Stenosis of superior mesenteric artery – can endoscopic ultrasound become a diagnostic method of choice?

Aims Mesenteric ischemia is a rare condition caused by a reduction in the intestinal blood flow and can be classified as acute or chronic depending on the time course of symptoms. The main etiological factor is atherosclerotic narrowing of the origins of the celiac or superior mesenteric arteries (SMAs), but clinical manifestations are rare. Due to the importance of timely diagnosis, guidelines recommend to perform the computed tomographic (CT) angiography as a gold standard in the patients with suggestive symptoms. The aim of this study was to present the diagnostic dilemmas in determining clinically significant stenosis of SMA that manifested with recurrent episodes of acute postprandial abdominal pain (also known as "intestinal angina") and significant weight loss.

Methods This prospective study recruited 11 patients with SMA stenosis admitted to the Division of Gastroenterology and Hepatology, University Hospital Center ‘’Sestre milosrdnice’’, Zagreb, from January 2018 to December 2022. Initial abdominal ultrasound with Duplex scanning and Doppler flowmetry was used to make diganosis [peak systolic velocity greater than 3 m/s (PSV>3 m/s) and end diastolic velocity greater than 45 cm/s (EDV>45 cm/s)]. Furthermore, CT angiography was performed in all patients to confirm the diagnosis. Patients with SMA stenosis greater than 50% were treated with an endovascular revascularization procedure [percutaneous transluminal mesenteric angioplasty with stenting (PTMAS)]. Patients were followed up for three months after the procedure.Endoscopic ultrasound with Doppler flowmetry (EUSDF) was initially used in a portion of patients with a suspected tumor of the pancreas. [1] [2] [3]

Results 90% of patients were female, mean age 75 years (±10.3 years). All patients had significant SMA stenosis (PSV>3 m/s and EDV>45 cm/s) seen on Doppler flowmetry. Additionally, in three patients the SMA stenosis was suspected on endoscopic ultrasound Doppler flowmetry (EUSDF). The diagnosis was confirmed using CT angiography. The cause of stenosis in all patients was generalized atherosclerotic disease while the main risk factors were smoking (50% of patients) and diabetes mellitus type 2 (60% of patients). 3 patients did not consent to endovascular procedure and were treated conservatively (acetylsalicylic acid). PTMAS was carried out in 6 patients and surgery revascularization was performed in one patient. One patient died from SMA thrombosis while awaiting PTMAS. All patients treated with PTMAS and surgical had resolution of abdominal pain and significant weight gain in the follow up period.

Conclusions Doppler flowmetry is a diagnostic method of choice in patients with suspected SMA stenosis with EUSDF being valuable auxiliary diagnostic tool. Due to small sample size, further investigation is needed to position the role of EUSDF in the diagnosis of SMA stenosis.

Publication History

Article published online:
15 April 2024

• References

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