the

left colic branch. A large meandering mesenteric artery, an

important vessel in the collateral circulation from the infe-

rior mesenteric artery, is frequently seen. Symptoms usually

occur only if two or more vessels are occluded or critically

stenosed.

Although clinical triad of postprandial abdominal pain,

weight loss, and altered bowel habits of CMI is theoretically

described, this clinical entity goes underdiagnosed for a long

duration till all the other causes for abdominal pain are ruled

out, with inordinate delay, and the patients health status has

deteriorated seriously. This case series documents the safety

and efficacy of mesenteric revascularization in the treatment

of chronic mesenteric ischemia and its effect on body mass

index (BMI).

S. K. Parameshwarappa:A. Savlania:S. Viswanathan :

M. Unnikrishnan (*)

Division of Vascular Surgery, Department of Cardiovascular and

Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciencesand Technology, Medical College PO, Trivandrum 695 011, India

e-mail: [email protected]

S. Gadhinglajkar

Department of Cardiac Anaesthesia, Sree Chitra Tirunal Institute

for Medical Sciences and Technology, Medical College PO,

Trivandrum 695 011, India

K. T. Raman

Department of Imaging Sciences and Interventional Radiology,

Sree Chitra Tirunal Institute for Medical Sciences and Technology,

Medical College PO, Trivandrum 695 011, India

Indian J Gastroenterol (MarchApril 2014) 33(2):169174

DOI 10.1007/s12664-013-0377-3


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Methods

The clinical data of all patients who underwent major arterial

intervention with involvement of mesenteric vessels at the

Sree Chitra Tirunal Institute for Medical Sciences and Tech-

nology, from November 2010 to October 2012, were retro-

spectively analyzed. Specifically excluded were patients who

had mesenteric ischemia of embolic origin and nonocclusivemesenteric ischemia and those asymptomatic patients detected

on imaging during repair of abdominal and thoracoabdominal

aortic aneurysms. The atherosclerotic nature of the lesion was

determined on review of age, risk factors, atherosclerotic

plaque in the aorta and the iliac arteries on preoperative

noninvasive imaging (Fig. 1), and operative notes. Eleven

patients underwent mesenteric revascularization, 10 for ath-

erosclerotic disease and 1 for Stanford B aortic dissection with

malperfusion. Nine of them underwent open retrograde surgi-

cal revascularization of SMA, and two underwent angioplasty

with stenting. All were males except a lone lady in this cohort

with age ranging from 41 to 69 years with mean age of56.45 years. Preoperative weight varied from 32.8 to 61.6 kg

with mean of 46.73 kg, and BMI, from 14.34 to 21.31 with

mean of 17.56. Three patients had associated extreme

aortoiliac occlusive disease with subcritical lower limb ische-

mia at presentation, one had Stanford B aortic dissection with

bowel malperfusion, one had renovascular hypertension due

to renal artery stenosis, and one had type B descending tho-

racic aortic aneurysm. In surgical group, five patients had all

three vessels occluded, and four patients had two vessels

occluded, ie. SMA and celiac artery (CA) with significant

stenosis of the inferior mesenteric artery (IMA). In

endovascular group, one patient had SMA and CA stenosis.

One patient had high-grade SMA stenosis only (Table 1).

Duplex evaluation was standard in our protocol, and

256-slice CT angiogram was done before planning

revascularization (Fig.1). Surgical procedure involved mid-

line transperitoneal laparotomy and dissection of the SMA

at the root of mesentery behind the duodenum. Inflow

taken from the infrarenal aorta, right common iliac artery,

or right limb of the aortobifemoral graft and outflow to the

SMA behind the duodenum at the root of mesentery

(Fig.2ad). The internal iliac artery was used as a conduit

in six and coated Dacron in one, and two had composite

graft of the internal iliac artery and Dacron.

In endovascular group, the first patient underwent SMA and

bilateral renal artery stenting with 6 mm 12 mm and

5 mm 12 mm balloon mounted nitinol stents for SMA and

renal arteries, respectively. Second patient had thoracic

endovascular aortic repair with the Medtronic Valiant

42 mm 169 mm aortic stent graft along with SMA and celiac

artery angioplasty with stenting using 6 mm 19 mm and

7 mm 12 mm, balloon mounted bare metal nitinol stent,

respectively (Fig.3).

All patients were followed up by a duplex flow to mesen-

teric vessels at 1 and 6 months and yearly thereafter following

procedure. Outcomes were measured by a symptomatic relief

and an increase in weight and BMI (Table 2). Follow up CT

angiogram at 1 year showed patent SMA bypass graft

(Fig.4).

