Mesenteric ischemia surgery: Difference between revisions

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(/* 2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Surgical Treatment of Chronic Intestinal Ischemia (DO NOT EDIT){{cit...)
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{{Mesenteric ischemia}}
{{Mesenteric ischemia}}
{{CMG}}
{{CMG}} {{AE}} {{FT}}


==Overview==
==Overview==
Surgery may be needed to treat mesenteric ischemia. Surgery for chronic mesenteric artery ischemia involves removing the blockage and reconnecting the arteries to the aorta. A bypass around the blockage is another procedure. It is usually done with a plastic tube graft. An alternative to surgery is a stent. It may be inserted to enlarge the blockage in the [[mesenteric artery]] or deliver medicine directly to the affected area. This is a new technique and it should only be done by experienced health care providers. The outcome is usually better with surgery. Surgical revascularisation remains the treatment of choice for mesenteric ischemia, but [[thrombolytic]] medical treatment and vascular interventional  radiological techniques have a growing role <ref name="pmid12816826">{{cite journal |author=Sreenarasimhaiah J |title=Diagnosis and management of intestinal ischaemic disorders |journal=BMJ |volume=326 |issue=7403 |pages=1372-6 |year=2003 |pmid=12816826 | doi=10.1136/bmj.326.7403.1372}}</ref>.
Surgery in [[mesenteric ischemia]] is performed to resect the [[Ischemic colitis|ischemic bowel]] in order to prevent the complications. However, in the case of acute [[Embolism|embolic]] type of [[mesenteric ischemia]], early [[laparotomy]] and surgical [[resection]] is the mainstay of treatment.


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Treatment of Nonocclusive Mesenteric Ischemia (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
==Surgery==
*The goals of surgical therapy are as follows:
**Re-establishment of blood supply to the [[Ischemia|ischemic]] bowel
**[[Resection]] of all non-viable areas of the bowel
**Preservation of the viable [[Intestine|bowel]]


{|class="wikitable"
*[[Intestine|Intestinal]] viability is defined as the maximum vital element influencing outcome in patients with AMI.
|-
*Non-viable bowel, if unrecognized, can cause multi-organ failure and lead to death.
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


|-
===Approach to treatment===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Treatment of the underlying shock state is the most important initial step in treatment of nonocclusive intestinal ischemia. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
The treatment modality chosen for the patient depends on the type and the location of occlusion, along with hemodyanamic stability.


|-
===Surgical versus endovascular intervention===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Laparotomy and resection of nonviable bowel is indicated in patients with nonocclusive intestinal ischemia who have persistent symptoms despite treatment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
* In 2009, endovascular intervention was preferred over surgical approach.<ref name="pmid21236616">{{cite journal| author=Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP et al.| title=A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. | journal=J Vasc Surg | year= 2011 | volume= 53 | issue= 3 | pages= 698-704; discussion 704-5 | pmid=21236616 | doi=10.1016/j.jvs.2010.09.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21236616 }}</ref><ref name="pmid23307340">{{cite journal| author=Björnsson S, Resch T, Acosta S| title=Symptomatic mesenteric atherosclerotic disease-lessons learned from the diagnostic workup. | journal=J Gastrointest Surg | year= 2013 | volume= 17 | issue= 5 | pages= 973-80 | pmid=23307340 | doi=10.1007/s11605-013-2139-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23307340  }} </ref><ref name="pmid22516890">{{cite journal| author=Sharafuddin MJ, Nicholson RM, Kresowik TF, Amin PB, Hoballah JJ, Sharp WJ| title=Endovascular recanalization of total occlusions of the mesenteric and celiac arteries. | journal=J Vasc Surg | year= 2012 | volume= 55 | issue= 6 | pages= 1674-81 | pmid=22516890 | doi=10.1016/j.jvs.2011.12.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22516890  }} </ref><ref name="pmid23885938">{{cite journal| author=Bobadilla JL| title=Mesenteric ischemia. | journal=Surg Clin North Am | year= 2013 | volume= 93 | issue= 4 | pages= 925-40, ix | pmid=23885938 | doi=10.1016/j.suc.2013.04.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23885938  }} </ref>
|}


