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A patient with acute occlusion of the superior mesenteric vessels resulting in superior mesenteric vessel ischaemia (SMVI) who presents to the ED with abdominal pain and unremarkable abdominal examination risks delay in diagnosis and treatment with adverse outcome. A comprehensive literature search was performed, and the evidence was reviewed. To-date, there are no accurate biomarkers of SMVI and so, heightened awareness among ED staff and rapidly actioning diagnostic imaging and surgical referral will help fast-track the patient with SMVI to surgical management. Management of SMVI is challenging and requires ongoing communication. Prompt surgical intervention may help reduce mortality and morbidity in SMVI. SMVI is associated with significant mortality and morbidity. With the lack of accurate biomarkers, diagnosis and management is challenging and requires heightened awareness among ED staff for prompt surgical referral and intervention., (© 2022 Australasian College for Emergency Medicine.)

Recent advances in the fields of electronics and microfabrication techniques have led to the development of implantable medical devices for use within the field of precision medicine. Monitoring visceral surface tissue O 2 tension ( P T o 2 ) by means of an implantable sensor is potentially useful in many clinical situations, including the perioperative management of patients undergoing intestinal resection and anastomosis. This concept could provide a means by which treatment could be tailored to individual patients. This study describes the in vivo validation of a novel, miniaturized electrochemical O 2 sensor to provide real-time data on intestinal P T o 2 . A single O 2 sensor was placed onto the serosal surface of the small intestine of anesthetized rats that were exposed to ischemic (superior mesenteric artery occlusion) and hypoxemic (alterations in inspired fractional O 2 concentrations) insults. Control experiments demonstrated that the sensors can function and remain stable in an in vivo environment. Intestinal P T o 2 decreased following superior mesenteric artery occlusion and with reductions in inspired O 2 concentrations. These results were reversible after reinstating blood flow or by increasing inspired O 2 concentrations. We have successfully developed an anesthetized rat intestinal ischemic and hypoxic model for validation of a miniaturized O 2 sensor to provide real-time measurement of intestinal P T o 2 . Our results support further validation of the sensors in physiological conditions using a large animal model to provide evidence of their use in clinical applications where monitoring visceral surface tissue O 2 tension is important. NEW & NOTEWORTHY This is the first report of real-time continuous measurements of intestinal oxygen tension made using a microfabricated O 2 sensor. Using a developed rodent model, we have validated this sensor's ability to accurately measure dynamic and reversible changes in intestinal oxygenation that occur through ischemic and hypoxemic insults. Continuous monitoring of local intestinal oxygenation could have value in the postoperative monitoring of patients having undergone intestinal surgery.

Superior mesenteric artery (SMA) and coeliac axis (CA) occlusion after endovascular abdominal aneurysm aortic repair (EVAR-AAA), using endograft with suprarenal fixation, are uncommon. However, we are reporting a case of visceral malperfusion, which occurred 7 days after successful EVAR with suprarenal fixation for symptomatic AAA. Endograft metal stent barbs caused severe stenosis of SMA and CA. A successful recovery of SMA was carried out by means of a balloon-expandable stent released through bare metal stent barbs. We believe that an unfavourable anatomy of a proximal aortic neck and visceral aorta may have caused a wrong stent strut deployment with the coverage of CA and SMA., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

It is presented 5 clinical observations of acute ischemia of intestine in which different endovascular interventions including isolated superior mesenteric artery stenting, rheolytic and aspiration thrombectomy and combination of techniques were applied. Surgical success with blood flow restoration in superior mesenteric artery was achieved in 4 of 5 patients. 2 patients have required laparotomy and intestinal resection. In 1 case extent of resection was significantly reduced after previous endovascular thrombectomy. There were no deaths. It is concluded that endovascular interventions may be considered as independent method of treatment of patients with acute mesenteric ischemia.

An 84-year-old female was admitted with sudden-onset upper abdominal pain. Contrast-enhanced computed tomography (CECT) revealed complete occlusion of the superior mesenteric artery (SMA). After transcatheter infusion of urokinase, embolic occlusion resolved. However, the pain recurred when she started eating. CECT revealed a lesion with thickening of the intestinal wall; therefore, laparoscopy-assisted surgery was undertaken. Histological examination yielded a definitive diagnosis of ischemic enteritis caused by SMA occlusion. Rapid diagnosis and treatment are important in SMA occlusion, and careful observation of the clinical course is recommended after transcatheter therapy.

