Chapter 132 - Chronic mesenteric ischemia Flashcards
First success mesenteric endarterectomy
1958
Shaw & Maynard
Balloon angioplasty first used for mesenteric stenosis
1980
Uflacker
Furrer
Gruntzig
Common collateral pathways of mesentery
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
Causes of chronic mesenteric ischemia
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)
Location of atherosclerotic lesions
origin to 2-3cm
Prevalence of mesenteric stenosis/occlusion of elderly
18%
Diagnostic for chronic mesenteric ischemia
1) clinical history
2) duplex
3) CTA
4) MRI
5) conventional aortography
6) 24 hr/exercise tonometry
Role of intestinal absorptive and excretory function in diagnosing chronic mesenteric ischemia
not useful
Epidemiology of chronic mesenteric ischemia
1) female: male 3:1
2) median age 65 (40-90)
3) abdominal pain
4) weight loss
5) food fear
Chronic mesenteric ischemia patients also have these other atherosclerotic presentations
1) Coronary 50-70%
2) cerebrovascular 20-45%
3) peripheral 20-35%
Bowersox criteria (Dartmouth group) on mesenteric duplex
> 50% stenosis if
PDV 45 cm/s or higher for SMA
PDV 55 cm/s or higher for CA
90% accuracy, sen, spe, ppv
Visible light spectroscopy what is it
Noninvasive measurement of mucosal capillary hemoglobin oxygen saturation during endoscopy
white light from fiber-optic probe used
Ideal lesion for endovascular stenting in SMA
1) short
2) focal stenosis/occlusion
3) minimal/moderate calcification thrombus
What type of contrast will minimize abdominal discomfort
Low-osmolar contrast
Visipaque
Optimal projection to see CA and SMA
lateral
Optimal projection to see IMA
15 degrees RAO
Benefit of stenting both SMA and CA
no proven benefit
SMA stent placement in relation to aorta
1-2 mm into aorta with flare to prevent missing ostia lesion and for ease of re-catherization
Complication following mesenteric stenting
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%
SMA exposure just below the pancreas
1) transverse mesocolon retracted cephalad
2) root of mesentery incised longitudinally
3) lymphatic and venous branches ligated
4) SMA dissected free and branches controlled
Transaortic mesenteric endarterectomy steps
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
Open mesenteric revascularization complication rate
20-40%
1) pulmonary 15%
2) GI 14%
3) cardiac 10%
4) renal 4%
Endo vs open repair for mesenteric ischemia
mortality, morbidity, LOS
Mortality 6% open vs 5% endo
Morbidity 33% vs 11%
LOS 14 vs 3 days
Endo vs open repair for mesenteric ischemia
patency
Primary patency 86% open vs 51% endo
secondary patency 87% vs 83%
Reintervention 9% vs 20%
Restenosis 15% vs 37%
Covered stent patency in mesenteric ischemia
92% primary
100% secondary
rivals that of open
better than bare
Risk of restenosis with endo treatment for mesenteric ischemia
1) bare metal stent use
2) smoking
3) age
4) female
5 year patient survival following chronic mesenteric ischemia treatment
1) low risk 71%
2) intermediate risk 49%
3) high risk 38%
Predictors of all cause mortality after mesenteric ischemia treatment
1) age > 80
2) CKD >4
3) home oxygen
4) DM
Factors associated with mesenteric related death following chronic mesenteric ischemia treatment
1) CKD > 4
2) DM