{|class="wikitable"
===Endovascular intervention===
|-
* Hemodyanamically stable patients and those who do not have clinical or radiological signs of ischemia are preferred candidates for endovascular intervention.<ref name="pmid22503176">{{cite journal| author=Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S et al.| title=Revascularization for acute mesenteric ischemia. | journal=J Vasc Surg | year= 2012 | volume= 55 | issue= 6 | pages= 1682-9 | pmid=22503176 | doi=10.1016/j.jvs.2011.12.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22503176  }} </ref><ref name="pmid19367243">{{cite journal| author=Kougias P, Huynh TT, Lin PH| title=Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia. | journal=Int Angiol | year= 2009 | volume= 28 | issue= 2 | pages= 132-7 | pmid=19367243 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19367243  }} </ref><ref name="pmid20620006">{{cite journal| author=Block TA, Acosta S, Björck M| title=Endovascular and open surgery for acute occlusion of the superior mesenteric artery. | journal=J Vasc Surg | year= 2010 | volume= 52 | issue= 4 | pages= 959-66 | pmid=20620006 | doi=10.1016/j.jvs.2010.05.084 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620006  }} </ref><ref name="pmid19372025">{{cite journal| author=Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli FB| title=Mesenteric revascularization: management and outcomes in the United States, 1988-2006. | journal=J Vasc Surg | year= 2009 | volume= 50 | issue= 2 | pages= 341-348.e1 | pmid=19372025 | doi=10.1016/j.jvs.2009.03.004 | pmc=2716426 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19372025  }} </ref>
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
* Using endovascular intervention as the primary modality of treatment helps reduce complications, provides better outcome and shortens the length of hospital stay.<ref name="pmid18295100">{{cite journal| author=Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S et al.| title=Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. | journal=J Vasc Surg | year= 2008 | volume= 47 | issue= 3 | pages= 485-491 | pmid=18295100 | doi=10.1016/j.jvs.2007.11.046 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18295100  }} </ref><ref name="pmid25757988">{{cite journal| author=Cai W, Li X, Shu C, Qiu J, Fang K, Li M et al.| title=Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis. | journal=Ann Vasc Surg | year= 2015 | volume= 29 | issue= 5 | pages= 934-40 | pmid=25757988 | doi=10.1016/j.avsg.2015.01.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25757988  }} </ref>
* Two types of endovascular interventions have been described:<ref name="pmid8087835">{{cite journal| author=McBride KD, Gaines PA| title=Thrombolysis of a partially occluding superior mesenteric artery thromboembolus by infusion of streptokinase. | journal=Cardiovasc Intervent Radiol | year= 1994 | volume= 17 | issue= 3 | pages= 164-6 | pmid=8087835 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8087835  }} </ref><ref name="pmid12828073">{{cite journal| author=Calin GA, Calin S, Ionescu R, Croitoru M, Diculescu M, Oproiu A| title=Successful local fibrinolytic treatment and balloon angioplasty in superior mesenteric arterial embolism: a case report and literature review. | journal=Hepatogastroenterology | year= 2003 | volume= 50 | issue= 51 | pages= 732-4 | pmid=12828073 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12828073  }} </ref>
(a)Pharmacomechanical thrombolysis


|-
(b)Mesenteric angioplasty/stenting
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Transcatheter administration of vasodilator medications into the area of vasospasm is indicated in patients with nonocclusive intestinal ischemia who do not respond to systemic supportive treatment and in patients with intestinal ischemia due to cocaine or ergot poisoning. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Surgical Treatment of Acute Obstructive Intestinal Ischemia (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
'''(a)Pharmacomechanical thrombolysis''':
* It is performed in the following patients:
** Who can undergo arteriography within eight hours of the onset of abdominal pain
** No contraindications to fibrinolytic therapy
** No clinical signs of ischemia
* '''Procedure:'''


{|class="wikitable"
===Retrograde open mesenteric stenting===
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


|-
===Revascularization===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Surgical treatment of acute obstructive intestinal ischemia includes revascularization, resection of necrotic bowel, and, when appropriate, a “second look” operation 24 to 48 hours after the revascularization. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
* '''Embolectomy:'''
|}
The conventional treatment offered for mesenteric embolism is embolectomy. It clears the thrombus and helps assess the bowel viability.
* '''Mesenteric bypass:'''
For mesenteric thrombosis, open surgical intervention is done followed by intraoperative retrograde superior mesenteric artery angiplasty and stenting for the        atherosclerotic plaques.


