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Digestive Disease Interventions 2022; 06(04): 317-322
DOI: 10.1055/s-0042-1757764
Review Article

Acute Mesenteric Ischemia: Evaluation, Management, and Interventions

Claire S. Kaufman 
1   Department of Interventional Radiology, Dotter Interventional Institute, Oregon Health Sciences University, Portland, Oregon
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Abstract

Acute mesenteric ischemia (AMI) is a dreaded, highly morbid pathology. Often this is due to acute occlusion of the superior mesenteric artery. This can be from thrombus or embolism; however, AMI can also be the result of mesenteric venous thrombus or nonocclusive mesenteric ischemia. There have been many recent advances in diagnosis and treatment including endovascular therapies. While there is increasing data to support an endovascular first approach, with improved 30-day mortality rates and in-hospital mortality, many patients will still require surgical intervention at some point. This article will review AMI for the interventional radiologist including etiologies, diagnosis, and management.

Keywords

acute mesenteric ischemia - embolism - thrombosis - nonocclusive mesenteric hypoperfusion syndrome - mesenteric venous thrombosis


Publication History

Received: 08 August 2022

Accepted: 07 September 2022

Article published online:
20 October 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Tilsed JV, Casamassima A, Kurihara H. et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg 2016; 42 (02) 253-270
    CrossrefPubMedGoogle Scholar
  • 2 Erben Y, Protack CD, Jean RA. et al. Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia. J Vasc Surg 2018; 68 (02) 459-469
    CrossrefPubMedGoogle Scholar
  • 3 Cokkinis AJ. Mesenteric Vascular Occlusion: Supplemented by an Appendix of 76 Original Cases. London: Bailliere, Tindall and Cox; 1926
    CrossrefGoogle Scholar
  • 4 Björck M, Koelemay M, Acosta S. et al; ESVS Guidelines Committee. Editor's choice - management of the diseases of mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 53 (04) 460-510
    CrossrefPubMedGoogle Scholar
  • 5 Erben Y, Spaulding AC, Oderich GS. et al. Acute mesenteric ischemia remains a highly morbid diagnosis after initial hospitalization survival. Int J Angiol 2020; 29 (03) 189-195
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg 2004; 91 (01) 17-27
    CrossrefPubMedGoogle Scholar
  • 7 Kärkkäinen JM. Acute mesenteric ischemia: a challenge for the acute care surgeon. Scand J Surg 2021; 110 (02) 150-158
    CrossrefPubMedGoogle Scholar
  • 8 Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (part I) - incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol 2017; 31 (01) 15-25
    CrossrefPubMedGoogle Scholar
  • 9 Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Intern Med 2004; 164 (10) 1054-1062
    CrossrefPubMedGoogle Scholar
  • 10 Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer Jr RM. Surgical management of thrombotic acute intestinal ischemia. Ann Surg 2001; 233 (06) 801-808
    CrossrefPubMedGoogle Scholar
  • 11 Bergqvist D, Svensson PJ. Treatment of mesenteric vein thrombosis. Semin Vasc Surg 2010; 23 (01) 65-68
    CrossrefPubMedGoogle Scholar
  • 12 Patel SD, Constantinou J, Hamilton H, Davis M, Ivancev K. Editor's choice - a shaggy aorta is associated with mesenteric embolisation in patients undergoing fenestrated endografts to treat paravisceral aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 47 (04) 374-379
    CrossrefPubMedGoogle Scholar
  • 13 Bala M, Kashuk J, Moore EE. et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2017; 12: 38
    CrossrefPubMedGoogle Scholar
  • 14 Liao G, Chen S, Cao H, Wang W, Gao Q. Review: acute superior mesenteric artery embolism: a vascular emergency cannot be ignored by physicians. Medicine (Baltimore) 2019; 98 (06) e14446
    CrossrefPubMedGoogle Scholar
  • 15 Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109 (14) 249-256
    CrossrefPubMedGoogle Scholar
  • 16 Bourcier S, Klug J, Nguyen LS. Non-occlusive mesenteric ischemia: diagnostic challenges and perspectives in the era of artificial intelligence. World J Gastroenterol 2021; 27 (26) 4088-4103
    CrossrefPubMedGoogle Scholar
