CT diagnosis of Acute mesenteric ischemia from various causes
S ymptomatic mesenteric ischemia is an often delayed diagnosis with typically slow progressive...
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Symptomatic mesenteric ischemia is an often delayed diagnosis with typically slow progressive complaints. Risk factors for chronic mesenteric ischemia are same as those for arteriosclerosis, such as diabetes, hyperlipidemia and previous surgeries. Given the anatomy of collateral circulation, significant multivessel mesenteric disease is required for clinical presentation. There is limited literature for direct measurements of mesenteric vessel pressures and induction of hyperemia using pressure wire technology. Pressure wire measurements yield an objective measure of vessel lesion and flow reserve standardized as a percentage under condition of induced hyperemia using agents such as adenosine. Pressure Wire and Fractional Flow Reserve (FFR) has been shown to be predictive of patient disease outcome especially in the setting of risk factors such as diabetes. The Fractional Flow Reserve (FFR) measurements in induced hyperemia correlate closely to the clinical picture and outcome in coronary arteries. It is a measure of physiologic pressure before and after a lesion and presented as a ratio. We used an FFR value of 0.74 as a cutoff for normal arterial response Introduction: Use of Fractional Flow Reserve and Induction Use of Fractional Flow Reserve and Induction of Hyperemia in Evaluation of Mesenteric of Hyperemia in Evaluation of Mesenteric Ischemia Ischemia Islam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MD Islam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MD Division of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell Consultants Division of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell Consultants Clinical Case: A 76-year old man presented with seven year history of recurrent episodes of abdominal pain and intermittent bloody stools especially after large meals for the past one year. Given his progressive complaints the patient required admission for extensive evaluation. Of note, he had received radiation therapy of the abdomen seven year prior. Physical exams, colonoscopy, and computed tomography failed to show any obvious cause for his continuing complaints. Magnetic Resonance Angiography revealed an area of patent narrowing at the origin of the celiac trunk Methods: Left heart catheterization demonstrated no significant angiographic disease Mesenteric angiography demonstrated an ostial stenosis of the celiac trunk, and a mild stenosis of the superior mesenteric artery Pressure wire measurements were obtained of the celiac, superior mesenteric and inferior mesenteric arteries Conclusions: Measurements of FFR are objectively predictive of the tissue perfusion, viability, and long-term outcome as demonstrated on laparotomy. Considering this diagnosis and performing the evaluation with FFR early can help reduce morbidity and recurrence similar to evaluating coronary arteries. There no literature describing the use of FFR, or adequate induction of hyperemia in patients with mesenteric disease. Further studies are needed. Use of pressure wire in non-coronary arteries is feasible and may help risk-stratify patients leading to earlier therapeutic options such as surgery, percutaneous intervention, or medical management. References: 1. Panagoulias G, Tentolouris, Ladas, SS., etal. Abdominal Pain in an adult with Type 2 Diabetes. Cases J. 2008 Sep 17;1(1) :154 2. Beleslin B, Ostojic M, Djordjevic-Dikic A., etal. The value of fractional and coronary flow reserve in predicting myocardial recovery in patients with previous myocardial infarction. Eur Heart J. 2008 Nov;29(21):2617-24. Epub 2008 Sep 30 3. Kocaman SA, Sahinarslan A,. etal. The delta fractional flow reserve can predict lesion severity and long-term prognosis. Atherosclerosis 2008 Jun 20 4. de Bruyne B, Bartunek J., etal. Simultaneous coronary pressure and flow velocity measurements in humans. Feasibility, reproducibility, and hemodynamic dependence of coronary flow velocity reserve, hyperemic flow versus pressure slope index, and fractional flow reserve. Circulation. 