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L. R. Howroyd et al.
a
c
b
d
Fig. 26.5 Features of mesenteric venous thrombosis (a) and (b) are axial venous phase CT images
showing lling defects within the superior mesenteric vein and portal vein (white arrowheads).
Note that the SMV appears expanded when compared to the adjacent patent SMA (white arrow).
(c) and (d) are coronal venous phase CT images showing prominent small bowel wall thickening
with a target pattern of mural enhancement (white arrowheads). There is also extensive stranding
of the mesentery and engorgement of the mesenteric veins (white arrows) and a small volume of
perihepatic ascites (black arrows)
26 Acute Mesenteric Ischaemia: Imaging andIntervention
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447
Ultrasound
Ultrasound can have a role in investigation of pregnant patients with suspected
MVT (100% sensitivity, 93% specicity). [41]
Magnetic Resonance Imaging (MRI)
It can demonstrate arterial or venous occlusion with near 100% sensitivity and specicity [42, 43]. However, much of the support apparatus required for resuscitation
and stabilisation of critically unwell patients cannot go into the MR scanner, the
access to emergency MR imaging is limited in most centres, and the acquisition
time (the time required to gather a complete set of images) is signicantly longer
than for CT.
There is a role in the acute management of pregnant women presenting with
suspected MVT where ionising radiation (from CT) should be avoided, if possible,
to protect the developing foetus [44]. However, there are some safety concerns from
foetal exposure to magnetic elds with MRI.
Percutaneous Catheter Angiography
Catheter angiography is now only performed in cases in which a CT has already
established that endovascular intervention is appropriate and can also be performed
in suspected NOMI if there is diagnostic uncertainty.
MAE: angiograms classically show a lling defect with partial or complete
occlusion of the artery (most commonly the SMA). A ‘tram-track’ sign can be seen
where thin parallel lines of contrast are seen between the embolus and the vessel wall.
NOMI: Diffuse constriction of the mesenteric arterial branches, with a ‘string of
sausages’ sign indicating alternate dilatation and narrowing seen in arterial spasm,
is occasionally documented. Absence of any constriction is a frequent nding
(Fig.26.6).
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a
Fig. 26.6 Features of non-occlusive mesenteric ischaemia. (a) and (b) are selective digital subtraction angiograms of the SMA.There is diffuse constriction of the distal arterial branches (black
arrowheads) with alternating dilatation and narrowing (black arrows) referred to as the ‘string of
sausages’ sign. Note that there is spasm within the main SMA trunk (white arrowhead) but no
gross occlusion is evident
b
Contribution ofInterventional Radiology
Supportive Management
Initial care should include resuscitation with intravenous uids, correction of acidbase status, pain management, nasogastric tube decompression and broad-spectrum
antibiotics. Open surgery has ceased to be the rst option in most circumstances.
Should it be envisaged, anticoagulation with heparin is preferable, to enable easy
reversal if required. In all circumstances where there is some hope of curative treatment, rapid and aggressive management is required to reduce mortality and morbidity [45].
Open Surgery or Endovascular Intervention?
The decision between open surgical approach and endovascular approach is typically governed by whether there is a suspicion that the bowel is viable or not, which
is determined based on imaging ndings and clinical signs of peritonism.
Open surgery has a high associated morbidity and mortality in these patients, and
the patient must be t for a general anaesthetic. Additionally, surgical embolectomy
and revascularisation can be incredibly challenging in peripheral emboli and
26 Acute Mesenteric Ischaemia: Imaging andIntervention
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heavily calcied atherosclerotic vessels. If the patient has been anticoagulated,
there is a risk of signicant bleeding.
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Endovascular Options
Endovascular treatments can be performed with local anaesthetic alone if necessary,
although they often are performed under conscious sedation, meaning a general
anaesthetic can be avoided in frail, comorbid, or physiologically compromised
patients [45, 46]. It is important to be aware that if endovascular therapy is unsuccessful, the patient can always progress to having open surgery if necessary.