  • 17 Al-Diery H, Phillips A, Evennett N, Pandanaboyana S, Gilham M, Windsor JA. The pathogenesis of nonocclusive mesenteric ischemia: implications for research and clinical practice. J Intensive Care Med 2019; 34 (10) 771-781
    CrossrefPubMedGoogle Scholar
  • 18 Kolkman JJ, Mensink PB. Non-occlusive mesenteric ischaemia: a common disorder in gastroenterology and intensive care. Best Pract Res Clin Gastroenterol 2003; 17 (03) 457-473
    CrossrefPubMedGoogle Scholar
  • 19 Björck M, Wanhainen A. Nonocclusive mesenteric hypoperfusion syndromes: recognition and treatment. Semin Vasc Surg 2010; 23 (01) 54-64
    CrossrefPubMedGoogle Scholar
  • 20 Montagnana M, Danese E, Lippi G. Biochemical markers of acute intestinal ischemia: possibilities and limitations. Ann Transl Med 2018; 6 (17) 341
    CrossrefPubMedGoogle Scholar
  • 21 van den Heijkant TC, Aerts BA, Teijink JA, Buurman WA, Luyer MD. Challenges in diagnosing mesenteric ischemia. World J Gastroenterol 2013; 19 (09) 1338-1341
    CrossrefPubMedGoogle Scholar
  • 22 Pérez-García C, de Miguel Campos E, Fernández Gonzalo A. et al. Non-occlusive mesenteric ischaemia: CT findings, clinical outcomes and assessment of the diameter of the superior mesenteric artery. Br J Radiol 2018; 91 (1081): 20170492
    CrossrefPubMedGoogle Scholar
  • 23 Brandt LJ, Boley SJ. American Gastrointestinal Association. AGA technical review on intestinal ischemia. Gastroenterology 2000; 118 (05) 954-968
    CrossrefPubMedGoogle Scholar
  • 24 Donaldson JK, Stout BF. Mesenteric thrombosis: (arterial and venous types as separate clinical entities) a clinical and experimental study. Am J Surg 1935; 29: 208-217
    CrossrefPubMedGoogle Scholar
  • 25 Dewitte A, Biais M, Coquin J. et al. [Diagnosis and management of acute mesenteric ischemia]. Ann Fr Anesth Reanim 2011; 30 (05) 410-420
    PubMedGoogle Scholar
  • 26 Aschoff AJ, Stuber G, Becker BW. et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging 2009; 34 (03) 345-357
    CrossrefPubMedGoogle Scholar
  • 27 Hawthorn BR, Ratnam LA. Acute mesenteric ischaemia: imaging and intervention. Clin Radiol 2020; 75 (05) 398.e19-398.e28
    CrossrefPubMedGoogle Scholar
  • 28 Saranteas T, Kostopanagiotou G, Panou F. Transesophageal echocardiographic examination in the diagnosis of bowel ischemia due to thoracic aorta thrombosis. J Cardiothorac Vasc Anesth 2012; 26 (02) e14-e15
    CrossrefPubMedGoogle Scholar
  • 29 Oliva IB, Davarpanah AH, Rybicki FJ. et al. ACR Appropriateness Criteria® imaging of mesenteric ischemia. Abdom Imaging 2013; 38 (04) 714-719
    CrossrefPubMedGoogle Scholar
  • 30 Morasch MD, Ebaugh JL, Chiou AC, Matsumura JS, Pearce WH, Yao JS. Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 2001; 34 (04) 680-684
    CrossrefPubMedGoogle Scholar
  • 31 Cenedese A, Monneuse O, Gruner L, Tissot E, Mennesson N, Barth X. Initial management of extensive mesenteric venous thrombosis: retrospective study of nine cases. World J Surg 2009; 33 (10) 2203-2208
    CrossrefPubMedGoogle Scholar
  • 32 Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route. Abdom Imaging 2011; 36 (04) 390-398
    CrossrefPubMedGoogle Scholar
  • 33 Corcos O, Nuzzo A. Gastro-intestinal vascular emergencies. Best Pract Res Clin Gastroenterol 2013; 27 (05) 709-725
    CrossrefPubMedGoogle Scholar
  • 34 Sise MJ. Mesenteric ischemia: the whole spectrum. Scand J Surg 2010; 99 (02) 106-110
    CrossrefPubMedGoogle Scholar
  • 35 Zettervall SL, Lo RC, Soden PA. et al. Trends in treatment and mortality for mesenteric ischemia in the United States from 2000 to 2012. Ann Vasc Surg 2017; 42: 111-119
    CrossrefPubMedGoogle Scholar
  • 36 Najdawi M, Garzelli L, Nuzzo A. et al. Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit. Eur Radiol 2022; 32 (08) 5606-5615
    CrossrefPubMedGoogle Scholar
  • 37 Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (Part II) - vascular and endovascular surgical approaches. Best Pract Res Clin Gastroenterol 2017; 31 (01) 27-38
    CrossrefPubMedGoogle Scholar
  • 38 Kärkkäinen JM, Lehtimäki TT, Saari P. et al. Endovascular therapy as a primary revascularization modality in acute mesenteric ischemia. Cardiovasc Intervent Radiol 2015; 38 (05) 1119-1129
    CrossrefPubMedGoogle Scholar
