Chronic mesenteric ischemia

Authors:: David A Tendler, MD; J Thomas Lamont, MD; Matthew R Smeds, MD, FACS, DFSVS
Section Editors:: John F Eidt, MD; Joseph L Mills, Sr, MD; Krishnan Raghavendran, MD, FACS
Deputy Editor:: Kathryn A Collins, MD, PhD, FACS

Literature review current through: Jan 2024.

This topic last updated: Aug 31, 2022.

INTRODUCTION — Mesenteric ischemia is caused by a reduction in intestinal blood flow and is classified as acute (sudden onset of intestinal hypoperfusion) or chronic depending on the time course of symptoms. Chronic mesenteric ischemia, also called intestinal angina, refers to episodic or continuous hypoperfusion of the small intestine that typically occurs in patients with multivessel mesenteric artery stenosis or occlusion.

The clinical features, diagnosis, and management of chronic mesenteric ischemia are reviewed. The diagnosis and management of acute mesenteric ischemia, including acute-on-chronic ischemia (usually thrombosis of a pre-existing stenosis), and colonic ischemia are reviewed separately. (See "Overview of intestinal ischemia in adults" and "Acute mesenteric arterial occlusion" and "Colonic ischemia".)

ETIOLOGY AND ASSOCIATIONS

Atherosclerosis — The majority of cases of chronic mesenteric ischemia are caused by atherosclerotic narrowing of the origins of the celiac or superior mesenteric arteries [1,2].

While atherosclerosis of the mesenteric vessels is common, clinical manifestations as a consequence of mesenteric arterial disease are rare [3,4]. Up to 18 percent of individuals over 65 years of age in the general population have significant stenosis of the celiac or superior mesenteric artery without any known prior symptoms [3,5,6]. (See 'Asymptomatic' below.)

●In one autopsy series, 29 of 120 individuals showed atherosclerotic disease within 2 cm of the origins of the celiac or mesenteric arteries, and 18 of 120 had at least two stenotic vessels; only one patient had evidence of bowel necrosis [7]. The occurrence of disease was strongly associated with aging and correlated with atherosclerotic disease of cerebral arteries at the skull base.

●In a study of 184 asymptomatic patients, the prevalence of celiac or superior mesenteric artery stenosis or occlusion was 18 percent for those over 65 using duplex ultrasound [6]. Single-vessel disease more commonly affected the celiac artery than the superior mesenteric artery (81 versus 19 percent).

●A population-based study found a similar prevalence of 17.5 percent among 870 patients over 65 [3]. Multivariate analysis identified renal artery stenosis as significantly associated with celiac or mesenteric artery stenosis or occlusion.

Others

●Inadvertent coverage of visceral vessels by aortic endografts during repair and migration or restenosis of the stents used in fenestrated aortic repair can cause partial obstruction of the visceral vessels during or after endovascular aortic aneurysm repair. (See "Endovascular repair of abdominal aortic aneurysm", section on 'Advanced devices and techniques' and "Complications of endovascular abdominal aortic repair", section on 'Intestinal ischemia'.)

●Rare causes of chronic mesenteric ischemia include fibromuscular dysplasia, aortic or mesenteric artery dissection, vasculitis (polyarteritis nodosum, Takayasu disease [8]), and retroperitoneal fibrosis [9].

•(See "Clinical manifestations and diagnosis of fibromuscular dysplasia".)

•(See "Clinical features and diagnosis of acute aortic dissection" and "Spontaneous mesenteric arterial dissection" and "Complications of endovascular abdominal aortic repair".)

•(See "Overview of gastrointestinal manifestations of vasculitis".)

•(See "Clinical manifestations and diagnosis of retroperitoneal fibrosis".)

CLINICAL PRESENTATIONS

Asymptomatic — Most patients with chronic mesenteric ischemia due to atherosclerotic disease do not exhibit symptoms because of the extensive collateral network within the mesenteric vasculature that can form to compensate for reduced flow (figure 1). In one review of 270 patients with occlusive disease of one or more splanchnic vessels, 61 (60 percent) had no symptoms [10].

