Chapter 131 - Mesenteric arterial disease introduction Flashcards
First case of acute mesenteric ischemia
1895 Elliott - intestinal resection
Chronic mesenteric ischemia first described
Intestinal angina
1918 Goodman
1936 Dunphy characterized it
Mesenteric venous thrombosis first described
Warren & Eberhard
1935
First SMA embolectomy
Klass 1950
First SMA thromboendarterectomy
1958 Shaw & Maynard
Massachusetts General
First SMA retrograde bypass
1962 Morris
First SMA antegrade bypass
1966 Stoney & Wylie
First endo dilation of SMA
1980 Furrer & Novelline
First stent celiac artery with Palmaz
Finch 1992
Embryologic origin of visceral vessels
Segmental branches from primitive ventral aorta
1) 10th - Celiac
2) 13th - SMA
3) 21st - IMA
Anatomic location of the celiac artery
1) L1
2) bordered by median arcuate ligament
3) aortic hiatus superioly
4) superior border of pancreas inferiorly
3 branches of the celiac artery
1) left gastric
2) splenic
3) common hepartic
Most frequent variation of the celiac trifurcation
Common hepatic comes from SMA or from aorta
SMA anatomic location
1) origin crossed by neck of pancreas and splenic vein
2) lies superior to uncinate process of pancreas and third portion of duodenum
3) SMV runs parallel along right border
SMA branches
1) inferior pancreaticoduodenal artery
2) middle colic artery
3) right colic
4) ileocolic
5) 3rd order mesenteric branches
IMA anatomic location
3-4 cm cephalad to aortic bifurcation to left of midline
L3
Major collateral arcade between SMA and IMA
Marginal artery of Drummond
Meadering mesenteric artery
of Moskowitz
Arc of Riolan
Variation of splanchnic blood flow in different states
1) shock/hypovolemia - 10%
2) fasting 20-25%
3) post-prandial large carb meal 35%
Distribution of mesenteric blood flow to layer of intestinal wall
70-80% to mucosal/submucosal layers
SMA and celiac flow pattern key points
1) SMA low resistance in post-prandial state
2) SMA flow reversal in fasting state and high resistance
3) Celiac always low resistance due to hepatic bed
Extrinsic Factors that control mesenteric arteriolar tone
1) sympathetic efferents in prevertebral celiac and mesenteric ganglia
2) RAAS angiotensin II action in hypovolemic states
3) low volume state hyperosmolarity –> vasopressin
4) shear stress –> NO synthase –> NO release and vasodilation
Intrinsic regulation of mesenteric arteriolar tone
1) metabolic pathway: mucosal ischemia –> metabolic byproduct –> vasodilation
2) myogenic pathway: decrease perfusion pressure –> arteriolar baroreceptors –> decrease wall tension
Prevalence of mesenteric stenosis in elderly
17.5%
Epidemiology of mesenteric ischemia gender ratio
female:male 3:1
Non-occlusive mesenteric ischemia diagnostic criteria
1) ileus/abdominal pain
2) catecholamine requirement
3) episode of hypotension
4) gradual rise in serum transaminase level
if 3/4 met then high dose PGE1 treatment
Moneta criteria for mesenteric ischemia
SMA PSV 275 cm/s
sen 92% with 96% accuracy
Celiac PSV 200 cm/s
sen 87% with 82% accuracy
for 70% stenosis
AbuRahma criteria for mesenteric ischemia
SMA PSV 295 = 50% stenosis
400 = 70% stenosis
sen 87%; spe 89%
Celiac PSV 240 = 50% stenosis
320 = 70% stenosis
Post-stenting SMA stenosis DUS criteria
> 275 cm/s PSV as significant in stent restenosis
Soult et al criteria for in-stent SMA and celiac stenosis > 70%
SMA 445 cm/s
Celiac 289 cm/s
CT to detect acute mesenteric ischemia sen and spe
sen 93%
spe 96%
Gastric tonometry what is it
Measurement of pCO2 in gastric, jejunal or colonic mucosa via NG tube to diagnose mesenteric ischemia
Medical treatment of mesenteric ischemia
1) statin
2) anticoagulation
3) fluid
4) TPN
5) antibiotics
Techniques to assess bowel viability
1) pulse oximetry
2) oxygen tension measurement
3) spectrophotometry
4) doppler ultrasound
5) fluorescein dye and Wood’s lamp
6) laser doppler flometry
7) infrared imaging
Clinical assessment of bowel viability
1) serosal color
2) bowel peristalsis
3) vessel palpation
Diagnosis of NOMI
Selective mesenteric angiography with papaverine or PGE1 vasodilator
Recurrence of mesenteric venous thrombosis without anticoagulation
36%
