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• 8 clinical parameters (SIRS, long duration between symptoms and surgery, high
BMI, coronary heart disease, shock, pulmonary embolism, mesenteric arterial
occlusion, organ failure).
• 7 biochemical parameters (elevated serum lactate, acidosis, leukocytosis, hae-
moconcentration, hyperamylasemia, increased neutrophil to lymphocyte ratio,
increased platelet to lymphocyte ratio).
• 6 radiological parameters (bowel loop dilatation, pneumatosis intestinalis,
thrombosis of the superior mesenteric vein, free intraperitoneal uid, portal vein
thrombosis, splenic vein thrombosis).
Murphy et al. [7] presented a systematic review of current literature addressing
endovascular management of acute mesenteric ischaemia. The population of interest was adult patients presenting with acute mesenteric ischaemia diagnosed by
either radiological imaging or intra-operatively. Studies in which patients underwent intervention via endovascular means alone or studies comparing endovascular
to open intervention were included. The 30-day mortality for endovascular approach
from all 13 studies was 16–42%. Of the 7 comparative studies including results of
open revascularisation, the 30-day mortality for patient treated with an endovascular
approach was 15–39% versus 33–50% for open revascularisation. Laparotomy rates
post-initial endovascular intervention ranged from 13 to 73%. Bowel resection postendovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel
resection in the endovascular group ranged 14–28% and 33–63% in the open cohort.
Endovascular intervention also demonstrated lower median length(s) of bowel
resected. Endovascular management may be associated with reduced mortality and
need for/length of bowel resection compared with the traditional open approach, but
there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more
insidious onset may garner benet from endovascular intervention.
8 Acute Mesenteric (Intestinal) Ischaemia
8.2.2 Studies
8.2.2.1 Open Surgery
Swerdlow et al. [8] performed a retrospective cohort study of patients in the
American College of Surgeons National Surgical Quality Improvement Program
database undergoing open mesenteric revascularization for AMI from 2005 to 2017.
The primary outcome was 30-day mortality. The study cohort included 918 patients;
their median age was 70years, 62% were female. Thirty-day mortality after open
revascularization for AMI was 32%, specically 35% after embolectomy, 31% after
thromboendarterectomy, and 28% after mesenteric bypass (Table8.1). Mortality
was higher in patients requiring concomitant bowel resection (38% vs. 29%, respectively, P < 0.01). The preoperative factor most strongly associated with 30-day
8.2 Results
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Table 8.1 30-day mortality after open revascularisation for AMI. National Surgical Quality
Improvement Program database from 2005–2017 (adapted from Swerdlow etal. [8])
Bowel
Parameter
All (n=918) 35% 38% 29% < .001
Bypass (n=341) 27% 39% 24% .01
– Aorto-mesenteric (vein)
(n=109)
– Aorto-mesenteric (graft)
(n=147)
– Ilio-mesenteric (n=85) 23% 29% 22% .53
Thromboendarterectomy
(n=98)
Embolectomy (n=479) 43% 38% 33% .28
resection rate
(%)
46% 41% 34% .52
31% 43% 20% .01
26% 36% 29% .50
Mortality with
concomitant bowel
resection (%)
Mortality without
bowel resection
(%) P
199
mortality was disseminated cancer (odds ratio = 8.8, 95% condence interval= 2.4–32, P = 0.001). Other factors independently associated with mortality
were renal dysfunction, preoperative intubation, preoperative blood transfusion,
diabetes, elevated preoperative international normalized ratio, elevated preoperative
white blood cell count, and increasing age.
Acosta-Mérida [9] reported on a total of 323 consecutive patients who underwent open surgery for AMI at a single centre between 1990 and 2015. The aim of
this study was to analyze whether there have been changes in terms of patient characteristics and operative mortality in the same institution over a long period of time.
Of the 323 patients, 178 were men (55%) and 145 were women (45%). The average
age of the sample cohort was 73years (±12.7). Regarding the etiology of AMI,
mesenteric arterial embolism was found to be the primary cause in 95 patients
(29.4%), followed by mesenteric arterial thrombosis in 94 patients (29.1%); 44
patients (16.9%) had mesenteric venous thrombosis, and 28 patients (10.7%) had
NOMI.In 62 patients (19.5%), it was not possible to exactly determine the cause.
