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Mesenteric Ischemia

Brian J. Schiro, MDVascular and Interventional Radiology

Disclosures

• Speaker– CR Bard

– Penumbra

Objectives

• Review common causes of mesenteric ischemia and clinical presentations

• Understand acute vs chronic mesenteric ischemia

• Discuss treatment options for mesenteric ischemia

Vascular Causes of Abdominal Pain

• Atherosclerosis– Stenosis

– Occlusion

• Thromboembolic– Acute arterial

ischemia

• Infectious– Mycotic aneurysms

• Inflammatory– Vasculitis

• Dissection– Spontaneous– Traumatic

• Venous Thrombosis– Acute– Chronic

Celiac

Splenic

Common HepaticGastroduodenal (GDA)

Left Gastric

Middle Colic

Right Colic

Ileoolic

Marginal artery of Drummond

Pancreaticoduodenal artery

SMA

Jejunal Branches

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Left Colic

Superior Hemorrhoidal

Arc of Riolan

Lower left Colic

Marginal artery of DrummondIMAMesenteric Collateral Pathways

Pancreaticoduodenal Arcade Collateral from SMA to Celiac

Arc of Riolan from IMA to SMA

Chronic Mesenteric Ischemia Chronic Mesenteric Ischemia• Mesenteric ischemia results from inadequate blood supply to the

intestine, most commonly in post-prandial states.

• Presenting symptoms of chronic mesenteric ischemia include1:

– Abdominal pain (92%)

– Weight loss (87%)

– Diarrhea (44%), Anorexia (33%), Food fear (18%)

• Most common etiology is atherosclerotic disease

• Female (70%) > Male affected

• Classically 2/3 mesenteric vessels must have

significant disease for pt to be symptomatic

1Mateo RB, et al. J Vasc Surg 1999; 29: 821-32

Chronic Mesenteric Ischemia

SMA Stenosis Celiac Stenosis

AbuRahma et al. Mesenteric/celiac duplex ultrasound interpretation criteria revisited. JVS 2012

Chronic Mesenteric Ischemia• Gold standard historically was surgical bypass

• Endovascular therapy:

– Large series report technical success rates of 95-97%

– Reported complication rates range from 4-15%

• Gupta PK, et al. JEVT 2010; 17(4): 540-549

Metanalysis of 1939 patients, 20 year review

Symptom Improvement 2.4x favoring surgery

5-Year Primary Patency 3.8x favoring surgery

5-Year Primary Assisted Patency 6.4x favoring surgery

Freedom from Recurrent Symptoms 4.4x favoring surgery

Complications 3.2x favoring surgery

Mortality No significant difference

Endovascular therapy was often performed in sicker patients

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Chronic Mesenteric Ischemia

ACC/AHA Guidelines for Chronic Mesenteric Ischemia

Class I Recommendation

1. Percutaneous endovascular treatment of intestinal arterial stenosis is indicated in patients with chronic intestinal ischemia (Level of Evidence: B)

2. Surgical treatment of intestinal arterial stenosis/occlusion is indicated in patients with chronic intestinal ischemia (Level of Evidence: B)

CMI Treatment

A. Jaster et al. / Clinical Imaging 40 (2016) 961–969

Case

• 54 yo female with progressive 2 year h/o epigastric and left abdominal pain beginning 5-10 minutes following solid meals.

• Fear of eating and 35-40 lbweight loss over past 2 years. (Cachectic 5ft 3in 86lbs)

• Underwent a multivesselmesenteric arterial bypass—infrarenal aorta to SMA and proper hepatic a. with 12mmx6mm bifurcated PTFE graft – Occluded.

Celiac artery stenosis

6mm balloon-expandable

Ballon-expandable 5 and 7mm stents; care taken not to occlude proximal branches

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POSTPRE

18 month F/U visit:

Life altering

Post-perandial pain resolved

Weight gain

Able to live a normal life again

Case

• 65 M p/w worsening chronic ab pain, predominantly localized to the epigastric region

• Pain exacerbated post-prandial• No fever, no additional GI symptoms• Multiple prior hospital admissions for

similar complaints and extensive w/u for the past year

• Associated 30 lbs. weight loss

Imaging

21 22

SMA

23

Pressure Gradient (Pre)

• Iliac 134/58 mmHg

• SMA 26/19 mmHg

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Pressure Gradient (Post)

• Aorta 132/62 mmHg

• SMA 129/56 mmHg

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Median Arcuate Ligament Syndrome (MALS)• Symptoms

– Abdominal pain– Bruit– Weight loss

• Treatment– Surgical decompression– Surgical bypass– Celiac ganglionectomy– Angioplasty/stenting?