1996 Oct 15;94(8):1842-9 5. Lawrence Garcia, M.D., Joseph Carrozza, M.D. Physiologic Evaluation of Translesion Pressure Gradients in Peripheral Arteries: Comparison of Pressure Wire and Catheter-Derived Measurements. Journal of Interventional Cardiology (2008; Vol. 20, Issue 1: 63-65 6. Nico H J Pijls, Pepijn van Schaardenburgh,.etal. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol. 2007 May 29;49 (21):2105- 11 7. Murtagh B, Higano S, Lennon R,. etal. Role of incremental doses of intracoronary adenosine for fractional flow reserve assessmen. Am Heart J. 2003 Jul;146(1):99-105. 8. McGeoch RJ, Oldroyd KG. Pharmacological options for inducing maximal hyperaemia during studies of coronary physiology. Catheter Cardiovasc Interv. 2008 Feb 1;71(2):198-204 9. Koo BK, Kim CH,. Etal. Intracoronary continuous adenosine infusion. Circulation 2005 Aug;69(8):908-12 10.Jones NJ, Bates ER, Chetcuti SJ, etal. Usefulness of translesional pressure gradient and pharmacological provocation for the assessment of intermediate renal artery disease. Catheter Cardiovasc Interv. 2006 Sep;68(3):429-34 11.Rieber J, Huber A, Erhard I., etal. Cardiac magnetic resonance perfusion imaging for the functional assessment of coronary artery disease: a comparison with coronary angiography and fractional flow reserve. Eur Heart J. 2006 Jun;27(12):1465-71. Epub 2006 May 23 12.Subramanian R, White CJ, Rosenfield K,. etal. Renal fractional flow reserve: a hemodynamic evaluation of moderate renal artery stenoses. Catheter Cardiovasc Interv. 2005 Apr;64(4):480-6 13.Aude, Y. W.; Garza, L. How to prevent unnecessary coronary interventions: identifying lesions responsible for ischemia in the cath lab. Current Opinion in Cardiology. 2003 Vol18(5) 394-399 14.Amaya, K.; Takazawa, K.; Tanaka, N.; Yamashina, A. Prediction of in-stent restenosis by measurement of fractional flow reserve and the influence of diabetes mellitus. Journal of Cardiology. 2002 Vol 39(6) 293-298 15.lbertal, M.; Voskuil, M.; Piek, J. J.; de Bruyne, B.; etal. Coronary flow velocity reserve after percutaneous interventions is predictive of periprocedural outcome. Circulation. 2002 Vol 105(13) 1573-1578 Results: The celiac trunk had a 95% angiographic stenosis with baseline FFR 0.79. At maximum hyperemia FFR was below 0.71 The superior mesenteric artery (SMA) had 90% stenosis with FFR of 0.84. At maximum hyperemia FFR was 0.78 The inferior mesenteric artery (IMA) had 30% stenosis with baseline FFR of 0.92 The patient became acutely ill the following day. Emergency laparotomy uncovered ischemic small intestine and proximal colon mainly at the distribution of the celiac and superior mesenteric arteries consistent with our angiographic findings. Left colon at the distribution of IMA was unaffected. The patient underwent extensive abdominal surgery, resection of the ischemic small bowel to the Figure 1. Angiographic images showing the ostial stenosis of the celiac trunk (left) and pressure wire in the artery (right) Figure 4. Pressure tracings for the celiac trunk prior to adenosine infusion Figure 6. Celiac Trunk angiography and stent placement Figure 2. Superior mesenteric artery after infusion of adenosine showing a borderline response Figure 5. Pressure tracings for the celiac trunk after adenosine infusion demonstrating a significant pressure drop Patient History Peripheral infusion of Adenosine was given to induce hyperemia and improve the pressure wire diagnostic sensitivity Figure 3. Inferior mesenteric artery after infusion of adenosine showing a normal response, and no significant pressure drop
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Transcript of S ymptomatic mesenteric ischemia is an often delayed diagnosis with typically slow progressive...
Symptomatic mesenteric ischemia is an often delayed diagnosis with typically slow progressive complaints. Risk factors for chronic mesenteric ischemia are same as those for arteriosclerosis, such as diabetes, hyperlipidemia and previous surgeries. Given the anatomy of collateral circulation, significant multivessel mesenteric disease is required for clinical presentation. There is limited literature for direct measurements of mesenteric vessel pressures and induction of hyperemia using pressure wire technology.