Global operative mortality was 59% (192 patients). Cumulative survival at 1, 3 and
5 years was 30.8%, 26% and 23%, respectively. Over time, an increasing linear
trend was observed in Charlson score (p=0.008), antiplatelet medication (p<0.001),
use of CT scan (p<0.001), arterial thrombosis (p<0.001) and intestinal resection
(p = 0.047), while a decreasing linear trend was observed in digoxin intake
(p<0.001), angiography use (p= 0.004), and embolism (p < 0.001). Changes in
operative mortality have also been detected, showing a tendency toward a progressive and signicant decrease, but remained high overall.
Data from another single institution were presented by Chou etal. [10]. This
study involved 303 AMI patients from the years 1993 to 2016, venous thrombosis
patients were excluded. Primary outcome was 30-day mortality. Patients were stratied by etiology and diagnosis date (before 2004 versus 2004 and later). AMI
mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive
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8 Acute Mesenteric (Intestinal) Ischaemia
(NOMI) (22%). 345 procedures were performed in 242 patients: 321 open and 24
hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n =85) underwent mesenteric revascularization while 39
(21%) had ndings of non-survivable bowel necrosis (NSBN). Among the 104
patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). Thirty- day
mortality was 61% and stable over time (P=0.91); 1-year survival was 28%, and
overall survival at 3 and 5years was 22% and 17%, respectively, without signicant
differences between temporal cohorts. When stratied by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since
2000, there was a signicant decrease in the percentage of embolic AMI events
(P = 0.04). The percentage of patients who underwent operative management
decreased also over time (P=0.01, 81%→61%). The study demonstrated the continued poor prognosis of AMI over a 25-year period.
Andraska etal. [11] reported on 148 patients who had undergone revascularization for AMI from 2010 to 2020. 26% of patients were admitted with peritonitis,
32% were clinically septic. Surgery was performed within 16h of admission in 96%
of patients. 89 patients underwent open surgical revascularization, most commonly
with embolectomy (n=72), and 17 patients with open bypass. Bowel resection had
to be performed in 49 of these patients (55.1%). Cumulative mortality was 44/89
(49.4%) with open surgery, 19/36 (52.8%) with endovascular management and 9/23
(39.1%) with retrograde open mesenteric stenting, for a total of n=72 (48.6%) for
AMI.The conclusion was that an open approach should remain the reference standard for AMI because it reduces the likelihood of bowel resection.
The objective of a study from Pittsburgh was to identify hospital-based determinants of delayed revascularization and their effects on postoperative morbidity and
mortality in AMI [12]. All patients who underwent any surgery for AMI from a
multi-center hospital system between 2010 and 2020 were divided into two groups
based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was dened as having both vascular consultation ≤12h of presentation and vascular surgery performed at the patient’s initial operation. Delayed
revascularization (DR) was dened as having either delays to vascular consultation
or vascular surgery. A total of 212 patients were analyzed. Ninety-nine patients
received ER, whereas the remaining 113 patients experienced a DR after hospital
presentation. Thirty-day mortality in patients who had DR was signicantly higher
when compared with ER (39.6% vs. 25.0%; P=.02). There was a two- to three-fold
increased risk of 30-day mortality and short bowel syndrome and an almost eightfold increased risk of bowel resection in patients who had DR compared with those
who had ER.Delayed vascular consultation and vascular surgery are both signicant hospital-based determinants of postoperative mortality and short bowel syndrome in patients with AMI.
8.2 Results
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8.2.2.2 Open Mesenteric Bypass andRetrograde Open
Mesenteric Stenting
Scali etal. [13] reviewed their experience with open mesenteric bypass (OMB) in
the treatment of AMI and compared outcomes between patients undergoing either
antegrade (supraceliac aortic inow) or retrograde (infrarenal aortoiliac
inow) bypass.
