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• Recommendation 28: In patients after revascularisation for CMI, repeated long-
term follow-up by imaging to detect asymptomatic restenosis might be consid-
ered. (Class IIb recommendation/Level of evidence C).
• Recommendation 29: In patients after revascularisation for CMI, antiplatelet
therapy is recommended. (Class I recommendation/Level of evidence A).
• Recommendation 30: In patients after endovascular revascularisation for CMI,
dual antiplatelet therapy might be considered for 3 to 12months. (Class IIb rec-
ommendation/Level of evidence C).
• Recommendation 31: Patients with CMI should preferably be investigated and
treated at specialised centres that can offer a multidisciplinary assessment, as
well as both open and endovascular treatment. (Class I recommendation/Level of
evidence C).
9 Chronic Mesenteric (Intestinal) Ischaemia
9.1.3 Clinical Practice Guidelines oftheSociety
forVascular Surgery
These are the most recently published guidelines [3]. To avoid repetition, only a few
recommendations are highlighted.
• We recommend revascularization in patients with CMI to reverse their present-
ing symptoms (ie, weight loss, food fear, diarrhea, postprandial pain) and
improve their overall quality of life. Level of recommendation: Grade 1 (Strong),
Quality of Evidence: A (High).
• We recommend that total parenteral nutrition is not an acceptable alternative to
revascularization for patients with CMI owing to the risk of clinical deteriora-
tion, bowel infarction, and catheter-related complications. Level of recommen-
dation: Grade 1 (Strong), Quality of Evidence: B (Moderate).
• We suggest that the superior mesenteric artery (SMA) is the primary target for
revascularization. Level of recommendation: Grade 2 (Weak), Quality of
Evidence: B (Moderate).
• We suggest that the celiac axis and inferior mesenteric artery are secondary tar-
gets for revascularization and that revascularization may aid in symptom relief if
the SMA is not suitable for intervention or the technical result is not acceptable.
Level of recommendation: Grade 2 (Weak), Quality of Evidence: B (Moderate).
• In patients with symptoms consistent with CMI and occlusive disease isolated to
a single mesenteric vessel, particularly the SMA, we suggest a shared decision-
making approach between the patient and provider to discuss revascularization
as a treatment option. Level of recommendation: Grade 2 (Weak), Quality of
Evidence: C (Low).
• We recommend endovascular revascularization as the initial treatment for
patients with CMI and suitable lesions. Level of recommendation: Grade 1
(Strong), Quality of Evidence: B (Moderate).
9.2 Results
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• We recommend reserving open surgical revascularization for patients with CMI
who have lesions that are not amenable to endovascular therapy, endovascular
failures, and a select group of younger, healthier patients for whom the long-term
benets may offset the increased perioperative risks. Level of recommendation:
Grade 1 (Strong), Quality of Evidence: B (Moderate).
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9.1.4 European Guidelines onChronic Mesenteric Ischaemia:
Joint United European Gastroenterology etal.
These gastroenterology guidelines recommend [4]:
• Chronic mesenteric ischaemia should be considered in patients with unexplained
postprandial abdominal pain, weight loss (>5% body weight), adapted eating
pattern (to avoid abdominal complaints) or diarrhoea. Strong recommendation/
Low quality of evidence.
• In symptomatic patients with single-vessel disease of either the CA or SMA,
a≥70% stenosis could be considered relevant. Weak recommendation/Very low
quality of evidence.
• In symptomatic patients with extensive multivessel mesenteric artery disease,
a≥50% stenosis of the SMA could be considered relevant. Weak recommenda-
tion/Very low quality of evidence.
• Mesenteric bypass procedures might be reserved for patients in whom endovas-
cular revascularization is not suitable. Weak recommendation/Low quality of
evidence.
• In patients with chronic mesenteric ischaemia, it might be disadvantageous to
increase oral intake, start enteral tube feeding or start total parenteral nutrition
before revascularization. Weak recommendation/Very low quality of evidence.
• In patients with occlusive disease of both the CA and SMA, endovascular revas-
cularization of both vessels might be attempted. The SMA is the preferred target
artery followed by the CA.Weak recommendation/Very low quality of evidence.
• After endovascular mesenteric artery stenting, we suggest administering dual
antiplatelet therapy for at least 1 month, followed by life-long antiplatelet mono-
therapy. Weak recommendation/Very low quality of evidence.