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Endovascular Treatment of Acute Intestinal Ischemia(DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
===Lapratomy and damage control:===
Lapratomy is performed once bowel infarction has occurred. It has the following indications and uses:


{|class="wikitable"
*Acute abdominal findings on physical exam consistent with peritonitis.
|-
*Facilitates general abdominal exploration for gross pathology and other signs of visceral thrombosis.
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
*Allows to determine the viability of the bowel.
|-
*Determines the extent and severity of intestinal ischemia.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Percutaneous interventions (including transcatheter lytic therapy, balloon angioplasty, and stenting) are appropriate in selected patients with acute intestinal ischemia caused by arterial obstructions. Patients so treated may still require laparotomy. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
*Assessment of arterial pulsations in the mesenteric vasculature and bleeding from cut surfaces.
|}


==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Surgical Treatment of Chronic Intestinal Ischemia (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
Procedure:
*After preliminary [[Cardiopulmonary resuscitation|resuscitation]], midline [[laparotomy]] should be done to observe the areas of gut with choices for resection of all the [[Necrosis|necrotic]] areas. In instances of uncertainty, intraoperative [[Doppler echocardiography|Doppler]] can be beneficial.


{|class="wikitable"
===Postprocedural care and follow up:===
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


|-
===Second-look lapratomy and abdominal wall closure:===
| bgcolor="LightGreen"| <nowiki>"</nowiki>'''1.''' Surgical treatment of chronic intestinal ischemia is indicated in patients with chronic intestinal ischemia. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
It is performed in patients who undergo revascularization for mesenteric ischemia for the following reasons:
|}
* Reevaluate the bowel after 24-48 hours of initial operation
* Assessment of bowel viability after revascularization
* Resection of irreversibly ischemic bowel
* Significantly reduces the mortality after surgery


{|class="wikitable"
===Surgical procedure options:===
|-
<ref name="pmid21810082">{{cite journal| author=Luo QZ, Lin L, Gong Z, Mei B, Xu YJ, Huo Z et al.| title=Positive association of major histocompatibility complex class I chain-related gene A polymorphism with leukemia susceptibility in the people of Han nationality of Southern China. | journal=Tissue Antigens | year= 2011 | volume= 78 | issue= 3 | pages= 178-84 | pmid=21810082 | doi=10.1111/j.1399-0039.2011.01748.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21810082  }} </ref><ref name="pmid18620112">{{cite journal| author=Lee RW, Bakken AM, Palchik E, Saad WE, Davies MG| title=Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease. | journal=Ann Vasc Surg | year= 2008 | volume= 22 | issue= 4 | pages= 541-6 | pmid=18620112 | doi=10.1016/j.avsg.2007.09.019 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18620112  }} </ref><ref name="pmid18295100">{{cite journal| author=Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S et al.| title=Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. | journal=J Vasc Surg | year= 2008 | volume= 47 | issue= 3 | pages= 485-491 | pmid=18295100 | doi=10.1016/j.jvs.2007.11.046 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18295100  }} </ref>
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
* [[Balloon catheter|Balloon]] catheter [[embolectomy]] of the [[superior mesenteric artery]]
|-
* For restoration of blood flow in acute mesenteric ischemia, antegrade aorto-mesenteric bypass from supraceliac aorta is the best choice.
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Revascularization of asymptomatic intestinal arterial obstructions may be considered for patients undergoing aortic/renal artery surgery for other indications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
* Percutaneous transluminal angioplasty is also considered for revascularization in some case reports.
|}
* A new hybrid endovascular-surgical technique for managing mesenteric ischemia has been proposed.
* Laprotomy is done when transmural bowel infarction has occurred.


