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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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177© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_22
Evaluating Patient
What are the two
main categories
of mesenteric
ischemia?
Acute mesenteric ischemia and chronic
mesenteric ischemia.
What is the main
reason for high
morbidity/mortality
in patients with
acute mesenteric
ischemia?
Delay in diagnosis is the main cause of the
high morbidity and mortality in patients
with acute mesenteric ischemia. The
symptoms can often be nonspecific and
similar to other causes of abdominal pain,
which can lead to misdiagnosis.
What are the
most common
symptoms of
chronic mesenteric
ischemia?
Chronic mesenteric ischemia is associated
with chronic, intermittent postprandial
pain and involuntary weight loss. These
symptoms should especially heighten your
concern for diagnosis of this disease in the
elderly or in patients with cardiovascular
disease.
Chapter 22
Mesenteric Ischemia
AkhilKhetarpal
A. Khetarpal (*)
Department of Vascular and Interventional Radiology, Virginia
Interventional and Vascular Associates (VIVA),
Fredericksburg, VA, USA
(continued)
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178
What are the most
common symptoms
of acute mesenteric
ischemia?
Acute mesenteric ischemia is associated
with severe abdominal pain, typically
epigastric pain, out of proportion to
physical exam findings. Unfortunately,
these symptoms are nonspecific and may
be associated with many other common
causes of abdominal pain such as bowel
obstruction or infection. Acute mesenteric
ischemia should always be considered in
the differential for patients who present
with abdominal pain and also have risk
factors for acute mesenteric ischemia.
What laboratory
tests should be
obtained?
A basic laboratory workup including a
CBC, BMP, and coagulation profile should
be obtained when evaluating patients with
mesenteric ischemia. In the case of acute
mesenteric ischemia, lactic acid should also
be monitored to help determine if there is
evidence for bowel ischemia and infarction.
What imaging tests
should be obtained?
A CTA of the abdomen and pelvis
should be obtained to evaluate the
mesenteric vessels for evidence of
thrombosis, embolism, or spasm. The
benefit of CTA is that it also allows you to
evaluate for evidence of bowel ischemia
(bowel distension, mucosal edema,
hyperenhancement, pneumatosis, free
air), as well as plan your intervention. In
patients with poor renal function or severe
iodinated contrast reactions, additional
imaging considerations include MRA and
Duplex US.
A. Khetarpal
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179
How may arterial
intestinal ischemia
be differentiated
from venous
intestinal ischemia
on CT?
Underlying atherosclerotic disease may
be a clue toward arterial source of disease.
Filling defects should be investigated in
the arteries and veins, which may suggest
thrombus and embolus as etiologies. Lack
of mucosal enhancement is more common
with arterial ischemia, while “misty”
stranding of infiltrated mesenteric fat is
seen more with venous ischemia. Increased
attenuation of the bowel wall related to
submucosal hemorrhage or hyperemia and
pneumatosis intestinalis are also features
of venous ischemia.
High Yield History
What are the
important
elements of the
patient history
in chronic
mesenteric
ischemia?
Chronic mesenteric ischemia is a slowly
progressing etiology for abdominal pain.
Important questions to ask when performing a
history in these patients are to determine the
chronicity of pain, any associated weight loss,
if the pain is specifically postprandial, and if
the patient has any history of cardiovascular
disease.
What are the
important
elements of the
patient history in
acute mesenteric
ischemia?
Acute mesenteric ischemia has a rapid onset
of symptoms. Important questions to ask when
performing a history in these patients are to
determine the acuity of pain, the quality of
the pain (traditional description is pain out
of proportion to exam findings), location of
pain, and any high-risk predisposing factors
for embolic events (e.g., atrial fibrillation) or
hypercoagulable state (e.g., factor V Leiden,
malignancy, protein C and S deficiency, etc.).
(continued)
22
Mesenteric Ischemia
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180
What is NOMI? NOMI stands for “nonocclusive mesenteric
ischemia.” This is a form of acute mesenteric
ischemia associated with low cardiac
output/hypovolemic states. There is no
focal obstructive lesion causing decreased
mesenteric blood flow but rather an overall
diminished volume of the mesenteric vessels.
What are the
important
elements of the
patient history
in instances of
NOMI?
In cases of suspected NOMI, the history
should aim at determining potential causes
of low cardiac output states. These include a
history of heart failure, myocardial infarction,
recent hypovolemic state, renal failure, and
liver failure.