A survival of 89% in patients treated with endovascular therapy has been reported
(with or without additional surgery) which is clearly a vast improvement.
The best results correspond to cases where the occlusion is less than 72h old [47].
Technique
Endovascular treatments can be performed in the same sitting as diagnostic angiography. Digital subtraction aortography is followed by selective mesenteric angiography, including availability and patency of any collateral supply.
Direct Intra-Arterial Thrombolytic Therapy
A guidewire is manipulated across the occlusion and followed by a catheter placed
into or usually just proximal to the thrombus/embolus. A bolus of thrombolytic
agent can then be introduced directly through the catheter. After the initial bolus, the
catheter is secured in a xed position and a continuous infusion of thrombolytic
agent is established. This requires close surveillance to ensure the catheter is not
displaced and to identify any bleeding complications swiftly.
In addition to thrombolysis via the catheter, a heparin infusion is commonly
administered via the arterial sheath in the groin. The rationale for this is that the
systemic heparin infusion acts to treat small residual thrombi or distal embolic fragments within the more distal mesenteric arteries. Complete restoration of ow in all
distal branches is not required, but rather the aim is to restore ow through enough
distal vessels to ensure there is a sufcient perfusion to the bowel by the network of
collaterals.
Arterial ow is rapidly re-established; however, somewhat longer treatment
gives more complete clot dissolution. A limit of 48h is widely accepted.
This is a relatively simple technique and as such often the approach chosen for
frail patients in the early stages of AMI.
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Risks andComplications
The main risk of any thrombolytic therapy is inadvertent bleeding. Contraindications
to endovascular thrombolytic therapy are the same as in thrombolytic therapy for
other thrombotic or embolic events, such as acute infarcts. Absolute contraindications include central nervous system tumours and recent haemorrhagic strokes.
Relative contraindications include pregnancy, severe uncontrolled hypertension and
recent major surgery.
In intra-arterial thrombolysis specically, bleeding complications can occur at
the percutaneous access site (usually the groin).
One of the most feared complications is haemorrhagic transformation of ischaemic bowel and catastrophic gastrointestinal haemorrhage. This is not common,
and in fact has not been reported in SMA occlusion treatment, but gastrointestinal
haemorrhage is a well-recognised complication in lower limb arterial occlusion
thrombolysis [47, 48].
Another disadvantage of this technique is the long period of continuous infusion
that is necessary. Reversible ischaemia may progress to irreversible ischaemia during
the initial hours of therapy. Careful monitoring for peritonism is therefore advised.
It is important for the treating team to be aware that initiation of thrombolysis does
not preclude surgery. If there is evidence of bowel gangrene thrombolysis can be
discontinued, heparin reversed and laparotomy performed without signicant delay.
Endovascular Embolectomy/Thrombectomy/Thrombo-Aspiration
An adjunct or alternative to intra-arterial thrombolytic therapy is mechanical thrombus fragmentation to reduce the embolic mass more rapidly and achieve arterial
reperfusion more quickly (Fig.26.4c).
The benets of these approaches are that the dose and time necessary for the
thrombolytic infusion is reduced, and thus the risk of bleeding complications are
also reduced. After removal of the clot, treatment of any underlying stenosis can be
performed in the same procedure.
Techniques
Techniques for fragmentation include use of a wire, using an angioplasty balloon
and specialised thrombectomy devices which work via endovascular vacuum aspiration of the clot fragments.
Angioplasty and Stenting
Endovascular treatment should be the rst line option in cases of MAT where there
is an underlying vascular stenosis (provided there are no clinical or radiological
features of irreversible ischaemia) [49, 50] (Fig.26.4d).
26 Acute Mesenteric Ischaemia: Imaging andIntervention
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Techniques
Following angiography, a guidewire is manipulated across the stenosis. Predilatation angioplasty using a balloon is usually performed, followed by deployment of a stent across the stenotic segment.