{|class="wikitable"
===Treatment strategy of acute embolic mesenteric ischemia:===
|-
Treatment for acute embolic mesenteric ischemia is mainly surgical and is managed according to the hemodyanamic stability or the presence/absence of [[Peritoneum|peritoneal]] signs.                                      
|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Surgical revascularization is not indicated for patients with asymptomatic intestinal arterial obstructions, except in patients undergoing aortic/renal artery surgery for other indications. (Level of Evidence: B)


|}
{{familytree/start}}
 
{{familytree | | | | | | | | | | A01 | | | | | |A01=Embolic mesenteric arterial occlusion}}
==2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)-Recommendations for Interventional Treatment of Chronic Intestinal Ischemia (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>==
{{familytree | | | | | | | | | | |!| | | | | | | | }}
 
{{familytree | | | | | | | | | | A02 | | | | | |A02= Anticoagulation with heparin
{|class="wikitable"
  Pain management}}
|-
{{familytree | | | | | | | | | | |!| | | | | | | | }}
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
{{familytree | | | | | | | | | | A02 | | | | | |A02= Peritoneal signs}}
 
{{familytree | | | | | | | | | | |!| | | | | | | | }}
|-
{{familytree | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| | | }}
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Percutaneous endovascular treatment of intestinal arterial stenosis is indicated in patients with chronic intestinal ischemia. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
{{familytree | | | | | B01 | | | | | | | | | B02 |B01= Yes|B02= No}}
|}
{{familytree | | | | | | | | | | | | | | | | |!| | | }}
{{familytree | | | | | | | | | | | | | | | | C02 | | | C01=|C02= Computed tomographic angiography }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | | | | | D01 | | | |D01= Embolus present}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | |}}
{{familytree | | | | | | | | | | | | | | | | E01 | | | | |E01= Thrombolysis}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | | | | E01 | | | | |E01= Repeat imaging
Resolution of thrombus and no persistent symptoms }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | | B01 | | | | | | | | | | B03 | | |B01= No|B02=B02|B03=Yes}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | C03 | | |C03=Observe}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | D01 | | |D01=Signs of non-viable bowel}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | |!| | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| | }}
{{familytree | | | | | | | | | | |!| | | | | | B01 | | | | | | | | | B02 | |B01=Yes|B02=No}}
{{familytree | | | | | | | | | | |!| | | | | | |!| | | | | | | | | | |!| | |}}
{{familytree | | | | | | | | | | |`|-|-|v|-|-|-|'| | | | | | | | | | C01 | | |C01=Initiate oral diet}}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | }}
{{familytree | | | | | | | | | | | | | B01 | | | | | | | | | | | | | |!| | | |B01=Exploration and open surgical embolectomy }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | |!| | | | | |}}
{{Familytree | | | | | | | | A01 | | | | | | | | A02 | | | | | | | | A03 | | | | |A01=Non-viable bowel|A02=Surgical revascularization for unsuccessful embolectomy|A03=A03}}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | }}
{{familytree | | | |!| | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | B01 | | | | | | | | B02 | | | | | | | |B01=No|B02=Yes}}
{{familytree | | | |!| | | | | | | | | |!| | | | | | | |}}
{{familytree | | | C01 | | | | | | | | C02 | | | | | | | |C01=Temporary abdominal closure|C02=Bowel resection}}
{{familytree | | | |!| | | | | | | | | | | | | | | }}
{{familytree | | | D01 | | | | | | | | | | | |D01=Second look lapratomy}}
{{familytree | | | |!| | | | | | | | | | | | |}}
{{familytree | | | E01 | | | | | | | | | | |E01=No additional resection}}
{{familytree | | | |!| | | | | | | | |}}
{{familytree | | | D01 | | | | | | | | |D01=Delayed abdominal closure}}
{{familytree/end}}


==References==
==References==
 
<references />
{{Reflist|2}}
[[Category:Up-To-Date]]

Latest revision as of 12:50, 14 April 2021

Mesenteric ischemia Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Surgery in mesenteric ischemia is performed to resect the ischemic bowel in order to prevent the complications. However, in the case of acute embolic type of mesenteric ischemia, early laparotomy and surgical resection is the mainstay of treatment.

