Clinical management of chronic mesenteric ischemia

Abstract

This This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, 's-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.

Keywords: Chronic mesenteric ischemia; atherosclerosis; computed tomography angiography; endovascular therapy; median arcuate ligament syndrome.

Figure 1.

A 48-year-old woman presented with postprandial abdominal pain and 10-kg weight loss. Computed tomography angiography (CTA) showed compression of the celiac artery (CA), with increased compression on expiration (a) and less compression on inspiration (b). Patient was planned for surgical release of CA. After successful release, patient had gained 5 kg in weight and was symptom free. CTA 11 months after surgery showed an open CA on expiration (c) and on inpiration (d).

Figure 2.

Algorithm for clinical management of chronic mesenteric ischemia. *Refer for functional test. Suitable functional tests are upper gastrointestinal endoscopy with visible light spectroscopy or gastric-jejunal tonometry (24-hour tonometry or exercise tonometry). CA: celiac artery; CMI: chronic mesenteric ischemia; CT: computed tomography; CTA: computed tomography angiography; DUS: duplex ultrasound; MR: magnetic resonance; MRA: magnetic resonance angiography; MALS: median arcuate ligament syndrome; NOMI: non-occlusive mesenteric ischemia; PMAS: percutaneous mesenteric artery stenting; SMA: superior mesenteric artery.

Figure 3.

A 69-year-old woman presented with postprandial abdominal pain and 10-kg weight loss over three months. A significant stenosis of the celiac artery (CA) and superior mesenteric artery (SMA) was shown on computed tomography angiography (CTA) (a). A consensus diagnosis of multi-vessel chronic mesenteric ischemia was established and patient was planned for endovascular revascularization. The CA and SMA were successfully stented. CTA 6 months after revascularization showed open stents (b). The patient was free of symptoms and her weight increased by 12 kg.

Figure 4.

A 50-year-old man presented with postprandial abdominal pain and 13-kg weight loss. Computed tomography angiography (CTA) showed a significant stenosis of the superior mesenteric artery (SMA) and <50% celiac artery stenosis (a). His mucosal saturation levels were decreased as detected by visible light spectroscopy. A consensus diagnosis of single-vessel chronic mesenteric ischemia was established and patient was planned for stent placement of the SMA. CTA 6 months after revascularization showed an open SMA stent (b). The patient was free of symptoms and his weight increased by 7 kg.