Pressure wire measurements yield an objective measure of vessel lesion and flow reserve standardized as a percentage under condition of induced hyperemia using agents such as adenosine. Pressure Wire and Fractional Flow Reserve (FFR) has been shown to be predictive of patient disease outcome especially in the setting of risk factors such as diabetes. The Fractional Flow Reserve (FFR) measurements in induced hyperemia correlate closely to the clinical picture and outcome in coronary arteries. It is a measure of physiologic pressure before and after a lesion and presented as a ratio.
We used an FFR value of 0.74 as a cutoff for normal arterial response
Introduction:
Use of Fractional Flow Reserve and Induction of Hyperemia Use of Fractional Flow Reserve and Induction of Hyperemia in Evaluation of Mesenteric Ischemiain Evaluation of Mesenteric Ischemia
Islam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MDIslam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MDDivision of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell ConsultantsDivision of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell Consultants
Use of Fractional Flow Reserve and Induction of Hyperemia Use of Fractional Flow Reserve and Induction of Hyperemia in Evaluation of Mesenteric Ischemiain Evaluation of Mesenteric Ischemia
Islam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MDIslam Abudayyeh MD MPH, Katayoun Seyedmadani PhD, Nabil Dib MDDivision of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell ConsultantsDivision of Cardiology Advocate Lutheran General Hospital, Arizona State Univerity, Cardiovascular and Stem Cell Consultants
Clinical Case:
A 76-year old man presented with seven year history of recurrent episodes of abdominal pain and intermittent bloody stools especially after large meals for the past one year. Given his progressive complaints the patient required admission for extensive evaluation. Of note, he had received radiation therapy of the abdomen seven year prior.
Physical exams, colonoscopy, and computed tomography failed to show any obvious cause for his continuing complaints.
Magnetic Resonance Angiography revealed an area of patent narrowing at the origin of the celiac trunk with difficulty visualizing the inferior mesenteric artery.
Methods: Left heart catheterization demonstrated no significant angiographic
disease
Mesenteric angiography demonstrated an ostial stenosis of the celiac trunk, and a mild stenosis of the superior mesenteric artery
Pressure wire measurements were obtained of the celiac, superior mesenteric and inferior mesenteric arteries
Conclusions: Measurements of FFR are objectively predictive of the tissue perfusion,
viability, and long-term outcome as demonstrated on laparotomy.
Considering this diagnosis and performing the evaluation with FFR early can help reduce morbidity and recurrence similar to evaluating coronary arteries.
There no literature describing the use of FFR, or adequate induction of hyperemia in patients with mesenteric disease. Further studies are needed.
Use of pressure wire in non-coronary arteries is feasible and may help risk-stratify patients leading to earlier therapeutic options such as surgery, percutaneous intervention, or medical management.
References:1. Panagoulias G, Tentolouris, Ladas, SS., etal. Abdominal Pain in an adult with Type 2 Diabetes. Cases J. 2008 Sep 17;1(1) :1542. Beleslin B, Ostojic M, Djordjevic-Dikic A., etal. The value of fractional and coronary flow reserve in predicting myocardial recovery in
patients with previous myocardial infarction. Eur Heart J. 2008 Nov;29(21):2617-24. Epub 2008 Sep 303. Kocaman SA, Sahinarslan A,. etal. The delta fractional flow reserve can predict lesion severity and long-term prognosis.