Data are limited regarding the progression of chronic disease and symptoms in previously asymptomatic patients; however, small retrospective reviews suggest that multivessel disease is associated with a higher incidence of developing symptomatic disease.

●In a study of 82 patients identified on arteriography as having 50 percent stenosis in at least one mesenteric artery, 4 of 15 patients with significant three-vessel disease developed mesenteric ischemia during follow-up [4]. One of these had no abdominal complaints prior to an acute presentation resulting in necrosis of the entire gut. The three others each developed typical symptoms of chronic mesenteric ischemia at 7, 24, and 24 months.

●A later review of 77 patients reported similar results [11]. The incidence of acute or chronic mesenteric ischemia was higher in initially asymptomatic patients with superior mesenteric artery (SMA) stenosis associated with celiac artery and/or inferior mesenteric disease compared with patients with isolated SMA stenosis (15.1 versus 0 percent). Among the eight patients who became symptomatic, acute mesenteric ischemia occurred in five patients at a median of 33 months, and chronic mesenteric ischemia developed in three patients at a median of 88 months.

Symptomatic — Patients who manifest symptoms of chronic mesenteric ischemia are typically over 60 years of age and are three times more likely to be female rather than male [4,12]. Most patients have a history of smoking (58 percent in one study [13]), and approximately one-half of patients have a history of coronary artery disease, cerebrovascular disease, or lower extremity peripheral artery disease [13,14]. Physical findings are usually nonspecific; abdominal examination may reveal an epigastric bruit in approximately 50 percent of patients due to turbulent flow related to arterial stenosis. Weight loss is present in approximately 80 percent.

Intestinal angina — Symptoms of chronic mesenteric ischemia manifest as recurrent episodes of acute abdominal pain after eating, which has also been referred to as "intestinal angina." Patients classically complain of dull, crampy, postprandial epigastric pain, usually within the first hour after eating. The pain usually subsides over the course of the next two hours. Two explanations have been proposed for the timing of symptoms. One suggests that pain arises from a mismatch between splanchnic blood flow and intestinal metabolic demand, while the other suggests that small intestinal hypoperfusion results from blood being shunted to the stomach [15]. The latter explanation is probably more consistent with the typical temporal pattern. (See "Overview of intestinal ischemia in adults", section on 'Physiology and mechanisms of ischemia'.)

The pain can be variable in intensity and location and may occasionally radiate to the back. The severity of the pain is greater following larger meals with high fat content [16].

Adapted eating pattern — The association of abdominal pain with eating results in patients avoiding eating (food aversion, food fear) due to the anticipation of postprandial pain and other symptoms, resulting in weight loss [17]. In a survey of 270 patients, the probability of chronic mesenteric ischemia was 60 percent if all four symptoms (postprandial pain, chronic diarrhea, adapted eating pattern, weight loss) were present compared with 13 percent if none were present [10]. Approximately one-third of patients have less typical symptoms, which may include nausea, vomiting, early satiety, or even gastrointestinal bleeding [15].

Acute abdominal pain — Thrombus formation in the narrowed mesenteric arterial segment can lead to acute, severe abdominal symptoms (acute-on-chronic mesenteric ischemia) [4]. However, the presentation of acute mesenteric ischemia in this group of patients is often more insidious given the collateral pathways that have typically formed. (See "Acute mesenteric arterial occlusion".)

Such patients have a much higher morbidity and mortality compared with patients with only chronic symptoms.

