Chapter 132 - Chronic mesenteric ischemia

Question 1

First success mesenteric endarterectomy

Answer 1

1958

Shaw & Maynard

Question 2

Balloon angioplasty first used for mesenteric stenosis

Answer 2

1980
Uflacker
Furrer
Gruntzig

Question 3

Common collateral pathways of mesentery

Answer 3

1) GDA - PDA
2) Arc of Buhler (celiac/hepatic to SMA)
3) Arc of Riolan (SMA to IMA)
4) Arcade of Drummond
5) superior rectal to middle rectal

Question 4

Causes of chronic mesenteric ischemia

Answer 4

1) atherosclerosis 90%
2) vasculitis (GCA, Takayasu, polyarteritis nodosa)
3) systemic lupus
4) Buerger disease
5) spontaneous dissection
6) FMD
7) Neurofibromatosis
8) radiation arteritis
9) coarctation
10) mesenteric venous stenosis/occlusion
11) drugs (cocaine, ergot)

Question 5

Location of atherosclerotic lesions

Answer 5

origin to 2-3cm

Question 6

Prevalence of mesenteric stenosis/occlusion of elderly

Answer 6

18%

Question 7

Diagnostic for chronic mesenteric ischemia

Answer 7

1) clinical history
2) duplex
3) CTA
4) MRI
5) conventional aortography
6) 24 hr/exercise tonometry

Question 8

Role of intestinal absorptive and excretory function in diagnosing chronic mesenteric ischemia

Answer 8

not useful

Question 9

Epidemiology of chronic mesenteric ischemia

Answer 9

1) female: male 3:1
2) median age 65 (40-90)
3) abdominal pain
4) weight loss
5) food fear

Question 10

Chronic mesenteric ischemia patients also have these other atherosclerotic presentations

Answer 10

1) Coronary 50-70%
2) cerebrovascular 20-45%
3) peripheral 20-35%

Question 11

Bowersox criteria (Dartmouth group) on mesenteric duplex

Answer 11

> 50% stenosis if
PDV 45 cm/s or higher for SMA

PDV 55 cm/s or higher for CA

90% accuracy, sen, spe, ppv

Question 12

Visible light spectroscopy what is it

Answer 12

Noninvasive measurement of mucosal capillary hemoglobin oxygen saturation during endoscopy

white light from fiber-optic probe used

Question 13

Ideal lesion for endovascular stenting in SMA

Answer 13

1) short
2) focal stenosis/occlusion
3) minimal/moderate calcification thrombus

Question 14

What type of contrast will minimize abdominal discomfort

Answer 14

Low-osmolar contrast

Visipaque

Question 15

Optimal projection to see CA and SMA

Answer 15

lateral

Question 16

Optimal projection to see IMA

Answer 16

15 degrees RAO

Question 17

Benefit of stenting both SMA and CA

Answer 17

no proven benefit

Question 18

SMA stent placement in relation to aorta

Answer 18

1-2 mm into aorta with flare to prevent missing ostia lesion and for ease of re-catherization

Question 19

Complication following mesenteric stenting

Answer 19

1) MI 1-7%
2) GI bleed 1-5%
3) bowel ischemia 1-7%
4) distal emboli 8%
5) thrombosis
6) dissection
7) access problem 3-16% most common
8) renal insufficiency 2-8%
9) respiratory complication 1-7%

Question 20

SMA exposure just below the pancreas

Answer 20

1) transverse mesocolon retracted cephalad
2) root of mesentery incised longitudinally
3) lymphatic and venous branches ligated
4) SMA dissected free and branches controlled

Question 21

Transaortic mesenteric endarterectomy steps

Answer 21

1) midline abdominal laparotomy
2) medial visceral rotation with left kidney left down
3) dissect anterior to renal vein
4) diaphragmatic crura transected longitudinally
5) dissect SMA free
6) longitudinal trapdoor aortotomy
7) endarterectomy
8) primary closure
9) +/- separate SMA arteriotomy and patch
10) intraoperative completion ultrasound

Question 22

Open mesenteric revascularization complication rate

Answer 22

20-40%

1) pulmonary 15%
2) GI 14%
3) cardiac 10%
4) renal 4%

Question 23

Endo vs open repair for mesenteric ischemia

mortality, morbidity, LOS

Answer 23

Mortality 6% open vs 5% endo
Morbidity 33% vs 11%
LOS 14 vs 3 days

Question 24

Endo vs open repair for mesenteric ischemia

patency

Answer 24

Primary patency 86% open vs 51% endo
secondary patency 87% vs 83%
Reintervention 9% vs 20%
Restenosis 15% vs 37%

Question 25

Covered stent patency in mesenteric ischemia

Answer 25

92% primary
100% secondary

rivals that of open
better than bare

Question 26

Risk of restenosis with endo treatment for mesenteric ischemia

Answer 26

1) bare metal stent use
2) smoking
3) age
4) female

Question 27

5 year patient survival following chronic mesenteric ischemia treatment

Answer 27

1) low risk 71%
2) intermediate risk 49%
3) high risk 38%

Question 28

Predictors of all cause mortality after mesenteric ischemia treatment

Answer 28

1) age > 80
2) CKD >4
3) home oxygen
4) DM

Question 29

Factors associated with mesenteric related death following chronic mesenteric ischemia treatment

Answer 29

1) CKD > 4

2) DM