Fig. 1 Volume rendered image showing ostial occlusion of the celiac

artery, SMA and IMA. Multiple collaterals filling up the celiac artery,

SMA and IMA from internal iliac and lumbar arteries

Table 1 Demography and materials

Patient demographics

N 11

Age range in years, range (mean) 4169 (56.45)

Sex (M/F) 10:01

Risk factors/comorbidities

Hypertension 8

Diabetes 4

Dyslipidemia 6

Smoking 10

COPD 2

Preoperative weight in kg (mean) 46.73

Preoperative BMI (mean) 17.56

Associated vascular disease

AI occlusion 3

Type B aortic dissection 1

Renal artery stenosis 1

Type B DTA aneurysm 1

Vessel involvement

SMA, CA, IMA occluded 5

SMA, CA occluded, IMA stenosed 4

SMA, CA stenosis 1

SMA stenosis 1

BMI body mass index, AIaortoiliac, DTA descending thoracic aorta,

COPDchronic obstructive pulmonary disease,SMA superior mesenteric

artery,CA celiac artery, IMA inferior mesenteric artery

170 Indian J Gastroenterol (MarchApril 2014) 33(2):169174


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Results

All patients except one made satisfactory recovery in both the

groups. Major complication included one graft thrombosis

leading to bowel ischemia and death 3 weeks following sur-

gery. The rest all recovered weight in 36 months in a followup period of 628 months. Mean gain in weight and BMI at

6 months were 5.22 and 2.11 kg, respectively. Two patients in

a long-term follow up, who continued to smoke, developed

recurrence of symptoms. These two patients had composite

graft of the internal iliac artery and Dacron. In these two

patients, the internal iliac artery was diseased, so it was

endarterectomized before using as a conduit for bypass. CT

angiogram showed smooth narrowing that corresponds to the

iliac segment of the prostheticinternal iliac composite SMAgraft. The distal SMA showed delayed filling from celiac col-

laterals (Fig.5a). These two patients required angioplasty with

stenting to obtain assisted primary patency of the graft,

Fig. 2 aDissection and harvest

of the right internal iliac artery. b

Preparation of internal iliac artery

conduit for aortaSMA bypass.c

End-to-side anastomosis of

internal iliac conduit to SMA

behind the duodenum and end-to-

side anastomoses to the right limb

of aortobifemoral bypass graft forconcomitant aortoiliac occlusive

disease. d Completed SMA

bypass with internal iliac artery

conduit

Table 2 Methods, results, follow up, and complications

Methods and Results

Surgical group

Procedure executed

SMA bypass alone 6

Concomitant AF+SMA bypass 3

Graft used

IIA 6

Dacron 1

Composite (Dacron+IIA) 2

Endovascular group

Procedure executed

TEVAR+SMA+celiac artery stenting 1

SMA+renal artery stenting 1

Follow up (months) 628

Postoperative weight in kg (mean) at 6 months 51.95

Postoperative BMI (mean) at 6 months 19.67

Mean gain in weight (kg)/BMI 5.22/2.11

Complications

Mortality 1

Graft stenosis 2

AF aortofemoral, IIA internal iliac artery, TEVAR thoracic endovascular

aortic repair, BMIbody mass index, SMA superior mesenteric artery Fig. 3 Angioplasty and stenting of SMA and celiac artery

Indian J Gastroenterol (MarchApril 2014) 33(2):169174 171


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successfully; 7 mm 40 mm self-expandable nitinol stent was

deployed, and was further dilated using a 7 mm x 40 mm

balloon (Fig. 5b, c). Symptoms improved in these patients

following the procedure, and they remain symptomatic

(Table2).

Discussion

Atherosclerosis is the leading cause of the visceral artery

occlusive disease responsible for chronic mesenteric ischemia.

A variety of other causes, including fibromuscular disease,

aortic dissection, isolated SMA dissection, neurofibromatosis,

rheumatoid arthritis, Takayasus arteritis[4], giant cell arteri-

tis, polyarteritis nodosa, radiation injury, Burgers disease, and

systemic lupus, has been reported.

Patients with chronic mesenteric ischemia usually

undergo an extensive and protracted evaluation before

the ultimate correct diagnosis. This usually includes an

esophagogastroduodenoscopy, colonoscopy, ultrasound,

and computed tomography, and it is common for pa-

tients to undergo appendicectomy as well cholecystectomy.

Usually more than a year passes between the onset of symp-

toms and the correct diagnosis. These patients are usuallymisdiagnosed and treated as gastric/duodenal ulceration,

gastroparesis, gastroduodenitis, gallbladder dysmotility, and

even renal calculi.

The majority of patients referred to our department with

chronic mesenteric ischemia have already undergone an ex-

tensive, prolonged work up, and the diagnosis is already

reached though with inordinate delay.

Significant steno-occlusive disease in all three visceral

vessels represents high-risk group for bowel infarction [5].

All patients with symptomatic CMI should undergo revascu-

larization. The goal is to augment the mesenteric flow so to

relieve abdominal pain, to prevent bowel infarction, and torestore nutritional status. The indication for revascularization

in asymptomatic patients with known visceral artery occlusive

disease is still unclear.