Eighty-two patients (female 54%; age 63 ± 12 years) underwent OMB for
AMI.An antegrade bypass conguration was used in most cases (76%; n=62). The
incidence of bowel resection at the index operation did not differ based on bypass
conguration (antegrade, 45%; retrograde, 45%) and 37% (n=30) underwent subsequent resection during second look operations. The overall in-hospital mortality
rate was 37%, with no difference between retrograde/antegrade cohorts. The median
follow-up was 8 months. The 1- and 3-year primary patency rates were both
82%±6%, with 10 patients requiring reintervention. 1-year freedom from reintervention rates were 89%±5% and 57%±10% for antegrade and retrograde bypass
patients, respectively. Overall survival, including follow-up after discharge, was
57%±6% and 50%±6% at 1 and 5years and did not differ between patients undergoing antegrade/retrograde OMB.The study suggested that antegrade aortomesenteric bypasses are preferred over retrograde bypasses because of a lower
reintervention rate.
Retrograde open mesenteric stenting (ROMS) is an alternative to traditional
bypass in patients who present with AMI.Andraska etal. [14] compared outcomes
of ROMS with those of conventional mesenteric bypass. A total of 34 patients were
included in the study; 16 underwent mesenteric bypass, and 18 underwent
ROMS.The majority of patients in both groups required bowel resection at the time
of presentation (bypass, 56.25%; ROMS, 77.78%). Average operative time was signicantly higher in the bypass arm (302 vs. 189min; P<.010). In the bypass group,
dacron graft was the most commonly used conduit (62.5%), followed by autologous
vein conduit. All ROMS procedures were performed with balloon expandable
stents. The majority of ROMS procedures were performed with covered stents
(55.56%). In-hospital mortality was comparable between groups (bypass, 43.75%;
ROMS, 38.89%; P=.459). Primary patency at 2years did not differ signicantly
between groups (bypass, 66.67%; ROMS, 87.50%; P=.600). Similarly, all-cause
mortality at 2years did not differ between groups (bypass, 62.50%; ROMS, 55.56%;
P=.476). Given similar postoperative outcomes and ability to perform these procedures in a conventional operating room but with signicantly shorter operative
times, ROMS should be considered a rst-line option in acute situations when the
operator is comfortable performing the procedure.
Oderich etal. [15] reviewed the clinical data and outcomes of all consecutive
patients treated by ROMS in seven academic centers from 2001 to 2013. There were
54 patients, 13 male and 41 female, with a mean age of 72±11years. Indications
for ROMS were AMI in 44 patients (81%) and subacute-on-chronic mesenteric
ischemia with ush mesenteric occlusion in 10 patients (19%). Bowel resection was
needed in 29 patients (66%) with AMI because of perforation or gangrene. Technical
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8 Acute Mesenteric (Intestinal) Ischaemia
success was achieved in all (98%) except one patient for whom ROMS failed, who
was treated by bypass. Early mortality was 45% (20/44) for AMI and 10% (1/10) for
subacute-on-chronic mesenteric ischemia (P=.04). Patient survival for the entire
cohort was 43%±9% at 2years. Freedom from symptom recurrence and freedom
from reinterventions were 72%±8% and 74%±8% at the same interval. The study
suggests that retrograde open mesenteric stenting is an appropriate alternative for
patients with mesenteric ischemia requiring a laparotomy for exploration or treatment of perforated or gangrenous bowel.
In most cases of AMI, intestinal inspection and resection of nonviable bowel are
required through laparotomy. Thus, ROMS, which is a hybrid technique, combines
the benets of both techniques: prompt blood ow restoration with an endovascular
approach and inspection and resection of the small bowel. Roussel etal. [16] retrospectively enrolled all consecutive patients who underwent ROMS revascularization for occlusive AMI in three participating tertiary care centers. Twenty-ve
patients were included. In two patients, ROMS was not possible because of failure
of re-entry in the aortic lumen (technical success, 92%).13 patients (52%) required
bowel or colon resection. The 30-day operative mortality rate was 25%, and the
overall 1-year survival rate was 65%. The 1-year primary patency rate was 92%.
The study suggested that retrograde open mesenteric stenting is a reasonable procedure for selected patients with acute mesenteric ischemia not amenable to percutaneous stenting.
8.2.2.3 Mesenteric Ischaemia inPatients withCOVID-19
The aim of a systematic review by Ojha etal. [17] was to assess the most common
CT imaging features of AMI in COVID-19 patients. A total of 47 studies comprising 75 patients were included in the review. In COVID-19 patients with AMI, small
bowel ischemia is the most prevalent imaging diagnosis and NOMI is the most common pattern of bowel involvement. Small bowel ischemia was seen in 46.7% of the
patients, followed by ischemic colitis (37.3%). Non-occlusive mesenteric ischemia
(NOMI) indicating microvascular involvement was found in 67.9% of patients with
AMI. 50% of the patients receiving conservative/medical management died, highlighting high mortality without surgery.