  • 39 Fidelman N, AbuRahma AF, Cash BD. et al; Expert Panel on Interventional Radiology. ACR Appropriateness Criteria® radiologic management of mesenteric ischemia. J Am Coll Radiol 2017; 14 (5S): S266-S271
    CrossrefPubMedGoogle Scholar
  • 40 Stahl K, Busch M, Maschke SK. et al. A retrospective analysis of nonocclusive mesenteric ischemia in medical and surgical ICU patients: clinical data on demography, clinical signs, and survival. J Intensive Care Med 2020; 35 (11) 1162-1172
    CrossrefPubMedGoogle Scholar
  • 41 Clark RA, Gallant TE. Acute mesenteric ischemia: angiographic spectrum. AJR Am J Roentgenol 1984; 142 (03) 555-562
    CrossrefPubMedGoogle Scholar
  • 42 Klotz S, Vestring T, Rötker J, Schmidt C, Scheld HH, Schmid C. Diagnosis and treatment of nonocclusive mesenteric ischemia after open heart surgery. Ann Thorac Surg 2001; 72 (05) 1583-1586
    CrossrefPubMedGoogle Scholar
  • 43 Ernst S, Luther B, Zimmermann N. et al. [Current diagnosis and therapy of non-occlusive mesenteric ischemia]. Röfo Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr 2003; 175 (04) 515-523
    PubMedGoogle Scholar
  • 44 Winzer R, Fedders D, Backes M. et al. Local intra-arterial vasodilator infusion in non-occlusive mesenteric ischemia significantly increases survival rate. Cardiovasc Intervent Radiol 2020; 43 (08) 1148-1155
    CrossrefPubMedGoogle Scholar
  • 45 Rebelo A, Mammadov M, Partsakhashvili J. et al. Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery. BMC Surg 2022; 22 (01) 56
    CrossrefPubMedGoogle Scholar
  • 46 Björck M, Acosta S, Lindberg F, Troëng T, Bergqvist D. Revascularization of the superior mesenteric artery after acute thromboembolic occlusion. Br J Surg 2002; 89 (07) 923-927
    CrossrefPubMedGoogle Scholar
  • 47 Kougias P, Lau D, El Sayed HF, Zhou W, Huynh TT, Lin PH. Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia. J Vasc Surg 2007; 46 (03) 467-474
    CrossrefPubMedGoogle Scholar
  • 48 Yun WS, Lee KK, Cho J, Kim HK, Huh S. Treatment outcome in patients with acute superior mesenteric artery embolism. Ann Vasc Surg 2013; 27 (05) 613-620
    CrossrefPubMedGoogle Scholar
  • 49 Park WM, Gloviczki P, Cherry Jr KJ. et al. Contemporary management of acute mesenteric ischemia: factors associated with survival. J Vasc Surg 2002; 35 (03) 445-452
    CrossrefPubMedGoogle Scholar
  • 50 Acosta S, Wadman M, Syk I, Elmståhl S, Ekberg O. Epidemiology and prognostic factors in acute superior mesenteric artery occlusion. J Gastrointest Surg 2010; 14 (04) 628-635
    CrossrefPubMedGoogle Scholar
  • 51 Gagnière J, Favrolt G, Alfidja A. et al. Acute thrombotic mesenteric ischemia: primary endovascular treatment in eight patients. Cardiovasc Intervent Radiol 2011; 34 (05) 942-948
    CrossrefPubMedGoogle Scholar
  • 52 Blauw JT, Meerwaldt R, Brusse-Keizer M, Kolkman JJ, Gerrits D, Geelkerken RH. Multidisciplinary Study Group of Mesenteric Ischemia. Retrograde open mesenteric stenting for acute mesenteric ischemia. J Vasc Surg 2014; 60 (03) 726-734
    CrossrefPubMedGoogle Scholar
  • 53 Hawkins BM, Khan Z, Abu-Fadel MS, Exaire JE, Saucedo JF, Hennebry TA. Endovascular treatment of mesenteric ischemia. Catheter Cardiovasc Interv 2011; 78 (06) 948-952
    CrossrefPubMedGoogle Scholar
  • 54 Block TA, Acosta S, Björck M. Endovascular and open surgery for acute occlusion of the superior mesenteric artery. J Vasc Surg 2010; 52 (04) 959-966
    CrossrefPubMedGoogle Scholar
  • 55 Swerdlow NJ, Varkevisser RRB, Soden PA. et al. Thirty-day outcomes after open revascularization for acute mesenteric ischemia from the American College of Surgeons National Surgical Quality Improvement Program. Ann Vasc Surg 2019; 61: 148-155
    CrossrefPubMedGoogle Scholar
  • 56 Arthurs ZM, Titus J, Bannazadeh M. et al. A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg 2011; 53 (03) 698-704 , discussion 704–705
    CrossrefPubMedGoogle Scholar
  • 57 Salsano G, Salsano A, Sportelli E. et al. What is the best revascularization strategy for acute occlusive arterial mesenteric ischemia: systematic review and meta-analysis. Cardiovasc Intervent Radiol 2018; 41 (01) 27-36
    CrossrefPubMedGoogle Scholar
  • 58 Beaulieu RJ, Arnaoutakis KD, Abularrage CJ, Efron DT, Schneider E, Black III JH. Comparison of open and endovascular treatment of acute mesenteric ischemia. J Vasc Surg 2014; 59 (01) 159-164
    CrossrefPubMedGoogle Scholar