DIAGNOSIS — A high index of clinical suspicion and focused evaluation is important for making a timely diagnosis of chronic mesenteric ischemia. A presumptive clinical diagnosis of chronic mesenteric ischemia in patients with appropriate symptoms (postprandial pain, adapted eating pattern, weight loss) is supported by the imaging that demonstrates high-grade stenosis or occlusion of two or more mesenteric vessels (image 1) [18] (see 'Vascular imaging' below). There is no direct relationship between symptoms and the number of vessels occluded. Patients with stenosis in only one of the three mesenteric arteries do not typically exhibit symptoms; however, complete occlusion of a single artery (typically the superior mesenteric artery) may be the cause of intestinal angina in approximately 5 percent of patients, particularly in association with prior gastrointestinal surgery that has disrupted the collateral circulation (figure 1) [19].

Nevertheless, prior to assigning a diagnosis of chronic mesenteric ischemia, excluding another diagnosis is necessary [16,20]. If a patient presents with symptoms suggestive of chronic mesenteric ischemia but has not had significant weight loss, an alternative diagnosis is more likely (see 'Differential diagnosis' below) [17]. The failure to identify another etiology in patients with otherwise unexplained symptoms should suggest chronic mesenteric ischemia. The studies necessary in the evaluation of other causes of symptoms may include esophagogastroduodenoscopy, colonoscopy, capsule endoscopy, or other functional studies depending upon the clinical scenario. Because patients are evaluated for other etiologies (especially malignancy) as an explanation for weight loss, the diagnosis if often delayed. The average delay from the onset of symptoms to diagnosis or treatment was 10.7 months in one review [21] and 15 months in another [2]. (See 'Differential diagnosis' below.)

Vascular imaging — Demonstration of stenosis of the major mesenteric vessels on vascular imaging is a requirement for a diagnosis of chronic mesenteric ischemia. Calcification of mesenteric vessels may be identified on plain abdominal films but is not specific.

For patients with suggestive symptoms, guidelines from both the Society for Vascular Surgery [22] and the American College of Radiology recommend computed tomographic (CT) angiography of the abdomen and pelvis as the best imaging study since it reliably identifies or excludes the presence of atherosclerotic vascular disease as the most likely etiology and simultaneously rules out other abdominal pathologies as the source of symptoms [23-26].

Conventional arteriography is indicated for diagnostic confirmation when the results of noninvasive testing are equivocal, when anatomic features preclude CT angiography, and when endovascular intervention is planned. (See 'Revascularization' below.)

Angiography — CT angiography timed to coincide with peak arterial or venous enhancement provides rapid and accurate three-dimensional renderings of the intestinal vasculature and bowel. The study should be performed with intravenous contrast. Oral contrast is not necessary and can interfere with the radiologic examination of the mesenteric vasculature.

CT angiography has sensitivities and specificities exceeding 90 percent for the diagnosis of chronic mesenteric ischemia due to atherosclerosis [27-30]. The finding of high-grade mesenteric stenoses in at least two major vessels (celiac, superior mesenteric, or inferior mesenteric) is most often encountered. Evidence for collateral formation to compensate for the reduced main arterial flow is typically present [1].

Contrast-enhanced magnetic resonance (MR) angiography is also highly sensitive for detecting stenoses at the origins of the celiac or mesenteric arteries; however, the technique is much less reliable for detecting more distal lesions. Quantification of postprandial flow on MR angiography may prove useful as a diagnostic modality, and noncontrast MR angiography is an alternative to CT angiography in patients who cannot tolerate an intravenous contrast load [31]. (See 'Functional studies' below.)

Role of duplex ultrasonography — Duplex ultrasonography of the mesenteric vessels has been advocated as a reasonably accurate modality for the detection of high-grade celiac and superior mesenteric artery stenosis [16,32]. For patients who are initially seen in an office setting, a duplex ultrasound is a reasonable first study to rule out mesenteric artery occlusive disease as a cause of abdominal symptoms. Sensitivity exceeding 90 percent has been reported in patients with more than a 50 percent stenosis of the superior mesenteric or celiac arteries based on the velocity of blood flow within a stenotic segment (table 1) [32-35]. (See "Noninvasive diagnosis of upper and lower extremity arterial disease", section on 'Anatomic sites'.)