The optimal treatment (endovascular or open) for patients

with CMI remains unresolved. Significant advances have

occurred over the past several years, with an increased em-

phasis on the endovascular approach, which has become a

first-line therapy in many institutions due to theoretical ad-

vantages of a shorter hospital stay (or outpatient procedure),

reduced morbidity and mortality, and improved quality of life

[6]. However, there are no randomized controlled trials com-

paring the two approaches; nevertheless, the long-term vessel

patency rates appear to be inferior to those obtained with open

revascularization.

Feasibility of stenting or open surgery in our study was

dictated by the type of lesion and atherosclerotic load, whether

high-grade stenosis or ostioproximal long-segment occlusion;

hence, the two modalities could not be strictly compared in

our cohort.

Fig. 4 Follow up CT angiogram at 1 year showing patent SMA bypass

graft

Fig. 5 aSmooth narrowing of an

internal iliac artery component of

composite graft delayed filling of

SMA from celiac branches.b

Angioplasty and deployment of

7 mm 40 mm self-expandable

nitinol stent.c Post-stent

angiogram showing reinstated

graft flow to SMA



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Several recent trials comparing the outcomes after

endovascular and open treatment for chronic mesenteric ische-

mia have suggested that the endovascular approach should be

used selectively and restricted to higher-risk patients who

cannot tolerate open repair [79] or as a bridge to open

revascularization whenever feasible by allowing time to opti-

mize the patients comorbidities and nutritional status [7].

Ostioproximal long-segment occlusion mandates surgicalbypass for treatment. The critical ongoing issues with regard

to open revascularization remain unresolved as well. These

include the type of revascularization, the number of vessels to

be vascularized, and the optimal conduit.

Mesenteric bypass, either antegrade multivessel bypass

from the supraceliac aorta or isolated retrograde SMA revas-

cularization from the infrarenal aorta or common iliac artery,

has emerged as the most common options, with the current

debate focusing on the specific configuration. The advantages

of antegrade bypass include the fact that the supraceliac aorta

is usually uninvolved with atherosclerosis and that the limbs

of the graft follow a direct path while maintaining a progradeflow. Disadvantages are the technically challenging nature,

and complications like hemodynamic instability and renal

ischemia are more. The advantages of retrograde bypass in-

clude the fact that infrarenal aortacommon iliac artery can be

exposed more easily faster, is less hemodynamic instability,

and is generally more familiar to most vascular surgeons.

Multivessel revascularization offers the hypothetical ad-

vantage that if one of the graft limbs (or stents) occludes, the

patient may not necessarily develop recurrent symptoms or

acute intestinal ischemia. Proponents of isolated retrograde

by pa ss to the SM A emp ha si ze tha t the pr oc edu re

revascularizes the primary vessel of concern predominantly,

if not the exclusive SMA, and that multivessel reconstructions

add to the complexity of the procedure. Moreover, concomi-

tant aortofemoral bypass as required in three out of nine

surgical patients curtails prudent revascularization of the crit-

ically mandated SMA. Cunningham et al. reported an 86 %

symptom-free rate at 5 years after surgical revascularization of

a single vessel, ie. superior mesenteric artery even in patients

with multiple-vessel occlusions [10].

Both prosthetic and autogenous conduits have been used

for the various mesenteric bypass procedures, although reports

comparing their long-term patency rates have been somewhat

inconclusive [11]. Notably, Kihara and colleagues reported

that patency rates for vein grafts were significantly lower than

those for prosthetic grafts [12]. Hence, it is our choice of

autologous internal iliac artery.

Technical success rates exceed 90 % in the most recent

endovascular series [7,8,1315] and are essentially close to

100 % for open repair [79,16]. Both the endovascular and

open approaches are successful in terms of relieving symp-

toms, with early symptom relief rates exceeding 80 % for

endovascular treatment [14, 15 ] a n d 9 0 % fo r o p e n

revascularization [17]. Objectively, documented patency rates

are significantly lower after endovascular treatment as com-

pared to open surgical revascularization. However, periopera-

tive morbidity, mortality, and hospital stay rates are signifi-

cantly lower for the endovascular approach. Limitations of our

study are that the numbers are small, follow up is midterm,

and comparison between open and endovascular procedure

was not meaningful.In our series of 11 patients, two had angioplasty with

stenting, and nine, open surgical graft to SMA; one patient died

due to subacute graft thrombosis and bowel gangrene after

discharge. All the others including two patients, who required

reintervention, are symptom free and keep good health.

Conclusion

SMA revascularization for CMI was performed with minimal

morbidity and mortality providing excellent symptom relief

and quality of life in medium term except in one patient.

Endovascular, whenever feasible, should be the preferred

option for combined viscerorenal occlusive disease as well

associated aortic aneurismal disease. BMI significantly im-

proves in 6 months following surgery. In our experience

where composite graft has been used, the diseased, so

endarterectomized iliac artery component of the composite

graft had significant stenosis in the follow up period. Angio-

plasty with stenting is viable and effective salvage procedures

for assisted primary patency of failing SMA bypass grafts.

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chronic mesenteric ischemia and therapeutic paradigm

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