Retrograde Open Mesenteric Stenting (ROMS)
Heavy calcication of the aortic wall, origin of the mesenteric artery (e.g., SMA)
and stenotic segment can sometimes mean attempts at recanalisation from an antegrade endovascular approach are not possible. In these cases, a surgical recanalisation can be considered. ROMS is a hybrid technique combining endovascular and
open surgical approaches. Via a midline laparotomy, the SMA is exposed and punctured distally, retrograde angiography is performed, and a wire is used to cross the
occlusion before a stent is deployed. In the same procedure, non-viable bowel can
be resected.
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Risks andComplications
Complications of these techniques include distal embolisation of thrombus fragments. Thrombo-aspiration and/or thrombolysis used as adjuncts may help to reduce
the risk of distal embolisation. Other complications are those associated with any
arterial manipulation (e.g. arterial dissection, rupture and occlusion) or those associated with any arterial stent use (e.g. stent migration, intimal hyperplasia and
re-stenosis).
Direct Intra-Arterial Vasodilator Therapy (NOMI)
Following angiography, a wire and catheter are manipulated into the proximal segments of the affected artery (usually the SMA). A direct bolus of a vasodilator can
then be injected through the catheter and a slow infusion initiated. This infusion
runs for approximately 24h. Vasodilator agents used for this include prostaglandin
E1 and papaverine. Results in small studies suggest a signicant reduction in mortality when compared to conservative management alone [51].
Venous Endovascular Techniques
In patients with MVT who deteriorate while on systemic anticoagulation, a more
aggressive treatment may be necessary to restore the venous ow [52].
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Techniques
Endovascular techniques to access the mesenteric veins include placement of a
trans-jugular intrahepatic portosystemic shunt (TIPS) or percutaneous transhepatic
access to a portal vein branch. Few groups advocate access via a surgically placed
SMV catheter.
Once access is obtained to the mesenteric veins, mechanical thrombo-aspiration
and thrombolysis can be combined to restore ow (in a similar way to the arterial
techniques described above). Additionally, if there is any residual venous stenosis,
this can be treated with balloon venoplasty, and even stenting if necessary. Another
less-effective alternative is to administer indirect thrombolysis via an intra-arterial
catheter (i.e. a catheter placed in the SMA).
Limitations toanEndovascular Approach
Specialist Knowledge and Logistics: To ensure the best management strategy is created for individual patients, a multidisciplinary approach is required, including
input from vascular surgeons, general surgeons and interventional radiologists.
Additionally, the specialised operating suites where endovascular procedures can be
performed must be available. Smaller hospitals typically lack the facilities and the
specialists.
Data Analysis: Caution is needed when comparing the outcomes in endovascular
techniques and traditional open surgical techniques. There is no prospective randomised data comparing the two, and there is an inherent selection bias as endovascular revascularisation is suitable only for the patients without irreversible ischaemia.
L. R. Howroyd et al.
Reperfusion Injury
Reperfusion injury is a worrying consequence of both open surgical and endovascular revascularisation. The exact mechanism is unclear but occurs when blood supply
is restored to the bowel after a period of ischaemia. It involves release of free oxygen radicals and neutrophil activation causing additional cell injury and local
inammation. The consequences can be catastrophic, leading to bowel necrosis,
pancreatitis and multi-organ failure [10, 53].
Reperfusion injury is difcult to distinguish from incomplete treatment and
ongoing persistent ischaemia. Post procedural CT is recommended if there are any
concerning clinical symptoms after revascularisation. These include abdominal
pain and bloody diarrhoea—which could be indicative of persistent ischaemia or
could be due to reperfusion injury. C-reactive protein levels rising post treatment
have also been described as a sensitive (but not particularly specic) marker of
reperfusion injury [54].
26 Acute Mesenteric Ischaemia: Imaging andIntervention
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453
The CT features are thickened bowel wall, oedema of the submucosa, and fat
stranding or free uid adjacent to the affected bowel segment. Additional features
are venous dilatation in the mesentery of the affected segment and luminal haemorrhage (seen best on the unenhanced phase).
Conclusions
Establishing dedicated tertiary centres offering multidisciplinary emergency revascularisation based on the stroke unit model has been shown to improve outcomes for
patients [55].