Because the negative predictive value of duplex ultrasonography approaches 99 percent, it is justifiable to pursue other etiologies of abdominal pain after a negative study [32]. However, technical considerations, including the expertise of the examiner, large body habitus, significant small bowel distention, and prior abdominal surgery should be considered in assessing the results [36,37].

Duplex ultrasound performed during inspiration and expiration can also be used to detect celiac artery compression (ie, median arcuate ligament syndrome), which may be an incidental finding or associated with abdominal symptoms (eg, postprandial pain) in some patients, but is rarely associated with intestinal ischemia [38]. (See 'Differential diagnosis' below and "Celiac artery compression syndrome", section on 'Diagnosis'.)

Functional studies — A possible role for tonometry, spectroscopic oximetry, and MR flow for the diagnosis of chronic mesenteric ischemia has been suggested, but the clinical usefulness of these studies, which are still under investigation, has not been adequately established [27,39-45].

Tonometry uses an intraluminal catheter to measure the intestinal pH in the jejunum after a test meal. Intramural acidosis that correlates with abdominal pain may be a good marker of tissue ischemia [39-43]. A visible light spectroscopy oximeter can also be used to objectively measure mucosal saturations during endoscopy to diagnose mesenteric ischemia [44]. In one study, abnormally low proximal small bowel mucosal oxygen saturations resolved after successful percutaneous intervention. Larger studies are needed to validate these findings.

Measuring the increase in superior mesenteric venous blood flow following a meal can be done using MR venography. In one study, the postprandial increase was significantly reduced in patients with chronic mesenteric ischemia compared with healthy controls (64 versus 206 percent) [45].

DIFFERENTIAL DIAGNOSIS — There are many causes of chronic abdominal pain and of weight loss in adults. The constellation of progressive abdominal pain and weight loss, particularly in older adult patients, frequently prompts an evaluation to rule out other conditions such as malignancy, chronic cholecystitis, chronic pancreatitis, inflammatory bowel diseases, or peptic ulcer disease. (See "Evaluation of the adult with abdominal pain" and "Causes of abdominal pain in adults" and "Approach to the patient with unintentional weight loss".)

Celiac artery compression syndrome (ie, median arcuate ligament syndrome; compression of the celiac artery from the median arcuate ligament of the diaphragm) does not typically result in intestinal ischemia but often presents with similar symptoms. (See "Celiac artery compression syndrome".)

Food aversion and weight loss may also be a sign of an eating disorder. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

MANAGEMENT

Medical management — In general, patients with an incidental diagnosis of mesenteric occlusive disease who do not have overt clinical manifestations are managed with tobacco cessation and risk factor modification to limit the progression of atherosclerotic disease in the mesenteric circulation as well as elsewhere in the body [2,18]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

Interestingly, in a retrospective review of patients with a typical risk profile for peripheral artery disease, 97 diagnosed with chronic mesenteric ischemia were more likely to be female, had lower incidences of hypertension and hypercholesterolemia, and had a lower than expected incidence of obesity and diabetes [13]. Reduced caloric intake, related to the postprandial pain, rather than sex alone likely explains the observed differences. In treated patients, factors are associated with poorer long-term survival included smoking, hypertension, chronic kidney disease, body-mass index (BMI) >25, and widespread atherosclerosis. Thus, all patients with atherosclerotic disease of the mesenteric vessels should receive standard preventive treatment [46]. Risk factor modification includes antiplatelet therapy, most commonly with aspirin, blood pressure and hypercholesterolemia management, and optimization of blood glucose levels [47]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk", section on 'Antiplatelet therapy' and "Spontaneous mesenteric arterial dissection", section on 'Antithrombotic therapy'.)

Systemic anticoagulation is indicated in the setting of acute thrombus (ie, acute-on-chronic mesenteric ischemia). (See "Overview of intestinal ischemia in adults", section on 'Anticoagulation' and "Acute mesenteric arterial occlusion".)