Objective: To investigate the predictive value of serum nitrate (nitrogen oxide: NOx) levels in the detection of peripheral and mesenteric ischaemia durations., Methods: Rats were sacrificed for determining the basal serum values of NOx in Group I without any intervention. The superior mesenteric artery was clamped in Groups II and III and blood samples were taken at 120 minutes in Group II and at 360 minutes in Group III. The right common femoral artery was clamped in Groups IV and V and blood samples were taken at 120 minutes in Group IV and at 360 minutes in Group V., Results: The peak values of NOx were obtained in Group II and Group IV. NOx levels were reduced in advanced periods of ischaemia. In the other words, the NOx levels were significantly higher at two hours of ischaemia (p < 0.05), and NOx levels were reduced to normal ranges at the sixth hour of ischaemia., Conclusion: Early diagnosis and rapid treatment are important for acute ischaemic disorders. Serum NOx levels can be a decisive biomarker for prediction of the critical ischaemia period.

Treatment results of the acute intestinal ischemia in 72 patients were analyzed. Patients aged 69.2 ± 5.8 years. Occlusive vascular lesions of the intestinal vessels (thrombosis and embolism of the superior mesenteric artery and thrombosis of the superior mesenteric vein) were obliged to the ischemic disorders in 84.5% of patients. The rest 15.5% of patients demonstrated microvascular disorders (nonocclusive ischemia). The issue presents the novel algorithm for treatment and diagnostics of the acute intestinal ischemia.

Dramatic unintentional weight loss can be caused by a spectrum of diseases ranging from very serious to benign and treatable. We describe the case of a 70-year-old woman with an extensive history of cardiovascular disease who presented with unintentional weight loss. Although she was diagnosed and treated for colitis, the patient continued to lose 50 pounds over 8 months, which prompted an angiogram. The angiogram revealed occlusion of her superior and inferior mesenteric arteries just distal to their origins, together with high-grade (80%-90%) stenosis at the origin of the celiac axis. After a stent was placed in the ostium of the celiac axis, the patient immediately began to regain weight. We suggest that clinicians consider chronic mesenteric ischemia when treating patients with undiagnosed unintentional weight loss and a history of atherosclerotic disease.

Background: We report the results of our single center series of patients with chronic mesenteric ischemia (CMI) to determine the role of stenting in the management of patients., Patients and Methods: We retrospectively reviewed all patients with CMI treated endovascularly with stent revascularisation from January 2008 to January 2011.CMI diagnosis was made according to clinical symptoms, including postprandial abdominal pain, food fear, and weight loss. Additionally, the diagnosis was confirmed by duplex ultrasonography and/or computed tomography angiography and/or contrast-enhanced magnetic resonance angiography., Results: All 45 patients presented with typical CMI symptoms: 45/45 (100 %) had postprandial pain, 31/45 (68.8 %) had a weight loss of more than 10 kilograms, and 11/45 (24.4 %) suffered from ischemic colitis combined with lower gastrointestinal bleeding. In three patients occlusion could not be crossed, therefore considered as technical failure. A total of 55 arteries were stented in the remaining 42 patients. Nineteen patients underwent SMA stenting alone, eight underwent celiac stenting, alone and three patients underwent stenting of inferior mesenteric artery (IMA) alone. We performed combined stenting of the celiac artery and superior mesenteric artery in ten patients, and one patient underwent a combined stenting of the celiac artery and the IMA. All three mesenteric arteries were stented in only one patient. Primary technical success was achieved in 42/45 (94.8 %) patients. Clinical symptom relief was achieved in 39/45 (86.6 %) patients with abdominal pain. Increased body weight was observed in 28/31 (90.3 %) patients with an average weight gain of 8.8 kilograms (5 - 12 kilograms), and 10/11 (90.9 %) patients recovered from ischaemic colitis/lower gastrointestinal bleeding., Conclusions: Stent revascularisation can be considered as the first-line therapy for patients with chronic mesenteric ischemia.

A 46-year-old woman presented with classic symptoms. Computed tomography-angiography and duplex ultrasonography showed stenosis of the aa. mesenteria superior et inferior. The patient was moved to a university hospital and a percutaneous transluminal angioplasty with insertion of stents was performed. She was discharged shortly after feeling well.