Peritonitis is well-recognised as a clinical marker of bowel infarction in AMI,
and currently used to differentiate whether a patient is suitable for endovascular
therapy or open surgery. However, this may change in future guidelines, with one
study showing that peritoneal irritation is not a signicant predictive factor for irreversible necrosis in AMI [35], and another showing that up to 86% of patients with
peritonitis on clinical examination had reversible ischaemia during their subsequent
operation [56]. If imaging features alone are utilised, many more patients would
initially undergo the less-invasive endovascular procedures which do not preclude
surgical intervention if still required.
References
1. Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F,
Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Bif WL, Ceresoli M, Chiara O,
Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick
AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli
S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier
RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni
MA, Koike K, Velmahos GC, Fraga GP, Fette A, de’Angelis N, Balogh ZJ, Scalea TM, Sganga
G, Kelly MD, Khan J, Stahel PF, Moore EE.Acute mesenteric ischemia: updated guidelines of
the World Society of Emergency Surgery. World J Emerg Surg. 2022;17(1):1–54.
2. Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch K, Luther B.Acute mesenteric ischemia: a vascular emergency. Deut Ärztebl Int. 2012;109(14):249–56.
3. Fuglseth H, Søreide K, Vetrhus M.Acute mesenteric ischaemia. Br J Surg. 2023;110(9):1030–4.
4. Tamme K, Reintam Blaser A, Laisaar K, Mändul M, Kals J, Forbes A, Kiss O, Acosta S,
Bjørck M, Starkopf J.Incidence and outcomes of acute mesenteric ischaemia: a systematic
review and meta-analysis. BMJ Open. 2022;12(10):e062846.
5. Hawthorn BR, Ratnam LA. Acute mesenteric ischaemia: imaging and intervention. Clin
Radiol. 2020;75(5):398.e19.
6. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, Mock C.Global
disease burden of conditions requiring emergency surgery. Br J Surg. 2014;101(1):e9–e22.
7. Bordet M, Tresson P, Huvelle U, Long A, Passot G, Bergoin C, Lermusiaux P, Millon A, Della
Schiava N.Natural history of asymptomatic superior mesenteric arterial stenosis depends on
coeliac and inferior mesenteric artery status. Eur J Vasc Endovasc Surg. 2021;61(5):810–8.
454
https://t.me/med1917
8. Magnus L, Lejay A, Philouze G, Chakfe N, Collange O, Thaveau F, Georg Y.Mortality and
delays of management of acute mesenteric ischemia: the need of a dedicated program. Ann
Vasc Surg. 2022;
9. Silva NGO, Barbosa ABM, Silva NA, Araύjo DN, Assis TO. Anatomical variations
of the superior mesenteric artery and its clinical and surgical implications in humans.
ABCD. 2020;33(2):e1508.
10. Strand-Amundsen RJ, Reims HM, Reinholt FP, Ruud TE, Yang R, Høgetveit JO, Tønnessen
TI. Ischemia/reperfusion injury in porcine intestine—viability assessment. World J
Gastroenterol. 2018;24(18):2009–23.
11. Clarysse M, Dubois A, Vanuytsel T, Pirenne J, Ceulemans LJ.Potential options to expand the
intestinal donor pool: a comprehensive review. Curr Opin Organ Transplant. 2022;27(2):106.
12. Gonzalez LM, Stewart AS, Freund J, Kucera CR, Dekaney CM, Magness ST, Blikslager
AT.Preservation of reserveintestinalepithelial stem cells following severe ischemic injury.
Am J Physiol Gastrointest Liver Physiol. 2019;316(4):G482–94.
13. Luther B, Mamopoulos A, Lehmann C, Klar E.The ongoing challenge of acute mesenteric
ischemia. Visceral Medicine. 2018;34(3):217–23.
14. Kärkkäinen JM.Acutemesentericischemia: a challenge for theacutecare surgeon. Scand J
Surg. 2021;110(2):150–8.