Nutritional assessment and support — Due to the often-delayed diagnosis, patients with chronic mesenteric ischemia may exhibit significant weight loss (eg, BMI <18.5). Thus, nutritional status should be evaluated in all patients [48,49]. The severity of nutritional deficiency may have a bearing on the approach to treatment [50]. However, while preoperative nutritional status is an important predictor of outcomes, there is no evidence to support delaying treatment to provide nutritional repletion, and revascularization should not be delayed in these patients given the theoretical risk of progression to acute-on-chronic mesenteric ischemia. (See "Overview of perioperative nutrition support", section on 'Consequences of malnutrition in surgical patients' and "Overview of perioperative nutrition support", section on 'Nutritional assessment in the surgical patient' and "Overview of perioperative nutrition support", section on 'Preoperative nutrition support'.)

Revascularization — The indication for revascularization (open or endovascular) is the presence of symptoms, including abdominal pain and weight loss, in the setting of documented severe splanchnic artery stenoses [22,51]. The aim of intervention is to relieve symptoms, prevent bowel infarction or ischemia that could lead to bowel stricture, and reverse weight loss/nutritional depletion [2].

In the absence of symptoms, there is little role for prophylactic intervention. An exception may be in patients with atherosclerotic occlusive disease of the mesenteric vessels who require aortic reconstruction for other indications (aneurysm, aortoiliac occlusive disease) or extensive foregut surgery (eg, pancreaticoduodenectomy), but such a decision depends on other factors as well. (See "Endovascular repair of abdominal aortic aneurysm", section on 'Anatomic considerations'.)

Options — Options for revascularization include endovascular, open surgical, or hybrid approaches. The extent of revascularization (number of vessels revascularized) may depend upon the approach chosen, but for patients with chronic mesenteric ischemia, revascularization of the superior mesenteric artery is the primary target. The celiac and inferior mesenteric artery are secondary targets [52,53]. Treatment of superior mesenteric artery occlusion is associated with better symptom relief compared with revascularization of other mesenteric arteries. The inferior mesenteric artery may be the only suitable vessel for revascularization, although it is not commonly revascularized in isolation [54].

In the setting of acute-on-chronic mesenteric ischemia, isolated revascularization of the superior mesenteric artery is more commonly performed either using an open or hybrid approach, which allows examination and resection of affected bowel [55].

Endovascular/hybrid revascularization — Endovascular revascularization for chronic mesenteric ischemia has evolved from balloon angioplasty alone to primary stenting using a bare metal stent to the use of a covered stent (image 2) by most interventionalists. The approach to stenting may be percutaneous or by using an open hybrid approach.

●Percutaneous angioplasty and stenting – Percutaneous angioplasty and stenting involves gaining arterial access and deploying a stent to restore flow. Percutaneous angioplasty and stenting are initially preferred if the patient is anatomically suited for this approach. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Mesenteric stenting'.)

●Retrograde open mesenteric stenting (hybrid technique) – With retrograde open mesenteric stenting (ROMS), the mid-superior mesenteric artery is accessed via laparotomy. Catheters and wires are introduced directly into the artery with which to position and deploy a stent in a retrograde manner. This approach is more commonly used to treat acute-on-chronic symptoms when abdominal exploration is also needed, and sometimes for chronic ischemia if the lesion cannot be crossed antegrade. Less intravenous contrast is needed when performing ROMS compared with a percutaneous stenting approach. (See 'Open surgical revascularization' below and "Surgical and endovascular techniques for mesenteric revascularization", section on 'Retrograde open mesenteric stenting'.)

Most authors have reported technical success rates greater than 80 percent with mesenteric stenting and relief of abdominal pain in 75 to 100 percent of patients, with one-half of patients experiencing weight gain [19,56-82]. In some cases, advanced percutaneous techniques, such as crossing total occlusions, may be attempted to avoid an open surgical approach [83-86]. (See "Surgical and endovascular techniques for mesenteric revascularization".)