Pirola etal. [18] provided further information. They analyzed the small bowel
radiological manifestations of SARS-CoV-2 infection in abdominal imaging studies. Of 62 patients, mesenteric ischemia was diagnosed in 31 cases (50%), small
bowel wall thickening in 10 cases (16%), pneumatosis in nine cases (15%), intussusception in eight cases (13%), pneumoperitoneum in two cases (3%) and paralytic
ileus in two cases (3%). Treatment of AMI was reported in 17 cases. Thirteen (76%)
were treated by segmental resection of small bowel, and anticoagulant therapy alone
was administered in four cases. Of the nineteen patients with a reported outcome,
nine (47%) died.
References
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8.3 Conclusions forClinical Practice
For the conclusions, we follow the recommendations of Björck etal. [19] in the
Trans-Atlantic Debate, whether an endovascular-rst strategy is the optimal
approach for treating acute mesenteric ischemia:
After having diagnosed the condition, most often with multislice computed
tomography images, and if an acute occlusion of the superior mesenteric artery
(SMA) is diagnosed, the treatment is organized in the following way:
1. The patient is taken to a hybrid operating room, thereby providing the option for
using both open and endovascular techniques. Angiography and endovascular
treatment is attempted, with access from the groin or the brachial artery, or both,
preferably under local anesthesia.
2. After endovascular revascularization, the abdomen is evaluated, and if there is
any suspicion of bowel gangrene, a laparotomy is performed; otherwise, close
surveillance follows for at least 48h. If percutaneous endovascular revascularization fails, laparotomy and hybrid retrograde recanalization of the SMA and
stenting, or open revascularization should be undertaken, without delay.
3. Completion angiography, followed by adjunctive endovascular procedures
(where necessary), including further aspiration embolectomy of SMA branches,
percutaneous transluminal angioplasty/stenting of residual stenosis, thrombolysis of occluded side branches.
4. Second-look angiography or laparotomy, or both, may be necessary, and should
be performed liberally.
References
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disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of
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practice guidelines. Circulation. 2013;127:1425–43.
2. Björck M, Koelemay M, Acosta S, et al. Editor’s choice—management of the diseases of
mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular
Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53:460–510.
3. Aboyans V, Ricco JB, Bartelink MEL, etal. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular
Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by: the European Stroke
Organization (ESO) the task force for the diagnosis and treatment of peripheral arterial diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular
Surgery (ESVS). Eur Heart J. 2018;39:763–816.
4. Hou L, Wang T, Wang J, Zhao J. Yuan D (2021) outcomes of different acute mesenteric
ischemia therapies in the last 20 years: a meta-analysis and systematic review. Vascular.
2021;30:669–80. https://doi.org/10.1177/17085381211024503; Epub ahead of print.
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5. Wu W, Liu J, Zhou Z.Preoperative risk factors for short-term postoperative mortality of acute
mesenteric ischemia after laparotomy: a systematic review and meta-analysis. Emerg Med Int.
2020;2020:1382475–12.
6. Emile SH, Khan SM, Barsoum SH.Predictors of bowel necrosis in patients with acute mesenteric ischemia: systematic review and meta-analysis. Updat Surg. 2021;73:47–57.
7. Murphy B, Dejong CHC, Winter DC.Open and endovascular management of acute mesenteric
ischaemia: a systematic review. World J Surg. 2019;43:3224–31.
8. Swerdlow NJ, Varkevisser RRB, Soden PA, Zettervall SL, McCallum JC, Li C, Wyers MC,
Schermerhorn ML. Thirty-day outcomes after open revascularization for acute mesenteric
ischemia from the American College of Surgeons National Surgical Quality Improvement
Program. Ann Vasc Surg. 2019;61:148–55.
9. Acosta-Mérida MA, Marchena-Gómez J, Saavedra-Santana P, Silvestre-Rodríguez J, ArtilesArmas M, Callejón-Cara MM.Surgical outcomes in acute mesenteric ischemia: has anything
changed over the years? World J Surg. 2020;44:100–7.
