Dr. Ahmed Abdallah Eisawy

MBBS M.Sc MD

Chronic Mesenteric Ischemia

CMI

Abdominal Angina (AA)

Imaging

acute or chronic

arterial or venous

occlusive or non-occlusive

Coeliac Axis

Superior Mesenteric Artery

Inferior Mesenteric Artery

A_ foregut supply by ceiolic artery or trunk

B_midgut supply by superior mesenteric artery

C_ hind gut supply by inferior mesenteric artery

Coeliac Axis

Splenic Artery

Common

Hepatic

Artery

Left HA

Right HA

Left Gastric Artery

Gastro-

duodenal

Artery

Superior

Pancreatico-

duodenal

artery

Right Gastro-epiploic Artery

SMA

Inferior Pancreatico-duodenal Artery

Jejunal

Branch

Ileal Branch

Middle

Colic

Artery

Right Colic

Artery

Ileocolic

Artery

Left Colic Artery

Sigmoid

branches

Superior

Hemorrhoidal

artery

IMA

Pancreatico

-duodenal

arteries Marginal

artery of

Drummond &

paracolic

arcade

Reverse flow from

the internal iliac

artery

Abdominal Angina (AA)

CMI

It is a disorder characterized by the classical triad of:

Recurrent transient episodes of post-

prandial abdominal pain

Steatorrhoea with sever loss of weight

The patient’s avoidance of food

Patients present in their 50s or 60s

Male: Female = 1:3

Causes :

atherosclerosis

Arteritis.

Fibro-muscular hyperplasia.

Pressure on the coeliec artery by the crus of the diaphragm.

1. Plain : Normal or dilated loops.

2. Ba. :

Dilated loops with thick oedematous folds.

Thumb printing, fold thickening and separation of bowel loops.

CT:

Confirms bowel dilatation and wall thickening.

Show the thrombus in artery or vein.

Confirms the presence of air in the bowel wall and portal venous system.

Diagnostic

Interventional

I. Abdominal Imaging Plain Film Barium Studies Contrast material-enhanced CT Ultrasonography Magnetic resonance cholangiography

II. Imaging of Visceral Arteries Duplex Ultrasound CT angiography MR angiography Conventional angiography

US&DUPLEX

Normal Celiac Artery

Uniform velocities and

waveform configuration

High-diastolic flow feeding a

low resistance bed

No turbulence

PSV 150 cm/sec

EDV 20 cm/sec

IMA similar to SMA but high RI

CELIAC similar but high diastolic velocity

Normal spectral waveforms in the superior mesenteric artery. (a) Fasting waveform from a 26-day-old neonate shows a high-resistance flow pattern .

(b) Postprandial waveform

from a 6-day-old neonate

shows a low-resistance

pattern with an increase

in diastolic flow velocity .

Arises 1.5 cm below celiac

Just superior to renal arteries

LRV passes underneath SMA

ARISES FROM LEFT ,ANTERIOR ASPECT OF AORTA

JUST DISTAL TO ITS DIVISION

COURSES INFERIOR AND SLIGHT TO LEFT

MAY BE ONLY 1-3 MM IN DIAMETER

Uniform velocities and waveform configuration

Low diastolic feeding a high resistent bed vascular

In a fasting patient

No turbulence

Stenosis 70% or greater

PSV < 200 cm/sec

EDV < 55 cm/sec

High-grade stenosis at the origin of the celiac trunk and superior mesenteric artery in a patient with abdominal angor; pulsed Doppler measurements show peak velocities of over 250 cm/sec and turbulence

Stenosis 70% or greater

PSV < 275 cm/sec

EDV < 45 cm/sec

Focal increase in velocity

Post-stenotic turbulence

Stenosis 70% or greater

PSV < 200 cm/sec

EDV < 45 cm/sec

Focal increase in velocity

Post-stenotic turbulence

No detectable Doppler flow

Collateral pathways visualized

Increase in velocities may be noted in remaining patent

Splanchnic vessels

Accurate imaging modality used for screening of proximal coeliac & SMA.

Gives anatomic & functional information.

PSV > 275 and 200cm/s is highly specific for 70% artery stenosis

EDV > 45 cm/s is more accurate.

Spiral CT and rapid bolus injection of CM

Multidetector row CT provides more detailed information. 3D volume rendering and MIP imaging.

http://radiographics.rsnajnls.org/cgi/content/full/21/6/1463/F11A

http://radiographics.rsnajnls.org/cgi/content/full/21/6/1463/F10

Takayasu SMA narrowing, Takayasu arteritis.

show high-grade stenoses at the origins of the celiac trunk and SMA.

Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

Multi-detector row CT angiogram

shows a mildly stenotic celiac trunk

and a high-grade atherosclerotic

obstruction of the SMA. The IMA is not

seen

SMA

Digital subtraction angiogram (DSA)

Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in ). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

6 months after stent placement to assess patency show that the stent is correctly positioned,

Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA

Time of Flight MRA

PC MRA

2D ECG gated cine PC MRA

Systolic-gated 3D PC MRA

3D Gd-enhanced MRA

AP projection

Lateral

projection

With or without digital enhancement, provides the most information in defining the anatomy of splanchnic arteries.

Collateral vessels are best visualized on AP projections.

Lateral view is essential in establishing osteal narrowing.

1. Acute Mesenteric Ischemia

2. Retroperitoneal or coelio-mesenteric Malignancy

3. Median Arcuate ligament syndrome

4. Mesenteric venous thrombosis

5. Gastroduodenal Ulcer

6. Non-occlusive Vascular lesions: Aneurysms & dissections.

Percutaneous Transluminal Angioplasty (PTA)

In stenotic or short occlusive lesions & in patients at high surgical risk.

Revascularization is performed in only one obstructive lesion.

SMA revascularization should be attempted before that of CA.

Occlusion: fibrinolytic agents prior to passing catheter.

Stent placement.

Complications: haematoma, spasm & thrombosis, dissection and acute ischemia.

Doppler Ultrasound

PTA in suspected re-stenosis