Periprocedural complications of mesenteric angioplasty and stenting include embolization, perforation, thrombosis, and dissection. In a retrospective review, these occurred in 7 percent of patients [87]. Five of 11 patients with complications required open conversion. Access site complications are more frequent with brachial arterial access, but the advantage of approaching the superior mesenteric artery from above may outweigh the risk. (See "Access-related complications of percutaneous access for diagnostic or interventional procedures".)

Open surgical revascularization — Open surgical techniques for mesenteric revascularization include aortomesenteric and/or celiac bypass grafting, mesenteric reimplantation, and transaortic endarterectomy. For patients deemed to be candidates for open surgery, procedure selection will depend on the surgeon's experience as well as anatomic factors including calcification of the aorta and coexisting atherosclerotic burden [2,12,88-91].

●Open mesenteric bypass – Open mesenteric bypass requires a laparotomy and exposure of the aorta and mesenteric vasculature. The mesenteric artery bypass may arise antegrade from the supraceliac aorta or thoracic aorta or retrograde from the infrarenal aorta or iliac arteries. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Mesenteric artery bypass'.)

●Transaortic endarterectomy – Transaortic endarterectomy requires laparotomy and retroperitoneal exposure of the aorta to perform local endarterectomy of the aorta and mesenteric orifices [90,92,93]. The procedure is more complex and is seldom needed in the era of endovascular mesenteric revascularization since the number of patients who are candidates for this procedure is limited [94]. However, it continues to have a role in the treatment of chronic focal disease of the para/supra-renal aorta, a disease pattern that is more common in females in their 50s and 60s [94]. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Transaortic endarterectomy'.)

Multiple observational studies have described excellent long-term results of surgical revascularization for chronic mesenteric ischemia [94-105]. Following open surgical bypass, primary graft patency rates at five years range from 57 to 69 percent [95,101,104]. Transaortic endarterectomy also appears to have reliable long-term symptom relief compared with open mesenteric bypass [90,92,93].

Endovascular versus open surgical approach — The decision to perform endovascular versus open surgical revascularization is generally based upon the patient's life expectancy, nutritional status, and medical comorbidities, as well as the number and severity of diseased vessels and the ability to access the vessels via endovascular means, as well as the operator's experience and preference [2,21,106-108]. The ability to offer endovascular or open treatment depends on the availability of experienced vascular surgeons or vascular interventionalists. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Indications and technique selection'.)

Percutaneous endovascular revascularization (image 2), most often using a covered mesenteric stent, is initially preferred and recommended by the Society for Vascular Surgery Chronic Mesenteric Ischemia Guidelines [22]. This recommendation stems from data that generally demonstrate improved perioperative outcomes for endovascular compared with open surgery with similar long-term survival rates (see 'Mortality' below) [21,54,106-126]. However, open surgical revascularization is more durable, and for patients deemed good risk for open surgery, it may be the best initial approach [12]. Open revascularization should be offered to young, otherwise healthy patients, particularly those with a longer life expectancy, or for those in whom endovascular approaches cannot be used. This may include patients who have failed endovascular therapy or those with a significant length of mesenteric occlusion or with access vessel issues.

Multiple observational studies have compared open with endovascular revascularization for chronic mesenteric ischemia, but there have been no large randomized clinical trials directly comparing revascularization approaches. A review evaluated outcomes of studies performed from 2000 to 2009 and reported more than 1000 patients treated for chronic mesenteric ischemia [2]. Patients were treated using an endovascular approach in 18 studies and by open surgery in 16 studies, and in 9, both approaches were used. Morbidity was higher for open surgical revascularization, while restenosis was higher for endovascular revascularization. (See 'Recurrence and reintervention' below.)