9.2 Results
9.2.1 Registries
Lima etal. [5] sought to compare in-hospital major adverse cardiac and cerebrovascular events (MACCE) following endovascular therapy with open surgery for
chronic mesenteric ischemia (CMI). Data were obtained from the 2007 to 2014
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9 Chronic Mesenteric (Intestinal) Ischaemia
National Inpatient Sample (NIS). Of 4150 patients with CMI, 3206 (77.2%) underwent endovascular therapy and 944 (22.8%) underwent surgery (weighted national
estimates of 15,850 and 4687, respectively). In a propensity score-matched cohort
comparison of 880 patients in each group, the incidence of MACCE was signicantly lower among patients undergoing endovascular therapy than surgery (8.6%
vs. 15.9%; p<0.001), driven mainly by signicantly lower in-hospital mortality
(5.1% vs. 9.9%; p< 0.001) and post-operative cardiac complications (<1.1% vs.
4.3%; p< 0.001). The composite, any in-hospital complications, occurred signicantly less often with endovascular therapy than surgery (15.3% vs. 20.3%;
p = 0.006). Median total hospital costs during the study period were lower for
patients undergoing endovascular treatment compared with open surgery. The data
suggest that endovascular therapy should be the preferred revascularization modality for patients with CMI (Table9.1).
In addition, Lima etal. [6] sought to determine the contemporary rates, reasons,
predictors, and costs of 30-day readmissions following endovascular or surgical
revascularization for CMI in the US. In the overall cohort, the mean age was
71.4±11.1years and 70.6% were women. Approximately one in ve patients overall underwent surgery as the mode of revascularization at index hospitalization. A
total of 35% of the overall index hospital admissions were elective. Among 4671
patients with CMI who underwent mesenteric revascularization, 19.5% were readmitted within 30days after discharge at a median time of 10days. The observed
unadjusted readmission rates were higher for the endovascular than surgical group
(20.6% vs. 14.7%, p<0.001). The most frequent reasons for 30-day readmissions
were cardiovascular and cerebrovascular conditions (27%), non-hemorrhagic gastrointestinal conditions (19%), and treatment-related complications (14%). Overall
median LOS during readmission hospitalizations was 5 (IQR 3–9) days. Median
overall cost per readmission stay was US $9586 (IQR $5670–$20,770). The national
estimate of aggregate costs for readmission after CMI revascularization was
Table 9.1 In-hospital adverse events after endovascular (ER) versus open (OR) revascularization
for chronic mesenteric ischemia. NIS database from 2007 to 2014. Propensity score-matched
comparison (according to Lima etal. [5])
Parameter ER (n=880) OR (n=880) P
MACCE, n (%) 76 (8.6) 140 (15.9) < 0.001
Any in-hospital complication, n (%) 135 (15.3) 179 (20.3) 0.006
Death, n (%) 45 (5.1) 87 (9.9) < 0.001
Myocardial infarction, n (%) 27 (3.1) 33 (3.8) 0.430
Stroke, n (%) 12 (1.4) 10 (1.1) 0.667
Other cardiac post-operative complications, n (%) < 10 (< 1.1) 38 (4.3) < 0.001
Peripheral vascular post-operative complications, n (%) 11 (1.3) < 10 (< 1.1) 0.031
Major bleeding, n (%) 18 (2.0) 30 (3.4) 0.079
Gastrointestinal hemorrhage, n (%) 53 (6.0) 27 (3.1) 0.002
Bowel resection, n (%) 0 (0.0) < 10 (< 1.1) 0.157
MACCE major adverse cardiac and cerebrovascular events
9.2 Results
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211
$14,634,678. Non-elective index admission, CKD, and discharge disposition, but
not revascularization modality, predicted 30-day readmission.
9.2.2 Studies
9.2.2.1 Open vs. Endovascular Revascularization
A retrospective study was performed by Zacharias et al. [7] of all consecutive
patients with CMI (161 patients, 215 vessels) treated from 2008 to 2012. There
were 116 (72%) patients who were rst treated with endovascular revascularization
(ER) and 45 (28%) patients with open revascularization (OR). Overall mortality
was 6.8% (11/161). Among the ER patients, 27 developed restenosis and required
OR (23%). Patients treated with ER were older (73 vs. 66years; P=.014), had similar comorbidities, and had higher rate of short lesions (≤2 cm) on preoperative
angiograms (23% vs. 47%; P=.004). Primary patency at 3years was higher in the
OR group compared with the ER group (91% vs. 74%; P=.018). Long-term survival rates were higher in the ER group (95% vs. 78%; P=.003). Hospital length of
stay and intensive care unit length of stay were shorter in the ER group (<.001).