Surgery

  • The goals of surgical therapy are as follows:
    • Re-establishment of blood supply to the ischemic bowel
    • Resection of all non-viable areas of the bowel
    • Preservation of the viable bowel
  • Intestinal viability is defined as the maximum vital element influencing outcome in patients with AMI.
  • Non-viable bowel, if unrecognized, can cause multi-organ failure and lead to death.

Approach to treatment

The treatment modality chosen for the patient depends on the type and the location of occlusion, along with hemodyanamic stability.

Surgical versus endovascular intervention

  • In 2009, endovascular intervention was preferred over surgical approach.[1][2][3][4]

Endovascular intervention

  • Hemodyanamically stable patients and those who do not have clinical or radiological signs of ischemia are preferred candidates for endovascular intervention.[5][6][7][8]
  • Using endovascular intervention as the primary modality of treatment helps reduce complications, provides better outcome and shortens the length of hospital stay.[9][10]
  • Two types of endovascular interventions have been described:[11][12]

(a)Pharmacomechanical thrombolysis

(b)Mesenteric angioplasty/stenting

(a)Pharmacomechanical thrombolysis:

  • It is performed in the following patients:
    • Who can undergo arteriography within eight hours of the onset of abdominal pain
    • No contraindications to fibrinolytic therapy
    • No clinical signs of ischemia
  • Procedure:

Retrograde open mesenteric stenting

Revascularization

  • Embolectomy:

The conventional treatment offered for mesenteric embolism is embolectomy. It clears the thrombus and helps assess the bowel viability.

  • Mesenteric bypass:

For mesenteric thrombosis, open surgical intervention is done followed by intraoperative retrograde superior mesenteric artery angiplasty and stenting for the atherosclerotic plaques.

Lapratomy and damage control:

Lapratomy is performed once bowel infarction has occurred. It has the following indications and uses:

  • Acute abdominal findings on physical exam consistent with peritonitis.
  • Facilitates general abdominal exploration for gross pathology and other signs of visceral thrombosis.
  • Allows to determine the viability of the bowel.
  • Determines the extent and severity of intestinal ischemia.
  • Assessment of arterial pulsations in the mesenteric vasculature and bleeding from cut surfaces.

Procedure:

  • After preliminary resuscitation, midline laparotomy should be done to observe the areas of gut with choices for resection of all the necrotic areas. In instances of uncertainty, intraoperative Doppler can be beneficial.

Postprocedural care and follow up:

Second-look lapratomy and abdominal wall closure:

It is performed in patients who undergo revascularization for mesenteric ischemia for the following reasons:

  • Reevaluate the bowel after 24-48 hours of initial operation
  • Assessment of bowel viability after revascularization
  • Resection of irreversibly ischemic bowel
  • Significantly reduces the mortality after surgery

Surgical procedure options:

[13][14][9]

  • Balloon catheter embolectomy of the superior mesenteric artery
  • For restoration of blood flow in acute mesenteric ischemia, antegrade aorto-mesenteric bypass from supraceliac aorta is the best choice.
  • Percutaneous transluminal angioplasty is also considered for revascularization in some case reports.
  • A new hybrid endovascular-surgical technique for managing mesenteric ischemia has been proposed.
  • Laprotomy is done when transmural bowel infarction has occurred.

Treatment strategy of acute embolic mesenteric ischemia:

Treatment for acute embolic mesenteric ischemia is mainly surgical and is managed according to the hemodyanamic stability or the presence/absence of peritoneal signs.