●Open surgical revascularization:

Mortality – 4.4 percent

Morbidity – 16 percent

Restenosis – 7 percent

●Endovascular revascularization:

Mortality – 5.6 percent

Morbidity – 11 percent

Restenosis – 34 percent

A later meta-analysis reported lower rates of perioperative complications, shorter hospital stays, and lower costs in patients undergoing endovascular compared with open mesenteric revascularization [54]. Patients treated with an endovascular approach had a slightly higher rate of reinterventions, which was offset by the low rate of complications.

OUTCOMES

Mortality — Perioperative mortality among patients with chronic mesenteric ischemia ranges from 0 to 16 percent but can be as high as 50 percent for those patients who develop acute-on-chronic symptoms [4,95,101,102,104,116,127,128]. Long-term survival is similar following mesenteric revascularization regardless of revascularization technique. Periprocedural complications and mortality are increased for open surgical compared with endovascular revascularization. (See 'Endovascular versus open surgical approach' above.)

Following mesenteric revascularization, late deaths are less likely to be related to mesenteric ischemia compared with other causes. In a retrospective review, 144 of 343 patients died during the follow-up period (median follow-up 96 months) [129]. Long-term patient survival was not influenced by type of arterial reconstruction (open, endovascular). Cardiac disease was the most common cause of death (35 percent), followed by cancer (15 percent), pulmonary complications (13 percent), mesenteric ischemia (11 percent), and other or unidentifiable causes (10 percent). Independent predictors of any cause mortality included age >80 years, diabetes, chronic kidney disease stage IV or V, and the requirement for home oxygen. Mesenteric ischemia-related death was associated with diabetes and stage IV or V chronic kidney disease.

Recurrence and reintervention — Following open or endovascular treatment for chronic mesenteric ischemia, lifelong follow-up with clinical evaluation every six months for the first year and then annually thereafter is important to uncover recurrent symptoms and detect restenosis. Many vascular specialists use duplex ultrasonography to monitor patency following revascularization, but the study chosen (duplex, CT angiography, MR angiography) often depends upon institutional resources and local expertise [130-132]. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Postoperative imaging and surveillance'.)

●Recurrence after endovascular revascularization – Recurrent stenosis occurs in 5 to 15 percent of patients and is higher after endovascular therapy compared with open surgery. Recurrent symptoms are usually associated with restenosis [60,73]. Following angioplasty/stenting, restenosis and recurrent symptoms occur in 17 to 50 percent of patients within the first year. Recurrence rates in the higher range are typically those who underwent angioplasty without stenting. In a systematic review that included more than 1000 patients treated for chronic mesenteric ischemia, restenosis occurred in 34 percent of patients following angioplasty/stenting [2].

●Recurrence after open surgical revascularization – Following open surgical bypass, primary graft patency rates at five years range from 57 to 69 percent [95,101,104]. In the systematic review above that included more than 1000 patients, restenosis occurred in 7 percent of patients who underwent open surgical revascularization [2]. Freedom from recurrence at 5 and 10 years is approximately 80 and 60 percent, respectively [94,104]. Long-term symptom relief may be influenced by the completeness of surgical revascularization. In a review of 86 patients, primary patency rates were 84 percent for complete revascularization and 87 percent for incomplete revascularization [105]. At 10-year follow-up, secondary patency rates were similar (92 and 93 percent), but more patients undergoing complete compared with incomplete revascularization were free from gastrointestinal symptoms (79 versus 65 percent).

Following either endovascular or open surgery, recurrent symptoms from restenosis can often be successfully managed with angioplasty/stenting (image 3). However, for recurrence following initial percutaneous intervention, some clinicians will proceed directly to open surgical revascularization, provided the patient is a reasonable surgical candidate.

