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Acute Mesenteric Ischemia. Isaac George, MD Resident in Surgery Department of Surgery Columbia University College of Physicians and Surgeons. Acute Mesenteric Ischemia. Incidence Pathophysiology Diagnosis Therapy Treatment Algorithm Objectives. Objectives. Understand pathophysiology

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acute mesenteric ischemia

Acute Mesenteric Ischemia

Isaac George, MD

Resident in Surgery

Department of Surgery

Columbia University

College of Physicians and Surgeons

acute mesenteric ischemia2
Acute Mesenteric Ischemia
  • Incidence
  • Pathophysiology
  • Diagnosis
  • Therapy
  • Treatment Algorithm
  • Objectives
objectives
Objectives
  • Understand pathophysiology
  • Identify patients at high-risk for mesenteric ischemia
  • Develop treatment plan for each patient/apply treatment algorithm
introduction
Introduction
  • Cokkinis (1921):

“occlusion of the mesenteric vessels is regarded as one of those conditions of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost useless.”

  • Occlusive or non-occlusive mechanism leading to hypoperfusion of one or more mesenteric vessels
rationale
Rationale
  • Incidence
    • 1-2/1000 hospital admissions
    • 1% of GI admissions1
  • Mortality
    • 1960’s - 70-100%2
    • 1970’s - 60-70%3
  • Morbidity
    • Cardiopulmonary, MOSF
    • Extended LOS, TPN dependence4
  • Recurrence
    • Up to 60%4

1 Ann Surg 2001;233(6):801-808

2 Ann Surg 1982;195:554-565

3 Ann Surg 1978;188;721-731

4 Ann Vasc Surg 2003;17:72-9

pathophysiology etiology
Pathophysiology: Etiology
  • Arterial Embolic Disease
  • Arterial Thrombotic Disease
  • Venous Thrombotic Disease
  • Non-occlusive Mesenteric Ischemia
pathophysiology
Pathophysiology

Arterial Embolism

  • Majority of cases (>50%): SMA occlusion
  • Location: origin of middle colic artery (ischemia from proximal jejunem to splenic flexure)
  • Embolic sources: cardiac (80%)1, aortic plaques
  • Celiac and IMA occlusion usually tolerated
  • SMA occlusion → death
  • Most have underlying stenoses as well

1 Ann Vasc Surg 1990;4:112-116

pathophysiology9
Pathophysiology

Arterial Thrombotic Disease

  • 15% of acute intestinal ischemia1
  • Pre-existing atherosclerotic disease
    • Worsening chronic mesenteric ischemia
  • Found at ostium of SMA
  • More delayed onset of symptoms

1 Vasc Surg 1996; 4th ed.

pathophysiology10
Pathophysiology

Venous Thrombotic disease

  • 5-10% of intestinal ischemia
  • Younger patient population
  • 80% have hypercoaguable state
  • Risk factors: oral contraceptives, previous DVT/PE, malignancy, portal HTN, nephrotic syndrome
  • May limit arterial flow→edema, segmental infarction
pathophysiology11
Pathophysiology

Non-Occlusive disease

  • 20-30% of acute intestinal ischemia
  • Response to systemic hypoperfusion
      • Sympathetic adrenergic system mediated
  • Visceral vasoconstriction/shunting for cerebral protection
  • Causes: any severe systemic illness, CHF, dehydration, drugs (cocaine, ergot alkaloids, digitalis, β-blockers,α-agonist, epo), hemodialysis
clinical presentation physical examination
Arterial Thromboembolic, Non-Occlusive

Severe abdominal pain

Sudden onset

Venous Thrombotic

Less severe pain

Subacute

Clinical Presentation:Physical Examination
  • Symptoms variable
  • Abdominal pain-non-specific, crampy vs. steady, anterior
  • Gastric emptying/vomiting
  • Peritonitis late
  • Hypotension, tachycardia
clinical presentation laboratory
Clinical Presentation: Laboratory