Perioperative mortality (30-day) was not statistically signicant between the groups
(5.2% vs. 11%; P=.165). Patients with short lesions ≤2cm who have higher operative risk are those who benet the most from ER.On the other hand, patients with
heavily diseased visceral aortas and long lesions ≥2cm in the celiac artery and
SMA that are close to the mesenteric takeoff from the aorta may benet from primary OR (Table9.2).
A study from Pittsburgh included 259 patients treated for CMI from 2010 to
2020 [8]. 56 (22%) of these patients underwent open bypass surgery, usually (70%)
antegrade (aortic inow), with a Dacron graft (82%). 230 patients underwent endovascular intervention, usually at the SMA (63%), with bare-metal stents (64%),
mostly balloon-expandable (97%). Postoperative major adverse events were
Table 9.2 Endovascular revascularization (ER) vs. open revascularization (OR) for chronic
mesenteric ischemia (according to Zacharias etal. [7])
Parameter ER (n=116) OR (n=45) P
Patient age, years (mean±SD) 73±10 66±13 .014
Gender, female, % 70 76 .459
Multivessel disease ≥2, % 83 66 .059
Location of vessel occlusion >2cm from origin, % 33 18 .059
Length of stenosis >2cm, % 23 47 .004
Perioperative mortality, % 5.2 11 .165
Intensive care unit length of stay, days 2±5 12±19 <.001
Hospital length of stay, days 5±8 23±20 <.001
Primary patency at 3years, % 74 91 .018
Survival at 3years, % 95 78 .003
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9 Chronic Mesenteric (Intestinal) Ischaemia
observed in 12% (27% after open, 9% after endovascular interventions (p<0.01).
30-day mortality was 10.7% vs. 4.4%. Primary patency rates at 1year were 85%
after endovascular intervention and 96% after open bypass. However, primary
assisted patency rates showed little difference (94% in the endovascular and 96% in
the open bypass group). The conclusion was to pursue an endovascular rst approach
in patients with CMI, but with strict post-interventional monitoring.
The impact of malnutrition on the outcomes of open and endovascular revascularization in 54 patients with CMI was investigated by Allain etal. [9]. The prevalence of malnutrition was 70% (38 patients), including 9 severely malnourished
patients. Twenty-nine patients (53.7%) underwent endovascular revascularization,
while 25 (46.3%) underwent conventional surgery. The 30-day mortality was null in
the non-malnourished group, whereas ten patients (26.3%) died in the malnourished
group (P=0.02). The mean duration of follow-up was 639 (±660) days. The 3-year
survival was not different between the endovascular group and the open surgery
group (43% vs. 52%, P=0.7). The 3-year survival was statistically higher in the
non-malnourished group (87%) than in the malnourished group (49.6%) (P=0.01).
The authors suggested perioperative nutrition for severely malnourished patients
with CMI, but according to guidelines this should not delay intervention.
9.2.2.2 Open Revascularization
72 patients with open mesenteric bypass (OMB) for CMI were reported by Crawford
etal. [10]. Previous mesenteric stent placement or bypass had been performed in
39%. An antegrade conguration (93%) was most common (retrograde conguration, 7%), with revascularization of the superior mesenteric artery/celiac vessels in
85% (superior mesenteric artery only in 15%). The 30-day mortality was 4% (n=3)
and in-hospital morbidity was 53%. The clinical follow-up period was
16±20months. The 1- and 3-year primary bypass patency and freedom from reintervention was 91%±5% and 83%±7%, respectively, with no association with the
Multiple Organ Dysfunction Scores (MODS) or sequential organ failure assessment
(SOFA) scores. The 1- and 3-year survival was 86%±4% and 71%±6% with signicantly worse outcomes for patients with higher MODSs and/or SOFA scores.
Most CMI patients undergoing OMB will experience signicant metabolic derangements resulting from sequelae of the ischemia-reperfusion phenomenon postoperatively. These can be objectively assessed in the early postoperative period using
simply applied scoring systems to reliably predict the early and long-term outcomes.
9.2.2.3 Endovascular Revascularization
Long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) for CMI in 76 consecutive were reported by Awouters etal.
[11]. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23
(29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical
9.3 Conclusions forClinical Practice
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success was achieved in n = 68 (89.5%), and procedural complications were
observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n= 21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0%
and 28.2% after 2, 5 and 10 years of follow-up, respectively. A trend towards longer
relapse-free survival was found in the circumferential stenosis group (78.2% at 5
years) compared with the non-circumferential stenosis group (55.5%) (P=0.063).
Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite
a substantial number of patients experiencing clinical relapse over time.