15. Gore RM, Yaghmai V, Thakrar KH, Berlin JW, Mehta UK, Newmark GM, Miller FH.Imaging
in intestinal ischemic disorders. Radiol Clin North Am. 2008;46(5):845–75.
16. Herbert GS, Steele SR. Acute and chronic mesenteric ischemia. Surg Clin North Am.
2007;87(5):1115–34.
17. Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM.Systematic review of survival
after acute mesenteric ischaemia according to disease aetiology. Br J Surg. 2004;91(1):17–27.
18. Kärkkäinen JM. Acute mesenteric ischemia in elderly patients. Expert Rev Gastroenterol
Hepatol. 2016;10(9):985–8.
19. Lawson RM.Mesentericischemia. Crit Care Nurs Clin North Am. 2018;30(1):29–39.
20. Demelo-Rodríguez P, Ordieres-Ortega L, Oblitas CM. Mesentericvenousthrombosis. Med
Clin (Barc). 2023;160(9):400–6.
21. Cangemi JR, Picco MF. Intestinal ischemia in the elderly. Gastroenterol Clin North Am.
2009;38(3):527–40.
22. Ozturk G, Aydinli B, Atamanalp SS, Yildirgan MI, Özoğul B, Kısaoğlu A.Acute mesenteric
ischemia in young adults. Wien Med Woch. 2012;162(15–16):349–53.
23. Bourcier S, Klug J, Nguyen LS.Non-occlusive mesenteric ischemia: diagnostic challenges and
perspectives in the era of articial intelligence. World J Gastroenterol. 2021;27(26):4088–103.
24. Veloso Costa A, Zhunus A, Hafeez R, Gupta A.Cocaine-induced mesenteric ischaemia requiring small bowel resection. BMJ Case Rep. 2021;14(1):e238593.
25. Yu H, Kirkpatrick IDC. An update on acute mesenteric ischemia. Can Assoc Radiol
J. 2023;74(1):160–71.
26. Adaba F, Askari A, Dastur J, Patel A, Gabe SM, Vaizey CJ, Faiz O, Nightingale JMD,
Warusavitarne J.Mortality after acute primary mesenteric infarction: a systematic review and
meta-analysis of observational studies Colorec Dis. 2015;17(7):566–77.
27. Shih MP, Hagspiel KD.CTA and MRA in mesenteric ischemia: Part 1: Role in diagnosis and
differential diagnosis. Am J Roentgenol. 2007;188(2):452–61.
28. Du S, Yang S, Jia K, Du P, Zhang L, Wang J.Fibromuscular dysplasia of mesenteric arteries: a
rare cause of multiple bowel resections-a case report and literature review. BMC Gastroenterol.
2021;21(1):133.
29. Mehta R, Deepak JA, Shine R, Balakrishnan. Takayasu arteritis presenting as chronic mesenteric ischemia. Ind J Gastroenterol. 2004;23(2):73–4.
30. Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J.Mesenteric artery dissection
and wall-thickening, case study and general review. Angiology. 2023;74(1):7–21.
31. Menke J.Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic
review and meta-analysis. Radiology. 2010;256(1):93–101.
L. R. Howroyd et al.
26 Acute Mesenteric Ischaemia: Imaging andIntervention
https://t.me/med1917
32. Lourenco PDM, Rawski R, Mohammed MF, Khosa F, Nicolaou S, McLaughlin P.Dual-energy
CT iodine mapping and 40-keV monoenergetic applications in the diagnosis of acute bowel
ischemia. Am J Roentgenol. 2018;211(3):564–70.
33. Kanasaki S, Furukawa A, Fumoto K, Hamanaka Y, Ota S, Hirose T, Inoue A, Shirakawa T,
Hung Nguyen LD, Tulyeubai S.Acute mesenteric ischemia: multidetector CT ndings and
endovascular management. Radiographics. 2018;38(3):945–61.
34. Furukawa A, Kanasaki S, Kono N, Wakamiya M, Tanaka T, Takahashi M, Murata
K. CT Diagnosis of acute mesenteric ischemia from various causes. Am J Roentgenol.
2009;192(2):408–16.