Case

• 63 year old female with mechanical heart valve with c/o abdominal pain, food aversion, and nausea after meals x 7 months.

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Persistent abdominal pain 48 hours after treatment

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Acute Mesenteric Ischemia

• Acute bowel ischemia – small bowel or colon• Caused by decrease flow or obstruction of flow typically

in the SMA

• Non-Occlusive Mesenteric Ishcemia (NOMI) is a low flow state with a patent SMA

• Ischemic Colitis is a very different entity that does not carry the morbidity and mortality that mesenteric ischemia does. It is not diagnosed angiographically.

Acute Mesenteric Ischemia• Embolus

– Cardiac sources – atrial fib, myocardial infarction– Aortic source

• Thrombosis/Stenosis– Secondary to low flow– Progression of atherosclerotic disease or FMD

• NOMI– Shock– Sepsis– Drug induced

• Dissection • Mesenteric Venous Thrombosis

– Hypercoagulable states• Bowel Torsion—non vascular

Embolic AMI Acute Mesenteric Ischemia• There are no large, multicenter published trials

demonstrating the effectiveness of endovascular treatment of acute mesenteric ischemia

• Cleveland Clinic published1 a retrospective study involving 70 pts treated between 1999-2008– Compared endovascular treatment and traditional surgical

therapy

– Endovascular group had lower rates of renal failure and pulmonary failure

– Successful endovascular therapy mortality 36% compared to 50% with surgery

1 Arthurs ZM, Titus J, et al. A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg 2011;53:698-705

Acute Mesenteric Ischemia– 69% of patients undergoing

undergoing endovascular

therapy required laparotomy

– In those with bowel resection:

• Endovascular group

52 cm bowel resected

• Surgical group

160 cm bowel resected

1 Arthurs ZM, Titus J, et al. A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia. J Vasc Surg 2011;53:698-705

Acute Mesenteric IschemiaACC/AHA Guidelines for Acute Mesenteric Ischemia

Class I Recommendation

Surgical treatment of acute obstructive intestinal ischemia includes revascularization, resection of necrotic bowel, and when appropriate, a “second look” operation 24-48 hours later (Level of Evidence: B)

Class IIb Recommendation

Percutaneous interventions (including lysis, PTA, and stenting) are appropriate in selected patients with acute intestinal ischemia. Patients so treated may still require laparotomy (Level of Evidence: C)

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Case

• 47 year old male with no significant past medical history. Presented to ER with 4 hr history of severe abd pain

• Exam: Tender abd, no rebound

• Labs: WBC 15.5, Normal lactic acid

Treatment

• 5 Fr Infusion catheter with a 10cm infusion length

• 0.25 mg/hr TPA infusion

• Heparin infusion through sheath at 300 IU/hr

Follow-Up

• 24 hr follow up angiogram:– Resolution of proximal and

distal thrombus

– Proximal aneurysm

– Likely dissection distal to aneurysm

Case

• 68 yo male with CHF/Afib presents with abdominal pain 2 weeks after D/C of anticoagulation for GI bleeding.

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Embolic Occlusion

Following Suction Thrombectomy

SIMILAR PRESENTATION

Following Lysis

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After Mechanical Thrombectomy Case

• 83 year-old female with distended abdomen and pain. The patient has a history of atrial fibrillation not on therapeutic anticoagulation. She had a recent episode of ventricular tachycardia.

CT at Presentation

SMA Angiogram

ACUTE MESENTERIC ISCHEMIA

• State of hypoperfusion in the absence of occlusion of the mesenteric vessels

• Synonymous with splanchnic vasoconstriction• Commonest causes:

• Cardiac failure• Sepsis• Shock

• Poor pump, hypovolemia, maximal endogenous sympathetic tone and exogenous vasopressor support occur in combination with many NOMI patients

NOMI NOMI Pre and Post Vasodilator Infusion

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Acute Aortic Dissection

• Intimal tear with flow in true and false lumen.