What is an
additional non-
arterial cause
of mesenteric
ischemia to be
aware of?
Mesenteric venous thrombosis resulting in
bowel ischemia is another form of acute
mesenteric ischemia to know. Bowel ischemia
in this case is caused by venous outflow
obstruction due to venous thrombosis instead
of an arterial etiology.
What are the
important
elements of the
patient history
in mesenteric
venous
thrombosis?
In cases of suspected mesenteric venous
thrombosis, the history should aim
at determining potential causes of a
hypercoagulable state. These causes can
include genetic predisposition, medication-
induced hypercoagulability, liver failure, and
low cardiac output states resulting in venous
stasis.
A. Khetarpal
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181
Indications/Contraindications
What is the most
important factor that
would necessitate an
additional surgical
approach to treatment
of a patient with acute
mesenteric ischemia?
The presence of necrotic bowel
contraindicates an endovascular-
only approach to treatment of acute
mesenteric ischemia. In these cases, the
nonviable portion of the bowel needs
to be resected. In these cases, open
surgical treatment of the affected vessel
can be performed, or a hybrid open and
endovascular approach to treatment can
be used.
What are the surgical
options for treatment
of acute mesenteric
ischemia?
The surgical options for treatment
of acute mesenteric ischemia include
exploratory laparotomy/laparoscopy to
evaluate for bowel ischemia followed by
mesenteric bypass, endarterectomy, or
embolectomy.
What are the
endovascular options
for treatment of acute
mesenteric ischemia?
The endovascular options for treatment
of acute mesenteric ischemia include
aspiration embolectomy, angioplasty,
stenting, and catheter-directed lysis.
The choice of treatment is dependent
on the underlying etiology behind
the development of acute mesenteric
ischemia.
What are treatment
options for NOMI?
The treatment of NOMI is aimed at
improving the generalized diminished
blood flow to the mesenteric vessels.
The treatment should employ a strategy
of general improvement in volume
status and treating the underlying cause
of the low cardiac output/hypovolemic
state. Catheter-directed vasodilator
injection into the mesenteric vascular
bed (papaverine) is a described
treatment strategy for NOMI.
(continued)
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182
What are treatment
options for mesenteric
venous thrombosis?
Treatment strategies in cases of
mesenteric venous thrombosis are
aimed at both removing the clot burden
in the mesenteric venous system and
preventing the propagation of further
clot. Treatment options include systemic
anticoagulation, catheter-directed lysis,
and catheter-directed thrombectomy.
As in other cases of acute mesenteric
ischemia, nonviable bowel should be
surgically resected.
What is a
contraindication to
use of thrombolytic
therapy?
It is important to know the
contraindications to thrombolytic
therapy as they are applicable to many
disease processes treated in IR.The
major contraindications include patients
with high risk of bleeding, recent
trauma, recent large surgery, recent
gastrointestinal bleed, recent stroke, and
history of malignancy with associated
risk of bleeding from a large malignant
mass.
What are the surgical
options for treatment
of chronic mesenteric
ischemia?
The open surgical options for treatment
of chronic mesenteric ischemia include
mesenteric bypass and mesenteric
vessel endarterectomy.
What are the
endovascular options
for treatment of
chronic mesenteric
ischemia?
The endovascular treatment options
for treatment of chronic mesenteric
ischemia include mesenteric angioplasty
and stenting.
A. Khetarpal
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183
Relevant Anatomy
What general bowel
territory does the
celiac axis supply?
The celiac axis mainly supplies the
stomach and small bowel including the
duodenum and jejunum (more proximal
portions).
What general bowel
territory does the
superior mesenteric
artery (SMA) supply?
The SMA mainly supplies the jejunum
(more mid and distal portions), ileum,
right colon, and transverse colon.
What general bowel
territory does the
inferior mesenteric
artery (IMA) supply?
The IMA mainly supplies the left colon,
sigmoid colon, and superior portion of
the rectum.
What is the source
of major collateral
pathways between the
celiac axis and SMA?
The gastroduodenal artery provides the
major collateral pathways between the
celiac axis and SMA.
What is the name of
the major arterial
collateral pathway
between the SMA
and IMA? What is
the name of a direct
arterial connection
between the SMA
and IMA?