 
 
 
 
 
 
 
 
 
Embolic mesenteric arterial occlusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anticoagulation with heparin Pain management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal signs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Computed tomographic angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Embolus present
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thrombolysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat imaging Resolution of thrombus and no persistent symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs of non-viable bowel
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate oral diet
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exploration and open surgical embolectomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-viable bowel
 
 
 
 
 
 
 
Surgical revascularization for unsuccessful embolectomy
 
 
 
 
 
 
 
A03
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Temporary abdominal closure
 
 
 
 
 
 
 
Bowel resection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Second look lapratomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No additional resection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Delayed abdominal closure
 
 
 
 
 
 
 
 

References

  1. ↑ Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP; et al. (2011). "A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia". J Vasc Surg. 53 (3): 698–704, discussion 704-5. doi:10.1016/j.jvs.2010.09.049. PMID 21236616.
  2. ↑ Björnsson S, Resch T, Acosta S (2013). "Symptomatic mesenteric atherosclerotic disease-lessons learned from the diagnostic workup". J Gastrointest Surg. 17 (5): 973–80. doi:10.1007/s11605-013-2139-z. PMID 23307340.
  3. ↑ Sharafuddin MJ, Nicholson RM, Kresowik TF, Amin PB, Hoballah JJ, Sharp WJ (2012). "Endovascular recanalization of total occlusions of the mesenteric and celiac arteries". J Vasc Surg. 55 (6): 1674–81. doi:10.1016/j.jvs.2011.12.013. PMID 22516890.
  4. ↑ Bobadilla JL (2013). "Mesenteric ischemia". Surg Clin North Am. 93 (4): 925–40, ix. doi:10.1016/j.suc.2013.04.002. PMID 23885938.
  5. ↑ Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S; et al. (2012). "Revascularization for acute mesenteric ischemia". J Vasc Surg. 55 (6): 1682–9. doi:10.1016/j.jvs.2011.12.017. PMID 22503176.
  6. ↑ Kougias P, Huynh TT, Lin PH (2009). "Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia". Int Angiol. 28 (2): 132–7. PMID 19367243.
  7. ↑ Block TA, Acosta S, Björck M (2010). "Endovascular and open surgery for acute occlusion of the superior mesenteric artery". J Vasc Surg. 52 (4): 959–66. doi:10.1016/j.jvs.2010.05.084. PMID 20620006.
  8. ↑ Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli FB (2009). "Mesenteric revascularization: management and outcomes in the United States, 1988-2006". J Vasc Surg. 50 (2): 341–348.e1. doi:10.1016/j.jvs.2009.03.004. PMC 2716426. PMID 19372025.
  9. ↑ 9.0 9.1 Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S; et al. (2008). "Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia". J Vasc Surg. 47 (3): 485–491. doi:10.1016/j.jvs.2007.11.046. PMID 18295100.
  10. ↑ Cai W, Li X, Shu C, Qiu J, Fang K, Li M; et al. (2015). "Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis". Ann Vasc Surg. 29 (5): 934–40. doi:10.1016/j.avsg.2015.01.010. PMID 25757988.
  11. ↑ McBride KD, Gaines PA (1994). "Thrombolysis of a partially occluding superior mesenteric artery thromboembolus by infusion of streptokinase". Cardiovasc Intervent Radiol. 17 (3): 164–6. PMID 8087835.
  12. ↑ Calin GA, Calin S, Ionescu R, Croitoru M, Diculescu M, Oproiu A (2003). "Successful local fibrinolytic treatment and balloon angioplasty in superior mesenteric arterial embolism: a case report and literature review". Hepatogastroenterology. 50 (51): 732–4. PMID 12828073.
  13. ↑ Luo QZ, Lin L, Gong Z, Mei B, Xu YJ, Huo Z; et al. (2011). "Positive association of major histocompatibility complex class I chain-related gene A polymorphism with leukemia susceptibility in the people of Han nationality of Southern China". Tissue Antigens. 78 (3): 178–84. doi:10.1111/j.1399-0039.2011.01748.x. PMID 21810082.
  14. ↑ Lee RW, Bakken AM, Palchik E, Saad WE, Davies MG (2008). "Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease". Ann Vasc Surg. 22 (4): 541–6. doi:10.1016/j.avsg.2007.09.019. PMID 18620112.
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