Haben etal. [12] conducted a retrospective review of patients with CMI treated
with angioplasty and stenting with bare-metal stents from 2003 to 2014. There were
150 patients (39 men, 111 women; age, 70.7± 11.1years) with CMI who underwent interventions on the CA (56 vessels) and the SMA (133 vessels); 38 patients
had both CA and SMA intervention. Primary patency for the CA was 86% at 1year
and 66% at 3years; for the SMA, primary patency was 81% at 1year and 69.0% at
3 years. Chronic total occlusion in the SMA conferred worse patency compared
with stenosis (HR, 2.38; 95% CI, 1.03–5.47; P = .042), and younger patients
(<70years) had a higher proportion of SMA occlusion (38.9% vs. 22.8; P=.045).
Intervention for CMI has acceptable midterm results. Patients older than 70years
have better results than younger patients, and this may reect a more malignant
presentation in the younger patients. Ostial aring proved to be the single factor on
multivariate analysis associated with improved patency.
Zhou etal. [13] analyzed the outcomes of patients treated for mesenteric artery
in-stent restenosis (MAISR). Clinical data from a single center between 2004 and
2017 were presented. During the study period, 91 patients underwent primary mesenteric angioplasty and stenting (MAS). In total, 113 mesenteric vessels were
treated with 20 covered stents and 93 bare-metal stents. Overall primary patency
was 69% at 2years. At 2years, primary patency was 83% for covered stents compared with 65% for bare-metal stents (P=.17). Of these 91 primary MAS patients,
27 (30%) were treated for MAISR (32 vessels). Two covered stent patients developed signicant restenosis (11%) compared with 25 (34%) bare-metal stent patients
(P=.02). The 30-day mortality rate after reintervention for mesenteric stent restenosis was 0%. Postoperative complications occurred in 15% of patients. The 2-year
patency was similar after balloon angioplasty alone and repeated stenting. Data suggest use of covered vs. bare-metal stents for mesenteric artery stenosis. Restenosis
treatment has low mortality and acceptable morbidity, and angioplasty alone appears
as effective as repeated stenting.
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9.3 Conclusions forClinical Practice
1. Chronic mesenteric ischaemia (CMI) should be considered in patients with
unexplained postprandial abdominal pain, weight loss (>5% body weight),
adapted eating pattern (to avoid abdominal complaints) or diarrhoea.
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9 Chronic Mesenteric (Intestinal) Ischaemia
2. In patients with symptomatic CMI caused by multi-vessel occlusive disease,
revascularization is recommended.
3. In symptomatic patients with single-vessel disease of either the celiac artery
(CA) or superior mesenteric artery (SMA), a>70% stenosis could be considered
relevant.
4. In patients with advanced CMI (severe weight loss, diarrhoea, continuous pain),
it is not recommended that revascularization is delayed by attempts to improve
the nutritional status.
5. In most centres angioplasty and stenting have become the primary treatment
modalities, relegating open surgical bypass to patients who are not candidates or
who fail endovascular therapy.
6. The SMA is the main primary target for revascularization, whenever possible.
Revascularization of the CA or IMA has also been performed, particularly when
the SMA is chronically occluded and not suitable for recanalisation.
References
1. 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.
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. Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad
MH.Chronic mesenteric ischemia: clinical practice guidelines from the society for vascular
surgery. J Vasc Surg. 2021;73(1S):87S–115S.
4. Terlouw LG, Moelker A, Abrahamsen J, etal. European guidelines on chronic mesenteric ischaemia—joint united European gastroenterology, European Association for Gastroenterology,
endoscopy and nutrition, European Society of Gastrointestinal and Abdominal Radiology,
Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology,
cardiovascular and interventional radiological Society of Europe, and Dutch mesenteric ischemia study group clinical guidelines on the diagnosis and treatment of patients with chronic
mesenteric ischaemia. United European Gastroenterol J. 2020;8:371–95.
5. Lima FV, Kolte D, Kennedy KF, Louis DW, Abbott JD, Soukas PA, Hyder ON, Mamdani
ST, Aronow HD. Endovascular versus surgical revascularization for chronic mesenteric
ischemia: insights from the National Inpatient Sample Database. JACC Cardiovasc Interv.
2017;10:2440–7.
6. Lima FV, Kolte D, Louis DW, Kennedy KF, Abbott JD, Soukas PA, Hyder ON, Mamdani
ST, Aronow HD.Thirty-day readmission after endovascular or surgical revascularization for
chronic mesenteric ischemia: insights from the nationwide readmissions database. Vasc Med.