The marginal artery of Drummond which
is found along the mesenteric border
of the colon and is formed by terminal
branches of the middle colic artery (from
the SMA) and terminal branches of the
left colic artery (from the IMA). The
arc of Riolan is a branch that provides
a more direct connection between SMA
and IMA, usually connecting a more
proximal middle colic branch to a more
proximal left colic branch.
What is the most
common artery
involved in cases of
acute mesenteric
ischemia?
SMA
(continued)
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Mesenteric Ischemia
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What is the most
common vein
involved in cases of
mesenteric venous
thrombosis?
SMV
In cases of mesenteric
ischemia caused
by vessel stenosis/
thrombosis, what
portion of the vessel
is most commonly
involved?
When vessel stenosis/thrombosis is
the underlying etiology for mesenteric
ischemia, the process typically occurs
near the origin/proximal portion of the
vessel.
In cases of mesenteric
ischemia caused by
embolic event, what
portion of the vessel
is most commonly
involved?
In embolic etiologies for mesenteric
ischemia, the SMA is most commonly
involved, and the embolus typically
lodges distal to the origin, beyond the
first branch points.
Relevant Materials
What size base catheter
is generally suitable for
selecting the mesenteric
vessels?
A 4 or 5 French curved or reverse
curved base catheter is generally used
to select the mesenteric vessels. In
patients with a very downward-sloping
SMA origin, upper extremity access
may facilitate selecting the vessel.
What are the general
categories of devices
that may be used in the
treatment of chronic
mesenteric stenosis/
thrombosis?
The general categories of devices
used in treating chronic mesenteric
ischemia are angioplasty balloons and
endovascular stents.
A. Khetarpal
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185
What are the general
categories of devices
that may be used in
the treatment of acute
mesenteric embolism/
thrombosis?
Devices used in treating acute
mesenteric ischemia are angioplasty
balloons, endovascular stents, lysis
catheters, and suction/aspiration
embolectomy devices.
General Step by Step
What is the most
common access
site for mesenteric
interventions?
Femoral artery access is the most
commonly used access for mesenteric
interventions.
What are the
situations in which
upper extremity
access is beneficial
in performing
mesenteric
interventions?
Brachial artery or radial artery access is
typically used in cases of severely diseased
iliofemoral vessels or in cases where the
origin of the SMA is difficult to cannulate
from the femoral approach, such as in cases
of a very downward-sloping SMA origin.
Left, as opposed to right, brachial or radial
artery access allows the operator to cross
over less of the head and neck vasculature
along the aortic arch.
When is a situation
where direct access
into the SMA is
obtained?
In certain cases, direct puncture into the
SMA may be performed, for example, in a
case where the patient’s abdomen is being
surgically explored to resect necrotic bowel
and endovascular revascularization is being
planned at the same time.
What additional
support should
be placed if
endovascular
intervention is
planned on the
mesenteric vessels?
If an intervention is planned, such as stent
deployment, a long sheath can be used to
add additional support to the catheter/
wire system to stabilize the system prior to
intervention, for example, a 6 or 7 French
curved sheath.
(continued)
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186
What are access
options in cases of
mesenteric venous
thrombosis?
The most commonly involved vessel in
cases of mesenteric venous thrombosis is
the SMV.The SMV drains into the portal
venous system which affects the type of
available access options. Percutaneous
transhepatic, percutaneous transplenic, or
TIPS access into the portal vein and SMV
can be obtained.
Complications
What type of
monitoring do patients
with acute mesenteric
ischemia need after
intervention with
thrombolysis?
Patients with acute mesenteric ischemia
should be monitored in the ICU setting
if they are undergoing lytic therapy.
Why are patients
with acute mesenteric
ischemia at higher
risk of bacterial
translocation and/or
sepsis?
The decreased blood supply to the
bowel results in degradation of the
intestinal mucosa resulting in easier
translocation of gastrointestinal flora
into the bloodstream, thus making close
monitoring for signs and symptoms of
sepsis critical.
What is the
major associated
complication with the
use of thrombolysis?
Bleeding events are the major
associated complication with the use
of thrombolysis. Patients should be
monitored closely in the ICU setting for
signs of intracranial and intra-abdominal
bleeding. Additional signs of concerning
bleeding are access site hematoma, large
volume of bleeding at the access site,
and drop in hemoglobin. Monitoring
of fibrinogen levels is also performed
at some centers. If patients are also
receiving systemic heparin, PTT values
should be checked as well as platelet
values to evaluate for heparin-induced
thrombocytopenia.
A. Khetarpal
https://t.me/med1917
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