Limited clinical utility

  • arterial lactate1
  • amylase2
  • CK, CK-BB3
  • Serum phosphate4
  • Other useless markers: LDH, PAF, TNF-α, AP, AST/ALT, α-glutathione

1 Eur J Surg 1994;160:381-4

2 Br J Surg 1986;73:219-21

3 Dig Dis Sci 1991;36:1589-93

4 Br J Surg 1982;69:S52-3

clinical presentation risk factors
Clinical Presentation: Risk Factors

J Vasc Surg 2002;35:445-52

clinical presentation risk factors15
Clinical Presentation: Risk factors

Ann Surg 2001;233(6):801-808

clinical presentation risk factors16
Clinical Presentation: Risk factors

Ann Surg 2001;233(6):801-808

clinical presentation
Clinical Presentation

Ann Vasc Surg 2003;17:72-79

clinical presentation18
Clinical Presentation

Ann Surg 2001;233(6):801-808

diagnosis non invasive imaging
Diagnosis: Non-Invasive Imaging

X-ray

Computed Tomography

(helical/angiography)

Ultrasound

MRI/MRA

diagnosis x ray
Diagnosis: X-Ray

Plain Films

  • pneumatosis
  • portal venous gas
  • thumbprinting →
  • Findings late, associated with high mortality
diagnosis computed tomography
Diagnosis: Computed Tomography

Criteria

  • pneumatosis
  • venous gas
  • SMA/celiac/IMA occlusion w/distal disease
  • arterial embolism

OR

  • bowel wall thickening + one of following:
    • lack of bowel wall enhancement
    • solid organ infarction
    • venous thrombosis

Sensitivity: 96%

Specificity: 94%

1 Radiol 2003;229:91-98

computed tomography
Computed Tomography

Radiol 2003;229:91-98

computed tomography23
Computed Tomography

Radiol 2003;229:91-98

computed tomography24
Computed Tomography

Radiol 2003;229:91-98

volume rendering normal
Volume Rendering:Normal

RG 2002;22:161-172

volume rendering ischemia
Volume Rendering:Ischemia

RG 2002;22:161-172

diagnosis ultrasound
Diagnosis: Ultrasound

High-grade stenosis or occlusion of SMA

  • Sensitivity for SMA stenosis: 96% (1993) 1
    • Prospective, n=100
    • Surgically confirmed embolism/thrombus
  • Sensitivity for SMA stenosis/occlusion: 100% (1999)2
    • Specificity: 98%
    • PPV: 93%, NPV: 100%
    • N=82, prospective
    • Confirmed with angiography

1 J Vasc Surg 1993;17:780-788

2 Radiol 1999;211:405-410

diagnosis mri
Diagnosis: MRI
  • Poor delineation of smaller vessels
  • Limited clinical application
  • Perfusion flow contrast studies show promise1

1 Radiol 2004;234:569-575

diagnosis angiography
Diagnosis: Angiography
  • Gold Standard
    • Anatomic delineation of occlusion and collaterals
    • Plan operative revascularization
    • Allow infusion of therapeutic agents (lytics, vasodilators)

1 Ann Surg 2001;233(6):801-808

principles of treatment
Principles of Treatment
  • Diagnose
  • Restore Flow
  • Resect non-viable tissue
  • Supportive Care
  • Second-Look
therapy
Therapy

Supportive measures

  • IV resuscitation
  • Optimize cardiac status
  • Broad-spectrum antibiotics (no data)
  • Nasogastric decompression
therapy pharmacologic
Therapy: Pharmacologic

Anticoagulation

  • Heparin IV
    • Prevents clot propagation
    • Systemic vs. intra-arterial
    • Timing of initiation
      • Immediately vs. 48 hr delay1,2
    • Restart 48 hrs after surgical intervention
  • Warfarin
    • Prevents clot propagation
    • Give for 6-12 mos if no clotting disorder (no data)

1 Surg Gynecol Obstet 1981;153:561-569

2 Vascular Emergencies. 1982;553-561

therapy pharmacologic33
Therapy: Pharmacologic

Vasodilators

  • Papaverine (30-60 mg/hr)
    • Increases cAMP, relaxes smooth muscle
    • Primary indication: Non-occlusive arterial disease
    • Criterion for use:
      • Peritoneal signs absent
      • Cannot undergo surgery
      • Must have good distal perfusion bed
therapy pharmacologic34
Therapy: Pharmacologic

Vasodilators (cont.)