2019;24:216–23.
7. Zacharias N, Eghbalieh SD, Chang BB, Kreienberg PB, Roddy SP, Taggert JB, Sternbach Y,
Darling RC 3rd. Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure. J Vasc Surg. 2016;63:1582–7.
References
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8. 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.
9. Allain C, Besch G, Guelle N, Rinckenbach S, Salomon du Mont L.Prevalence and impact of
malnutrition in patients surgically treated for chronic mesenteric ischemia. Ann Vasc Surg.
2019;58:24–31.
10. Crawford JD, Scali ST, Khan T, Back MR, Cooper M, Arnaoutakis DK, Berceli SA, Upchurch
GJ, Huber TS, Giles KA.Effect of ischemia-reperfusion on outcomes after open mesenteric
bypass for chronic mesenteric ischemia. J Vasc Surg. 2021;74:1301–8.
11. Awouters J, Jardinet T, Hiele M, Laenen A, Dymarkowski S, Fourneau I, Maleux G.Factors
predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia. Vasa. 2021;50:431–8.
12. Haben C, Park WM, Bena JF, Parodi FE, Lyden SP.Improving midterm results justify the
continued use of bare-metal stents for endovascular therapy for chronic mesenteric ischemia.
J Vasc Surg. 2020;71:111–20.
13. Zhou Y, Ryer EJ, Garvin RP, Pham A, Irvan JL, Orlova K, Elmore JR.Outcomes of endovascular treatments for in-stent restenosis in patients with mesenteric atherosclerotic disease. J
Vasc Surg. 2019;69:833–42.
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Chapter 10
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Median Arcuate Ligament Syndrome
(MALS)
Preliminary Note In the following, the term “median arcuate ligament syndrome”
(MALS), the most common term in PubMed, is used. MALS is also known as
Dunbar syndrome or coeliac artery compression syndrome.
10.1 Guidelines
10.1.1 The Appropriateness Criteria oftheAmerican College
ofRadiology [1] Recommend
Diagnostics:
• CTA or MRA should be performed prior to catheter angiography.
• Mesenteric angiography in lateral projection during both inspiration and
expiration.
Treatment:
• Surgery with median arcuate ligament release, with or without bypass. This pro-
cedure is performed once diagnosis is conrmed by angiography.
• Percutaneous transluminal angioplasty with stent placement. This procedure is
the second-line intervention in patients with recurrent or persistent symptoms
despite surgical decompression and where there is evidence of celiac artery
narrowing.
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_10
217© The Author(s), under exclusive license to Springer Nature
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10 Median Arcuate Ligament Syndrome (MALS)
10.1.2 European Guidelines onChronic Mesenteric
Ischaemia—Joint United European Gastroenterology.
These Guidelines Recommend [2]
• CA compression in MALS can be diagnosed by inspiration/expiration duplex
ultrasound, CTA or CE-MRA.In patients of younger age, suspected of having
MALS, both duplex ultrasound and CE-MRA (2mm slices with 3D reconstructions) in inspiration and expiration are recommended imaging techniques. Strong
recommendation / Very low quality of evidence
• Patients with MALS might be considered for surgical coeliac artery release.
Weak recommendation / Very low quality of evidence
• In patients with MALS (and no preceding adequate coeliac artery release) endo-
vascular stenting of the CA is contraindicated. Strong recommendation/Very low
quality of evidence
10.2 Results
10.2.1 Reviews
A review aimed to outline the anatomy and pathophysiology of MALS.Evidence
pertaining to its clinical presentation, diagnosis, and management was also
reported [3]:
• Anatomy
The median arcuate ligament (MAL) is a tough brous arch connecting the
right and left crura of the diaphragm at the level of the aortic hiatus (T12-L1). It
traverses anterior to the aorta and is usually cranial to the celiac artery. The position of the MAL and the origin of the celiac artery vary between individuals.
• Presentation
The true prevalence of MALS is unclear, which is partly due to its variable
clinical presentation. There is a tendency toward a female phenotype (4:1), and
the median age typically lies between 30 and 50years. Cases have also been
reported in pediatric. Frequently reported symptoms include epigastric pain,
nausea, vomiting, weight loss, and postprandial or exercise-induced abdominal
pain. Clinical signs may include abdominal bruits (amplied with expiration),
epigastric tenderness, and marked weight loss.
• Diagnosis
Duplex ultrasound (DUS) is the rst-line recommended investigation. In
patients in whom there is a moderate to high suspicion of chronic mesenteric
ischemia, CTA is recommended to map occlusive disease and to detect or to
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