Technique profile: mesenteric reconstructions for occlusive disease

Abstract

Visceral ischemic syndromes are rare but catastrophic disorders. In acute presentations, treatment modalities include thrombolytic therapy, open surgical revascularization and percutaneous endovascular therapy. Endovascular therapy has become the most commonly utilized treatment option for chronic mesenteric ischemia and should be considered the first line of therapy for patients with anatomically suitable lesions or excessive open surgical risk. Open surgical revascularization has been associated with outstanding long-term outcomes. The various surgical and endovascular techniques and their associated outcomes for the treatment of mesenteric ischemic syndromes are reviewed in detail.

Keywords:

• acute mesenteric ischemia
• chronic mesenteric ischemia
• endovascular therapy
• operative techniques
• surgical revascularization

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

Key issues

• The celiac, superior mesenteric and inferior mesenteric arteries, all of which arise directly from the aorta, provide sequentially blood supply to the fore-, mid- and hindgut.

• Acute mesenteric ischemia (AMI) is a surgical emergency. A high index of suspicion is required if one is to make an early diagnosis and decrease the mortality from this condition.

• The most common etiologies of AMI include acute superior mesenteric artery embolism (50%), in situ superior mesenteric artery thrombosis superimposed on chronic atherosclerosis (20%), non-occlusive mesenteric ischemia (NOMI, 20%) and mesenteric venous thrombosis (10%).

• Treatment modalities for AMI include systemic anticoagulation, thrombolytic therapy, surgical revascularization, percutaneous endovascular therapy (ET) and laparotomy in the majority of cases for bowel evaluation.

• ET treatment options include a combination of thrombolytic therapy, mechanical thrombectomy and balloon angioplasty, and most recently retrograde open mesenteric stenting.

• Chronic mesenteric ischemia (CMI) results from atherosclerosis in 90% of cases and classically presents with dull, cramping epigastric or mid-abdominal pain occurring shortly after eating. Weight loss is also a frequent finding in these patients.

• In patients suspected to have CMI, the extent of disease in the major blood vessels supplying the bowel should be carefully evaluated by imaging and selective arteriographic studies.

• Various surgical and endovascular techniques are available to treat CMI. Complete revascularization of both the celiac trunk and superior mesenteric artery should be performed if feasible.

• Operative surgical revascularization has been the mainstay of the treatment of CMI and remains the most durable long-term treatment option.

• ET has now become the most commonly utilized treatment option for CMI. Recent analyses have demonstrated no difference in mid-term reintervention rates or symptomatic recurrence compared with open surgical therapy.

• ET should be considered the first-line therapy for patients with CMI with anatomically suitable lesions or excessive open surgical risk.

Notes