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187
What contrast-related
complications should
the interventionalist
be aware of during
endovascular
treatment of
mesenteric ischemia?
In patients with diminished renal
function, there should be monitoring for
acute kidney injury. The benefits versus
the risks of performing an endovascular
intervention should be weighed in
patients with diminished renal function.
As with all interventions requiring
iodinated contrast, any contrast allergy
and the severity of the allergy should be
clearly understood with premedication
administered as clinically warranted.
What are rare
complications
associated with
angioplasty and/
or stenting of the
mesenteric vessels that
the operator should be
conscious of?
Complications associated with
endovascular treatment of the
mesenteric vessels to be aware of include
vessel perforation, dissection, and stent
malposition/migration.
What is reperfusion
injury?
Reperfusion injury is a paradoxical
increase in tissue damage caused by
oxidative stress from rapid return of
blood supply to tissues after flow is
restored in an occluded mesenteric
vessel. The mechanism of this injury is
multifactorial; however, some proposed
causes include tissue damage resulting
from oxygen free radicals and cytokine
release.
Landmark Research
Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC,
Pomposelli FB. Mesenteric revascularization: management
and outcomes in the United States, 1988–2006. J Vasc Surg.
2009 Aug;50(2):341–348.
22 Mesenteric Ischemia
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188
• Retrospective review of nationwide database looking at
patients who underwent open surgical (16,071 patients) or
endovascular treatment (6342 patients) treatment of acute
and chronic mesenteric ischemia from 1988 to 2006.
• Lower mortality rate for endovascular treatment of acute
and chronic mesenteric ischemia when compared to open
surgical treatment.
• Showed that endovascular treatments were appropriate as
first-line therapy for appropriately selected patients.
• Inherent selection bias in this retrospective study since
patients who necessitated open surgical treatment often
were sicker already with more severe states of disease (i.e.,
needing bowel resection).
Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC,
Chung TK, Cambria RP. Surgical revascularization versus
endovascular therapy for chronic mesenteric ischemia: a
comparative experience. J Vasc Surg. 2007
Jun;45(6):1162–71.
• Retrospective analysis of open surgical treatment (49
patients) versus endovascular treatment (31 patients) for
chronic mesenteric ischemia at a single center
(Massachusetts General Hospital) from 1991 to 2005
• Similar incidence of symptomatic recurrence requiring
reintervention in surgical and endovascular groups with a
decreased rate of primary patency and primary assisted
patency seen in the endovascular group
• Similar incidence of inhospital morbidity and mortality in
both groups
• Showed that open surgical and endovascular treatment
options should be selectively applied in cases of chronic
mesenteric ischemia based on individual patient anatomy
and comorbidities
Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ,
Burger CD.Acute mesenteric ischemia: a clinical review.Arch
Intern Med. 2004 May 24;164(10):1054–62. Review.
A. Khetarpal
https://t.me/med1917
189
• In-depth review of the evaluation and treatment of acute
mesenteric ischemia including discussion on the diagnostic
and treatment challenges involved with this disease
process
• Outlines the pathophysiology and common causes of acute
mesenteric ischemia
Common Questions
What is the mortality
associated with acute
mesenteric ischemia?
The mortality of acute mesenteric
ischemia is high and shown to range from
40 to 90%.
What vessel is most
commonly involved
in cases of acute
mesenteric ischemia
from embolic sources
and why?
The SMA is most commonly involved due
to its oblique angle of takeoff from the
abdominal aorta.
What are common
risk factors for
embolism leading
to acute mesenteric
ischemia?
Common risk factors for embolic
etiologies of acute mesenteric ischemia
include cardiac arrhythmias (e.g., atrial
fibrillation), cardiac valve disease,
history of myocardial infarction, and
an aneurysmal disease of the thoracic/
abdominal aorta with intraluminal
thrombus.
What is the common
mechanism of
thrombotic etiologies
for acute mesenteric
ischemia?
In cases of acute mesenteric ischemia due
to thrombotic etiologies, there is usually
superimposed acute thrombosis of a
chronically stenosed origin of the SMA
and/or celiac axis.
What is the
common mechanism
of thrombotic
etiologies for chronic
mesenteric ischemia?
Cardiovascular disease risk factors such
as hypertension, hyperlipidemia, and
diabetes.
(continued)
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190
What treatment
should be instituted
after interventions
for mesenteric
ischemia?
Treatment of underlying cardiovascular
risk factors should be initiated
including management of hypertension,
hyperlipidemia, and diabetes and smoking
cessation. In cases of acute mesenteric
ischemia, therapeutic anticoagulation
and broad-spectrum antibiotic coverage
should also be administered.