35. Nuzzo A, Maggiori L, Ronot M, Becq A, Plessier A, Gault N, Joly F, Castier Y, Vilgrain V,
Paugam C, Panis Y, Bouhnik Y, Cazals-Hatem D, Corcos O.Predictive factors of intestinal
necrosis in acute mesenteric ischemia: prospective study from an intestinal stroke center. Am
J Gastroenterol. 2017;112(4):597–605.
36. Schieda N, Fasih N, Shabana W.Triphasic CT in the diagnosis of acute mesenteric ischaemia.
Eur Radiol. 2013;23(7):1891–900.
37. Zeng Y, Yang F, Hu X, Zhu F, Chen W, Lin W.Radiological predictive factors of transmural
intestinal necrosis in acute mesenteric ischemia: systematic review and meta-analysis. Eur
Radiol. 2023;33(4):2792–9.
38. Calame P, Grillet F, Delabrousse E.Reply to “Small-bowel dilatation is the most consistent
feature of transmural intestinal necrosis”. Am J Roentgenol. 2020;215(4):W43.
39. Zarrouk M, Salim S, Elf J, Gottsäter A, Acosta S.Testing for thrombophilia in mesenteric
venous thrombosis—retrospective original study and systematic review. Best Pract Res Clin
Gastroenterol. 2017;31(1):39–48.
40. Bagnacci G, Guerrini S, Gentili F, Sordi A, Mazzei FG, Pozzessere C, Guazzi G, Mura G,
Savelli V, D’Amico S, Calomino N, Volterrani L, Mazzei MA.Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question.
Abd Imag. 2022;47(5):1603–13.
41. Hauenstein K, Li Y.Radiological diagnosis of portal/mesenteric vein occlusion. Visc Med.
2014;30(6):382–7.
42. Alzubaidi S, Patel I, Saini A, Knuttinen G, Naidu S, Kriegshuaser S, Albadawi H, Oklu
R.Current concepts in portal vein thrombosis: etiology, clinical presentation and management.
Abdom Radiol (NY). 2019;44(10):3453–62.
43. Michaely HJ, Dietrich O, Nael K, Weckbach S, Reiser MF, Schoenberg SO.MRA of abdominal vessels: technical advances. Eur Radiol. 2006;16(8):1637–50.
44. Zachariah SK, Fenn M, Jacob K, Arthungal SA, Zachariah SA. 'Management of acute abdomen in pregnancy: current perspectives. Int J Wom Health. 2019;11:119–34.
45. Kougias P, Lau D, El Sayed HF, Zhou W, Huynh TT, Lin PH.Determinants of mortality and
treatment outcome following surgical interventions for acute mesenteric ischemia. J Vasc Surg.
2007;46(3):467–74.
46. Gnanapandithan K, Feuerstadt P. Mesenteric ischemia. Curr Gastroenterol Rep.
2020;22(4):17.
47. Schoots IG, Levi MM, Reekers JA, Lameris JS, van Gulik TM.Thrombolytic therapy for acute
superior mesenteric artery occlusion. J Vasc Interv Radiol. 2005;16(3):317–29.
48. Darwood R, Berridge DC, Kessel DO, Robertson I, Forster R, Berridge DC. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Datab Syst Rev.
2018;2018(8):CD002784.
49. Tilsed JV, Casamassima A, Kurihara H, Mariani D, Martinez I, Pereira J, Ponchietti L,
Shamiyeh A, Al-Ayoubi F, Barco LA, Ceolin M, D'Almeida AJ, Hilario S, Olavarria AL,
Ozmen MM, Pinheiro LF, Poeze van Bokhoven M, Triantos G, Fuentes FT, Sierra SU, Soreide
K, Yanar H. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg.
2016;42(2):253–70.
50. Acosta S, Björck M. Modern treatment of acute mesenteric ischaemia. Br J Surg.
2014;101(1):e100–8.
455
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