Atherosclerosis 2008 Jun 204. de Bruyne B, Bartunek J., etal. Simultaneous coronary pressure and flow velocity measurements in humans. Feasibility, reproducibility,
and hemodynamic dependence of coronary flow velocity reserve, hyperemic flow versus pressure slope index, and fractional flow reserve. Circulation. 1996 Oct 15;94(8):1842-9
5. Lawrence Garcia, M.D., Joseph Carrozza, M.D. Physiologic Evaluation of Translesion Pressure Gradients in Peripheral Arteries: Comparison of Pressure Wire and Catheter-Derived Measurements. Journal of Interventional Cardiology (2008; Vol. 20, Issue 1: 63-65
6. Nico H J Pijls, Pepijn van Schaardenburgh,.etal. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol. 2007 May 29;49 (21):2105-11
7. Murtagh B, Higano S, Lennon R,. etal. Role of incremental doses of intracoronary adenosine for fractional flow reserve assessmen. Am Heart J. 2003 Jul;146(1):99-105.
8. McGeoch RJ, Oldroyd KG. Pharmacological options for inducing maximal hyperaemia during studies of coronary physiology. Catheter Cardiovasc Interv. 2008 Feb 1;71(2):198-204
9. Koo BK, Kim CH,. Etal. Intracoronary continuous adenosine infusion. Circulation 2005 Aug;69(8):908-1210. Jones NJ, Bates ER, Chetcuti SJ, etal. Usefulness of translesional pressure gradient and pharmacological provocation for the
assessment of intermediate renal artery disease. Catheter Cardiovasc Interv. 2006 Sep;68(3):429-3411. Rieber J, Huber A, Erhard I., etal. Cardiac magnetic resonance perfusion imaging for the functional assessment of coronary artery
disease: a comparison with coronary angiography and fractional flow reserve. Eur Heart J. 2006 Jun;27(12):1465-71. Epub 2006 May 23
12. Subramanian R, White CJ, Rosenfield K,. etal. Renal fractional flow reserve: a hemodynamic evaluation of moderate renal artery stenoses. Catheter Cardiovasc Interv. 2005 Apr;64(4):480-6
13. Aude, Y. W.; Garza, L. How to prevent unnecessary coronary interventions: identifying lesions responsible for ischemia in the cath lab. Current Opinion in Cardiology. 2003 Vol18(5) 394-399
14. Amaya, K.; Takazawa, K.; Tanaka, N.; Yamashina, A. Prediction of in-stent restenosis by measurement of fractional flow reserve and the influence of diabetes mellitus. Journal of Cardiology. 2002 Vol 39(6) 293-298
15. lbertal, M.; Voskuil, M.; Piek, J. J.; de Bruyne, B.; etal. Coronary flow velocity reserve after percutaneous interventions is predictive of periprocedural outcome. Circulation. 2002 Vol 105(13) 1573-1578
Results: The celiac trunk had a 95% angiographic stenosis with baseline FFR
0.79. At maximum hyperemia FFR was below 0.71
The superior mesenteric artery (SMA) had 90% stenosis with FFR of 0.84. At maximum hyperemia FFR was 0.78
The inferior mesenteric artery (IMA) had 30% stenosis with baseline FFR of 0.92
The patient became acutely ill the following day. Emergency laparotomy uncovered ischemic small intestine and proximal colon mainly at the distribution of the celiac and superior mesenteric arteries consistent with our angiographic findings.
Left colon at the distribution of IMA was unaffected.
The patient underwent extensive abdominal surgery, resection of the ischemic small bowel to the level of the ileum, and resection of the proximal third of the large bowel.
Following the laparotomy the patient underwent abdominal angiography and stent placement at the ostium of the celiac trunk.
Figure 1. Angiographic images showing the ostial stenosis of the celiac trunk (left) and pressure wire in the artery (right)
Figure 4. Pressure tracings for the celiac trunk prior to adenosine infusionFigure 6. Celiac Trunk angiography and stent placement
Figure 2. Superior mesenteric artery after infusion of adenosine showing a borderline response
Figure 5. Pressure tracings for the celiac trunk after adenosine infusion demonstrating a significant pressure dropPatient History Peripheral infusion of Adenosine was given to induce hyperemia
and improve the pressure wire diagnostic sensitivity
Figure 3. Inferior mesenteric artery after infusion of adenosine showing a normal response, and no significant pressure drop