• Can result in acute mesenteric ischemia due to occlusion or hypoperfusion.

First and Last Name, Degree

Pathophysiology

Case

• 68 year old male presents with 6 hours of tearing chest pain with radiation into his back. He also complains of severe abdominal pain for 3 hours.

Aortic dissection with acute mesenteric ischemia

Aortic Dissection

n

VisceralAngio

Celiac

R Renal

SMA

IVUS Dissection

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Pre & Post Endograft

Courtesy of Michael D. Dake, M.D.

Post Endograft

Mesenteric Venous Thrombosis

• Hematologic Diseases

• Trauma– Blunt trauma– Post splenectomy– Endoscopic

Sclerotherapy

• Infection– Inflammatory bowel

disease– Peritonitis

• Mechanical venous occlusion– Malignant

compression– Pregnancy– Cirrhosis

• Miscellaneous– CHF– Decompression

sickness

CT Findings

• Ascites

• Bowel wall thickening

• Pneumatosis

• Engorged varices

• Enlarged portal/mesenteric veins

*Delayed diagnosis contributes to an up to 40% 30-day mortality rate

McManimon et al. Mesenteric Venous Thrombosis. Techniqes in Vasc Int Rad 1998.,

Pre Treatment

Post Treatment

Mesenteric Venous Thrombosis Case

• Hx: 53 yo woman who presented to ED with severe abdominal pain with onset approximately 3 hours after lunch.

• Pertinent PMH: obesity s/p R-en-Y gastric bypass 16 yrs prior, bunionectomy one week prior

• Meds: noncontributory

• Pertinent labs: lactate 2.4 at presentation

72

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Noncontrast CT at presentation, 7/18/17

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Follow up Duplex, 7/18/17

MPV Portal confluence

Hospital course

• Conservative treatment with Enoxaparin Sodium 90mg bid initiated in the ED. Pain improved and lactate normalized.

• Hospital day 2, attempted to eat cracker and apple juice with recurrence of initial severe abdominal pain and became hypotensive. Concern for mesenteric ischemia. Lactate remained normal, however.

• MRV of the abdomen and heparin gtt ordered.

75 76

MRA abdomen, 7/20/17

Extensive thrombus in the right, left, main portal veins and SMV

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Thrombolysis, 7/20/17

Transhepatic access to the portomesenteric system

78

Thrombolysis, 7/20/17

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Thrombolysis, 7/20/17

24cm US accelerated catheter directed thrombolysis Coolant: 35ml/hourHeparin: 300u/hourtPA: 0.7mcg/hour

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Follow up, 7/21/17

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TIPS using catheter directed thrombolysis as a guide

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Portomesenteric angio through TIPS

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TIPS

Overlapping Smart stents8 x 60 mm, x28 x 40 mm, x1

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Post TIPS angio

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85

CAT8 Penumbra

86

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Post thrombectomy angioChronic Mesenteric Venous Thrombosis

• Months to years after the acute occlusion episode

• Chronic abdominal pain

• Variceal hemorrhage

• Ascites

• Splenomegaly

• Cirrhosis

• Bowel wall thickening

Case

• 58 year old female who had acute portal vein thrombus in 2013 now with worsening abdominal pain and hemoptysis.

Initial Presentation 2013

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Current Presentation 2017 Current Presentation 2017

Trans-Splenic Access

Percutaneous Bullseye Approach

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Case

• 72-year-old male with history of cholangiocarcinoma s/p extended left hepatic lobe resection with Roux-en-Y hepaticojejunostomy in March 2015 and XRT. Over one year, the patient has had progressive narrowing of the portal vein at the surgical site/junction of the margin with the intrahepatic and extrahepatic portal vein.

97 98

6/28/2016

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Transhepatic Portogram

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12mm Self-Expanding Stent

101

Post Stent

102

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Post Stent

103

Conclusion

• Mesenteric ischemia has multiple etiologies and clinical presentations

• Acute mesenteric ischemia (arterial and venous) is a life-threatening condition and early recognition is paramount– Always evaluate mesenteric vessels on

CT/MRI presentation of acute abdominal pain

Thank You!