  • Papaverine
    • Early SMA infusion reduces mortality to 40-50%1
    • Directed infusion via angiography
    • Rx: 24-48 hrs
      • Endpoints both clinical and angiographic
      • Subsequent surgery

1 Surg 1977;82:848-855

therapy pharmacologic35
Therapy: Pharmacologic

Thrombolysis

  • urokinase>streptokinase, rtPA
    • Short t½, easily reversed
    • Dose: high vs. low
      • 5,000 U/hr - 600,000 U/hr
    • Direct SMA infusion vs. operative placement

Am Surg 2004;70(7):600-604

therapy pharmacologic36
Therapy: Pharmacologic

Thrombolysis

  • Duration: minutes – 48 hrs1
    • too long → risk of bowel necrosis
    • Treat to re-establish flow vs. complete dissolution
    • > 48 hrs
      • Greater risk of bleeding
    • Discontinue
      • Worsening abdominal symptoms without evidence of thrombolysis
      • Bleeding
      • No angiographic improvement

1 JVIR 2005;16:317-329

slide37

Pooled Data

JVIR 2005;16:317-329

slide38

Outcomes

  • Technical success: 43/48
  • Technical failure: 5/48
  • Outcome most dependent on age of thrombus/embolus
  • Improvement of abd pain in 1st hour is a favorable prognostic sign
  • Technical success does not equal clinical success
  • Survival: 43/48
  • Safety

JVIR 2005;16:317-329

therapy pharmacologic39
Therapy: Pharmacologic

Thrombolysis

  • Criterion for use:
    • Embolic/thrombotic disease
    • Poor operative candidates
    • No contraindications to fibrinolytics
    • No bowel infarction (no peritonitis/acidosis)
  • Expansion of use to all patients without bowel infarction
therapy endovascular
Therapy: Endovascular

Angioplasty/Stenting

  • Long-term durability questioned vs. surgical repair
  • Utility in acute ischemia setting
  • Advantages:
    • Shorter duration of treatment than thrombolysis
    • Definitive treatment

JVIR 1999;10(7):861-867

therapy endovascular41
Therapy: Endovascular

Angioplasty/Stenting

  • Ideal for thrombotic lesions
    • Calcified ostial lesions
    • Flow-limiting dissections
    • Chronic occlusion
  • Advanced techniques for embolic lesions
    • Flow-limiting dissections
    • Embolectomy w/distal protection
therapy endovascular42
Therapy: Endovascular

J Vasc Surg 2003;38:692-8

therapy endovascular43
Therapy: Endovascular

Stenting Outcomes (Chronic, SMA/Celiac)

1998: Primary patency 100% at 14 mos (n=3)1

0% mortality

1999: Primary patency 74% at 18 mos (n=12)2

8.3% mortality <30 days

2003: Technical success 96% (n=26)3

Clinical success 88%

Primary patency at 34 mos 65%

Restenosis at 34 mos 12%

1 Cardiovasc Int Radiol 1998;21:305-313

2 JVIR 1999;10(7):861-867

3 J Vasc Surg 2003;38:692-8I

therapy endovascular stenting
Therapy: Endovascular Stenting

Indications

  • Simple stenotic lesions
  • Complex lesions (long-segment, irregular, heavily calcified)
  • Total occlusion

Contraindications

  • Suspected bowel necrosis (peritonitis, acidosis, etc)
  • diffuse distal disease
  • Median arcuate ligament compression syndrome

1 J Vasc Surg 2003;38(4):692-8

surgery
Surgery

Anyone with peritonitis needs to be explored.