If the patient has a
stent placed, what
other medications
should be
considered?
If an arterial stent is used for the
treatment of mesenteric ischemia,
antiplatelet medications including aspirin
and/or Plavix should be considered based
on patient risk factors.
What kind of
surveillance should
be performed
on patients who
have undergone
endovascular
interventions for
mesenteric ischemia?
Patients should undergo routine clinical
follow-up to evaluate for recurrence of
symptoms as well as compliance with
prescribed medications and lifestyle
modifications (e.g., smoking cessation).
If patients have undergone endovascular
stent placement, it is reasonable to
perform routine imaging surveillance
with duplex ultrasound and/or CTA to
evaluate for stent patency and stenosis.
Further Reading
Arthurs ZM, Titus J, Bannazadeh M, etal. A comparison of endovas-
cular revascularization with traditional therapy for the treatment
of acute mesenteric ischemia. J Vasc Surg. 2011;53:698.
Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung TK,
Cambria RP. Surgical revascularization versus endovascular
therapy for chronic mesenteric ischemia: a comparative experi-
ence. J Vasc Surg. 2007;45(6):1162–71.
Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Long-term
results after surgery for acute mesenteric ischemia. Surgery.
1997;121:239.
A. Khetarpal
https://t.me/med1917
191
Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger
CD.Acute mesenteric ischemia: a clinical review. Arch Intern
Med. 2004;164(10):1054–62. Review
Plumereau F, Mucci S, Le Naoures P, et al. Acute mesenteric isch-
emia of arterial origin: importance of early revascularization. J
Visc Surg. 2015;152:17.
Rasmussen T, Darrin Clouse W, Tonnessen B.Handbook of patient
care in vascular diseases. 5th ed. Philadelphia: Lippincott
Williams & Wilkins; 2008.
Ryer EJ, Kalra M, Oderich GS, et al. Revascularization for acute
mesenteric ischemia. J Vasc Surg. 2012;55:1682.
Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli
FB.Mesenteric revascularization: management and outcomes in
the United States, 1988-2006. J Vasc Surg. 2009;50(2):341–8.
Sidawy A, Perler B.Rutherford’s vascular surgery and endovascular
therapy. 9th ed. Elsevier; 2018.
Silen W, Cope Z.Cope's early diagnosis of the acute abdomen. 22nd
ed. Oxford: Oxford University Press; 2010.
van Petersen AS, Kolkman JJ, Meerwaldt R, et al. Mesenteric ste-
nosis, collaterals, and compensatory blood flow. J Vasc Surg.
2014;60:111.
22
Mesenteric Ischemia
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193© Springer Nature Switzerland AG 2022
R. Chand et al. (eds.), Essential Interventional Radiology
Review, https://doi.org/10.1007/978-3-030-84172-0_23
Evaluating Patient
According to the
ISSVA, what are
the five major
simple vascular
malformations?
Capillary malformation, arteriovenous
malformation, arteriovenous fistula, venous
malformation, and lymphatic malformation.
Mixed variants also exist, and combined
vascular malformations are defined as two
or more vascular malformations found
within the same lesion.
What do
arteriovenous
malformations and
arteriovenous fistula
have in common?
Arteriovenous malformation and
arteriovenous fistula are classified as high-
flow lesions.
How do soft tissue
AVMs present on
physical exam?
The mass may be felt with a palpable
thrill. The skin may be red and warm
to touch. There may be a bruit on
auscultation.
Chapter 23
Arteriovenous
Malformation (AVM)
CharlesHua
C. Hua (*)
Mount Sinai Interventional Radiology, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
e-mail: huacharl@hawaii.edu
(continued)
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194
How do you
differentiate
AVMs from
low-flow venous
malformations on
physical exam?
Low-flow venous malformations do
not have a palpable thrill. Simple low-
flow malformations include venous
malformation, capillary malformation, and
lymphatic malformation. These low-flow
lesions may empty on compression and
collapse if raised above the level of the
heart.
True or false? Brain
AVMs are a frequent
cause of headaches.
False. Approximately 0.2% of patients
with headache and normal neurological
exam were found to have an AVM.
Name two types
of benign vascular
tumors as classified
by ISSVA and their
associated properties.
The two types of benign vascular tumors
are infantile hemangiomas, also known as
hemangiomas of infancy, and congenital
hemangiomas. Infantile hemangiomas
appear after birth, usually within the
first 2months of life, and the majority
require no specific treatment as they
spontaneously involute over a period
of years. Propranolol may be used for
large hemangiomas that may cause
disfigurement and growth disturbance,
intrude upon the eye or impact the lips,
and prevent attachment during feeding.