10. Chou EL, Wang LJ, McLellan RM, Feldman ZM, Latz CA, LaMuraglia GM, Clouse WD,
Eagleton MJ, Conrad MF.Evolution in the presentation, treatment, and outcomes of patients
with acute mesenteric ischemia. Ann Vasc Surg. 2021;74:53–62.
11. Andraska EA, Tran LM, Haga LM, Mak AK, Madigan MC, Makaroun MS, Eslami MH, Chaer
RA.Contemporary management of acute and chronic mesenteric ischemia: 10-year experience from a multihospital healthcare system. J Vasc Surg. 2022;75:1624–33.
12. Tran LM, Andraska E, Haga L, Sridharan N, Chaer RA, Eslami MH.Hospital-based delays to
revascularization increase risk of postoperative mortality and short bowel syndrome in acute
mesenteric ischemia. J Vasc Surg. 2022;75:1323–33.
13. Scali ST, Ayo D, Giles KA, Gray S, Kubilis P, Back M, Fatima J, Arnaoutakis D, Berceli SA,
Beck AW, Upchurch GJ, Feezor RJ, Huber TS.Outcomes of antegrade and retrograde open
mesenteric bypass for acute mesenteric ischemia. J Vasc Surg. 2019;69:129–40.
14. Andraska E, Haga L, Li X, Avgerinos E, Singh M, Chaer R, Madigan M, Eslami MH.Retrograde
open mesenteric stenting should be considered as the initial approach to acute mesenteric ischemia. J Vasc Surg. 2020;72:1260–8.
15. Oderich GS, Macedo R, Stone DH, Low Frequency Vascular Disease Research Consortium
Investigators, etal. Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia. J Vasc Surg. 2018;68:470–80.
16. Roussel A, Della Schiava N, Coscas R, Pellenc Q, Boudjelit T, Goëau-Brissonnière O, Corcos
O, Lermusiaux P, Coggia M, Castier Y, Association Universitaire de Recherche en Chirurgie
Vasculaire (AURC). Results of retrograde open mesenteric stenting for acute thrombotic mesenteric ischemia. J Vasc Surg. 2019;69:1137–42.
17. Ojha V, Mani A, Mukherjee A, Kumar S, Jagia P. Mesenteric ischemia in patients with
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Radiol (NY). 2022;47:1565–602.
18. Pirola L, Palermo A, Mulinacci G, Ratti L, Fichera M, Invernizzi P, Viganò C, Massironi
S.Acute mesenteric ischemia and small bowel imaging ndings in COVID-19: a comprehensive review of the literature. World J Gastrointest Surg. 2021;13:702–16.
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8 Acute Mesenteric (Intestinal) Ischaemia
Chapter 9
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Chronic Mesenteric (Intestinal) Ischaemia
9.1 Guidelines
Preliminary note: in the following, the terms “chronic intestinal ischaemia” and
“chronic mesenteric ischaemia” are used synonymously, as specied in the literature database (MEDLINE, PubMed). Chronic mesenteric ischaemia (CMI) is the
more commonly used term and is preferred here.
9.1.1 European Society ofCardiology (ESC)/European Society
forVascular Surgery (ESVS)
The ESC/ESVS guidelines recommend [1]:
Chronic mesenteric artery disease includes stenosis or chronic occlusion of the
coeliac trunk or the mesenteric arteries. Its prevalence increases with age, especially
in the presence of other atherosclerotic diseases and abdominal aortic aneurysms
(AAAs). In patients with an AAA and lower extremities arterial disease signicant
stenosis (mostly asymptomatic) of at least one of the three arteries was detected in
40% and 27%, respectively.
9.1.1.1 Diagnosis
• In patients with suspected chronic mesenteric ischaemia (CMI), duplex ultra-
sound is recommended as the rst-line examination. (Class I recommendation/
Level of evidence C).
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_9
205© The Author(s), under exclusive license to Springer Nature
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• In patients with suspected CMI, occlusive disease of a single mesenteric artery
makes the diagnosis unlikely and a careful search for alternative causes should
be considered. (Class IIa recommendation/Level of evidence C).
9.1.1.2 Treatment
• In patients with symptomatic multivessel CMI, revascularization is recom-
mended. (Class I recommendation/Level of evidence C).