  • Midline incision
  • Evaluate extent of ischemia
  • Doppler of entire SMA
  • Revascularization (embolectomy vs. bypass)
  • Re-evaluate ischemia
  • Lastly, non-viable bowel must be resected
surgery options for revascularization
Surgery:Options for Revascularization

Ann Vasc Surg 2003;17:72-79

surgery principles
If embolus suspected, transverse arteriotomy proximal to middle colic takeoff

Embolectomy

Allow reperfusion for 20-30 minutes and then re-assess bowel viability

Surgery:Principles

Curr Opin Cardiol 1999;14(5):453-460

surgery options for revascularization48
Thrombosis requires a bypass

Longitudinal arteriotomy

Thrombectomy

Inflow adequate: 

Inflow inadequate:

Bypass

Vein vs. graft

Surgery:Options for Revascularization

Curr Opin Cardiol 1999;14(5):453-460

surgery options for revascularization49
Surgery:Options for Revascularization

Curr Opin Cardiol 1999;14(5):453-460

surgery damage control
24-hr second look operation

Ischemia continues after acute event and reperfusion

No way to determine viability initially

Allows time for supportive measures to recover tissue

Surgery:Damage Control
surgery options
Surgery:Options

Case Reports

  • Angiography + Laparoscopy
outcomes after surgery
20011

30 day mortality

Embolic 59%

Thrombotic 62%

20022

30 day mortality 32%

1 year mortality 57%

3 year mortality 68%

20033

Peri-op mortality 62%

20034

Peri-op mortality 15%

20055

Peri-op mortality 35%

Outcomes After Surgery

1 Ann Surg 2001;233(6):801-808

2 J Vasc Surg 2002;35:445-52

3 Ann Vasc Surg 2003;17:72-79

4 Vasc Endovasc Surg 2003;37:245-252

5 W J Surg 2005;29:645-648

outcomes after surgery53
Outcomes After Surgery

J Vasc Surg 2002;35:445-52

outcomes after surgery54
Outcomes After Surgery

Ann Vasc Surg 2003;17:72-79

outcomes
TPN dependence:

8-31%1,2

Significant morbidity

No studies comparing stenting vs. open surgery

No studies comparing embolectomy vs. bypass

Early intervention most important factor for survival

Outcomes

1 J Vasc Surg 2002;35:445-52

2 Ann Surg 2001;233:801-808

management of mesenteric vein thrombosis
Management of Mesenteric Vein Thrombosis
  • 5-10% of mesenteric ischemia
  • Subacute vs. chronic
  • Better prognosis
  • Diagnosis: CT scanning, venography
  • Therapy: anticoagulation, thrombolysis
    • surgery if bowel compromise suspected
  • No role for venous thrombectomy
  • Long-term anticoagulation
  • Hypercoaguable workup

1 JVIR 2005;16:317-329

2 Surg Lap Endo Perc Tech 2003;13(3):215-217

what should you do
What Should You Do?

Supportive

  • IV heparin
  • Broad-spectrum antibiotics
  • Hemodynamic optimization
    • Volume status
    • Cardiac function
slide58

Supportive Measures

AXR

Other cause (perforated viscous)

Peritonitis

Yes

No

Not sure??

(? Laparoscopy)

Suspect arterial occlusion

  • Prompt laparotomy
  • Open bypass vs. Angiography ± Stenting

CT Angio

Arterial occlusion

Abdominal angiogram

Venous occlusion

  • Filling of SMA
  • Good collaterals
  • SMA occluded
  • No collaterals

± Second look

Thrombolysis

  • Open bypass vs. Angiography ± Stenting

Anticoagulation

Anticoagulation

Anticoagulation

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