Congenital hemangiomas are typically
fully formed at birth and may rapidly
involute (rapidly involuting congenital
hemangioma) or not involute (non-
involuting congenital hemangioma).
Embolization of large hemangiomas
may be performed prior to planned
surgical resection to minimize the risk of
intraoperative bleeding.
Where are AVMs
typically found?
Liver (41–85%), pulmonary (23–61%),
and central nervous system (10%)
C. Hua
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195
What are common
findings of AVM
on MRI T1 and T2
sequences?
Flow voids are demonstrated on both
T1 and T2 sequences. There may be
associated muscle atrophy with a lack
of mass effect. Of note, phleboliths and
calcifications seen in slow-flow venous
malformations may also show signal
voids, which is demonstrated on all pulse
sequences. Draining veins in AVMs
may show early enhancement on MR
angiography due to shunting.
High Yield History
What are
the common
symptoms
associated with
arteriovenous
malformation?
Hemorrhage, pain, ulceration, high-output
cardiac failure, pulsatile mass, ischemia, and
cosmetic deformation
What syndrome
predisposes
patients to
pulmonary AVMs
(PAVMs)?
Osler-Weber-Rendu syndrome, also known
as hereditary hemorrhagic telangiectasia
(HHT)
What additional
clinical
manifestations can
be seen in patients
with PAVM?
Hemoptysis, headaches, paradoxical
embolization, and pulmonary hypertension
What percentage
of patients with
PAVM have
HHT?
HHT is an autosomal dominant disorder
found in 95% of patients with PAVM.
What is the
prevalence of
HHT?
The estimated occurrence of HHT
is 1in 10,000. However, this is likely
underestimated because many cases are
asymptomatic.
(continued)
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196
List two
populations that
are at greater
risk of PAVM
complications.
Pregnancy may lead to PAVM growth from
the effects of estrogen and progesterone,
which increase venous distensibility, resulting
in increased vascular volume and cardiac
output.
The second population at risk of PAVM
complications are patients with severe
pulmonary hypertension. The elevated
vascular resistance can result in increased
blood flow through the PAVM.Embolization
of the PAVM in patients with severe
pulmonary hypertension may alter the
hemodynamics (increased preload)
and worsen the underlying pulmonary
hypertension.
What are the
clinical diagnostic
criteria for HHT?
A consensus of the clinical diagnostic
criterion for HHT, known as the Curaçao
criteria, is based upon the four findings
outlined in Table
23.1. The diagnosis of HHT
is “definite” if three criteria are present;
“possible or suspected” if two criteria
are present; and “unlikely” if fewer than
two criteria are present. HHT can also be
diagnosed using genetic testing.
T .
Curaçao diagnostic criteria for hereditary hemorrhagic
telangiectasia
Criteria Description
Epistaxis Spontaneous and recurrent
Telangiectasia Multiple, at characteristic sites, including the lips,
mouth, fingers, and nose
Visceral
lesions
Gastrointestinal telangiectasia; arteriovenous
malformations in the lung, liver, and central
nervous system
Family history A first-degree relative with HHT
C. Hua
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197
Why do patients
develop distal
ischemia in
extremity
AVMs?
Arterial steal phenomenon occurs when a
high volume of blood is shunted through the
AVM and away from the distal extremity. The
peripheral limb beyond the AVM can present
with pain, appear pale, or even ulcerate.
What type of
vascular anomaly
are phleboliths
associated with?
Low-flow venous malformation
What is Klippel-
Trenaunay
syndrome
(KTS)?
A congenital, but not heritable, venous
syndrome defined as having at least two of the
following: cutaneous capillary malformation,
atypical varicose veins, venous malformations,
and unilateral limb hypertrophy.
What is a patent
vena marginalis
lateralis?
Also known as the Klippel-Trenaunay vein
or the lateral marginal vein of Servelle, it is a
persistent embryonic vein ascending along the
lateral leg, which lacks normal venous valves
and is associated with limb length discrepancy,
deep venous system hypoplasia of the affected
extremity, chronic venous insufficiency, and
venous thromboembolic disease. It is commonly
associated with KTS and its presence should
warrant further investigation. Most practitioners
recommend surgical excision. The persistent
sciatic vein is another persistent embryonic
remnant associated with KTS and courses along
the midline of the posterior thigh.
How does
Parkes-Weber
syndrome (PWS)
compare to
KTS?
PWS is more rare as compared to KTS
and involves high-flow arteriovenous
malformations. KTS is associated with low-
flow malformations. Both syndromes manifest
as unilateral soft tissue and bone hypertrophy.
What type
of vascular
malformation
is Maffucci
syndrome
associated with?
Venous malformation
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