• In patients with symptomatic multivessel CMI, it is not recommended to delay
revascularization in order to improve the nutritional status. (Class III recommen-
dation/Level of evidence C).
These guidelines do not specify the revascularization procedure (open surgery or
endovascular intervention), but they note:
Although endovascular treatment has been increasingly used, open surgery is
still indicated in the following situations:
• After failed endovascular therapy without possibility for repeat endovascular
treatment.
• Extensive occlusion, calcications or other technical difculties.
• Young patients with non-atherosclerotic lesions due to vasculitis or mid-aortic
syndrome.
9 Chronic Mesenteric (Intestinal) Ischaemia
9.1.2 Clinical Practice Guidelines oftheEuropean Society
ofVascular Surgery (ESVS)
The ESVS guidelines recommend [2]:
• Recommendation 13: The diagnosis of CMI should be considered less likely in
the absence of multi-vessel stenosis or occlusion and warrants careful investiga-
tion for alternative causes. (Class IIa recommendation/Level of evidence C).
• Recommendation 14: In patients with otherwise unexplained abdominal symp-
toms, and occlusive disease of two or three mesenteric arteries, CMI should be
considered to be the cause of the symptoms. (Class IIa recommendation/Level of
evidence C).
• Recommendation 15: In patients with suspected CMI, duplex ultrasound of the
mesenteric arteries is recommended as the rst-line examination. (Class I recom-
mendation/Level of evidence B).
• Recommendation 16: In patients with a moderate to high suspicion of CMI, CTA
(computed tomography angiography) is recommended to map the occlusive dis-
ease, and to detect or exclude other intra-abdominal pathology. (Class I recom-
mendation/Level of evidence C).
9.1 Guidelines
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207
• Recommendation 17: MRA (magnetic resonance angiography) may be consid-
ered as an alternative to CTA for diagnosis of suspected CMI, although there is
some evidence that images obtained with MRA are not as accurate or complete
as those obtained with CTA. (Class IIb recommendation/Level of evidence C).
• Recommendation 18: In patients with symptomatic CMI caused by multi-vessel
occlusive disease, revascularisation is recommended. (Class I recommendation/
Level of evidence B).
• Recommendation 19: In patients with symptomatic single vessel disease, revas-
cularisation may be considered. (Class IIb recommendation/Level of evidence B).
• Recommendation 20: In patients with advanced CMI (severe weight loss, diar-
rhoea, continuous pain), it is not recommended that revascularisation is delayed
by attempts to improve the nutritional status. (Class III recommendation/Level of
evidence C).
• Recommendation 21: In patients with CMI, needing revascularisation, the supe-
rior long-term results of open surgery must be offset against a possible early
benet of endovascular intervention with regard to peri-procedural mortality and
morbidity. (Class I recommendation/Level of evidence B).
• Recommendation 22: In patients requiring revascularisation for CMI, the supe-
rior mesenteric artery is the main target vessel using either open or endovascular
techniques. (Class I recommendation/Level of evidence B).
• Recommendation 23: In patients requiring endovascular treatment of CMI, rou-
tine mesenteric stenting should be used, as opposed to plain balloon angioplasty.
(Class I recommendation/Level of evidence C).
• Recommendation 24: In patients requiring mesenteric artery stenting, covered
stents as opposed to bare metal stents, may be considered. (Class IIb recommen-
dation/Level of evidence C).
• Recommendation 25: In patients with CMI, open revascularisation should be
considered in the following situations:
– In a patient who has failed endovascular therapy or
– In patients who are not candidates for endovascular intervention because of
extensive occlusion and calcication precluding safe angioplasty and
stenting or
– In young patients with complex non-atherosclerotic lesions caused by vascu-
litis or mid-aortic syndrome.
(Class IIa recommendation/Level of evidence B)
• Recommendation 26: In patients needing mesenteric revascularisation, ROMS
(retrograde open mesenteric stenting) should be considered when trans-aortic
stenting and open reconstruction are impossible. (Class IIa recommendation/
Level of evidence C).
• Recommendation 27: In patients after revascularisation for CMI, repeated fol-
low- up by clinical assessment to detect symptomatic restenosis might be consid-
ered. (Class IIb recommendation/Level of evidence C).
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