Restenosis following open surgical revascularization can often be approached using endovascular techniques with secondary patency rates >90 percent [101,105]. In a case-control study, among 47 patients with recurrent symptoms, repeat open surgery was performed in 28 patients, and endovascular intervention was performed in 19 patients [69]. Repeat operation or endovascular intervention for recurrent symptoms had similar mortality, recurrence, and reintervention rates. Morbidity was significantly higher for repeat surgery compared with endovascular treatment (63 versus 16 percent). Compared with the index surgical revascularization, repeat surgery was associated with similar morbidity and mortality but lower primary patency (66 versus 94 percent). Primary and secondary patency rates at one year were 61 and 92 percent for repeat open surgery and 77 and 100 percent for endovascular treatment.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Occlusive carotid, aortic, renal, mesenteric, and peripheral atherosclerotic disease".)

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SUMMARY AND RECOMMENDATIONS

●Chronic mesenteric ischemia – Chronic mesenteric ischemia (also called intestinal angina) refers to episodic or constant intestinal hypoperfusion and is usually due to mesenteric atherosclerotic disease resulting from stenosis or occlusion of at least two mesenteric vessels. (See 'Introduction' above.)

●Symptoms – Patients classically complain of dull, crampy, postprandial epigastric pain, usually within the first hour after eating. The pain can be of variable intensity and location and may occasionally radiate to the back. The severity of the pain is increased after larger meals with high fat content. The pain usually subsides over the course of the next two hours. Symptoms are often progressive and may culminate in a more acute presentation (acute-on-chronic mesenteric ischemia) from thrombus formation. (See 'Clinical presentations' above.)

●Diagnosis – The diagnosis of chronic mesenteric ischemia is supported by the demonstration of high-grade stenoses usually in multiple mesenteric vessels, in patients with investigated but unexplained chronic abdominal pain, adapted eating pattern, and weight loss. A high clinical index of suspicion is crucial to making a timely diagnosis. (See 'Diagnosis' above.)

●Indications and goals for revascularization – For patients with chronic mesenteric ischemia, the indication for revascularization is the presence of symptoms, including abdominal pain and weight loss. The aim of intervention is to relieve symptoms, prevent bowel infarction or ischemia that could lead to bowel stricture, and reverse weight loss/nutritional depletion. (See 'Revascularization' above.)

●Options and revascularization approach – Options for revascularization include endovascular (percutaneous stenting or open hybrid retrograde mesenteric stenting [ROMS]) and open surgical revascularization (antegrade or retrograde mesenteric bypass, mesenteric replantation, transaortic endarterectomy). The decision to perform endovascular or open surgical revascularization is generally based upon the patient's life expectancy, medical comorbidities, pattern of disease and anatomy, as well as the operator's experience and preference (See 'Options' above.)

•For most patients with chronic mesenteric ischemia and suitable vascular anatomy, we suggest initial percutaneous endovascular revascularization, rather than open surgical bypass (Grade 2C). Perioperative complication rates are lower for endovascular techniques with similar long-term survival rates. (See 'Endovascular versus open surgical approach' above.)

•For young, otherwise healthy patients with a longer life expectancy, an open approach should be offered as the initial approach to revascularization because the revascularization is more durable. Long-term patency rates are higher for open compared with endovascular revascularization. In addition, open revascularization is the only option for those with anatomy unsuitable for an endovascular approach (eg, a significant length of mesenteric occlusion, access vessel issues), or those with restenosis and recurrent symptoms after multiple prior endovascular interventions.

•For patients with acute-on-chronic mesenteric ischemia in whom abdominal exploration is needed, ROMS is an alternative to open surgical bypass.

●Outcomes and follow-up – Long-term patient survival is similar regardless of method of revascularization. Cardiac disease is the most common cause of late death. Routine follow-up is important to identify recurrent symptoms and restenosis. Recurrent stenosis occurs in 5 to 15 percent following revascularization and occurs at a higher rate for endovascular compared with open surgery. (See 'Outcomes' above.)

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Topic 2563 Version 29.0

خرید پکیج

Chronic mesenteric ischemia

References