Background: Surgical bypass as treatment for chronic mesenteric ischemia (CMI) is performed to alleviate symptoms of weight loss and postprandial pain and to prevent catastrophic intestinal necrosis. Among the studies that report outcomes for mesenteric bypass, few focus on the type of conduit. The purpose of this study was to evaluate contemporary short-term outcomes of patients who underwent aortomesenteric bypass for CMI, with specific attention given to the conduit used--prosthetic versus vein., Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program Participant Use File were analyzed for demographic and clinical risk variables, mortality, and 22 defined complications (morbidity) between 2005 and 2009 from more than 200 participating hospitals. The database was queried for patients undergoing aortomesenteric bypass with vein (Current Procedural Terminology [CPT] 35531) or nonvein (CPT 35631) whose preoperative diagnosis was CMI (International Classification of Diseases, 9th Revision code 557.1). Outcomes and risk variables were compared using univariate analysis and independent sample t tests for continuous variables., Results: One hundred fifty-six patients underwent mesenteric revascularization--119 (76%) women and 37 (24%) men with an average age of 65 ± 13 years. The conduit used was vein in 44 (28%) and prosthetic graft in 112 (72%). There were no statistically significant differences between the two groups in mean age, smoking history, recent weight loss, obesity (body mass index: >25) rates, length of operation, reoperation frequency, and early graft failure. More patients undergoing bypass with vein had an associated bowel resection and preoperative sepsis or systemic inflammatory response syndrome. Additionally, patients with a vein graft had a higher percentage of a contaminated surgical site (30% vs. 7%, P = 0.001) and underwent emergent surgery more frequently (16% vs. 4%, P = 0.012). Mortality was higher in patients in whom a vein graft was used (16% vs. 5%, P = 0.039). There were no differences noted between the two groups in length of stay or postoperative complications, including infectious complications, renal insufficiency, myocardial infarction, and stroke., Conclusions: Thirty-day mortality was higher in patients who underwent mesenteric bypass with vein. However, this group also had a higher incidence of emergent surgery, bowel resection, and contaminated operative field. This suggests that vein grafts were preferentially used when bowel infarction was suspected. The higher mortality is likely due to patient factors, such as the extent of bowel ischemia at the time of operation, rather than the type of conduit used. If expeditious revascularization is done before development of bowel infarction, vein or prosthetic conduit would be expected to function equally well., (Copyright © 2012. Published by Elsevier Inc.)

Acute mesenteric ischaemia is a vascular emergency that arises when blood flow to the intestine is compromised leading to tissue necrosis. It is primarily a condition of the elderly associated with significant morbidity and mortality. Causes include arterial thromboembolism, venous thrombosis and splanchnic vasoconstriction (so-called nonocclusive mesenteric ischaemia). Reperfusion injury and breakdown of the intestinal mucosal barrier lead to metabolic derangements, sepsis and death from multiorgan failure. The diagnosis may be difficult to make clinically and numbers of cases are increasing due to ageing of the population. The clinical and pathological features are reviewed with discussion of predisposing conditions. Careful dissection of the mesenteric vasculature is required at autopsy with appropriate histologic sampling and documentation of associated comorbidities. Other organs need to be checked for thrombi and the possibility of testing for inherited thombophilias should be considered. Toxicological evaluation, particularly in younger individuals, may reveal evidence of cocaine use. On occasion no obstructive lesions will be demonstrated, however the confounding effects of post-mortem autolytic and putrefactive changes may mean that nonocclusive mesenteric ischaemia may be difficult to diagnose., (Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background and Objectives: Mesenteric ischemia which can be acute or chronic depending on the rapidity of compromised blood flow produces bowel ischemia, infarction, bacterial transmigration, endotoxemia, multisystem organ failure and death. High altitude can precipitate thrombosis because of hypobaric hypoxia and its effect on coagulation system. The objectives of this study are to determine the risk factors, clinical presentation, type and pattern of acute occlusive mesenteric ischemia in high-altitude of southwestern region of Saudi Arabia., Materials and Methods: We reviewed the records of all the patients with acute occlusive mesenteric ischemia admitted to the Armed Forces Hospital, southern region, Kingdom of Saudi Arabia during the period of 2005 to 2010, and compiled data including demographics, clinical presentation, risk factors, preoperative investigations, management, histopathological examination, and complications. The cases of mesenteric ischemia resulting from conditions such as volvulus and strangulated hernias were excluded., Results: Our study included 21 patients, 10 (48%) men and 11 (52%) women with a mean age of 56 years (SD 14). Abdominal pain was the most common presenting symptoms. CT angiography depicted occlusive arterial disease in 8 patients (38%) and venous thrombosis in 13 patients (62%). Diabetes mellitus was the most frequent risk factor for arterial mesenteric ischemia. Chronic liver disease particularly liver cirrhosis was the most prominent risk factor for venous mesenteric thrombosis. Intestinal ischemia was confirmed by histopathological examination., Conclusion: Acute occlusive mesenteric ischemia can mimic other more common intra-abdominal diseases clinically; therefore a high index of suspicion is required particularly for patients with relevant risk factors to prompt early diagnosis and intervention. Venous mesenteric thrombosis was more common than arterial mesenteric ischemia in our region.

We report an unusual case of chronic mesenteric ischemia presenting in a 12-year-old girl with idiopathic infantile arterial calcinosis (IIAC). This is the first reported case in the literature of chronic mesenteric ischemia in the setting of IIAC. The girl presented with a classical history of postprandial abdominal pain. Imaging demonstrated significant stenoses of the celiac axis, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Angioplasty of the celiac axis and SMA was attempted, with successful dilation of the SMA only. At 3-, 6- and 12-month follow-ups, the child's symptoms had almost resolved. This case report has three important ramifications: chronic mesenteric ischemia is a possible clinical presentation in children with IACC, pre-angioplasty imaging is important in guiding treatment approach, and angioplasty was effective in this case of chronic mesenteric ischemia and offers hope for other similarly affected children.

Chronic mesenteric ischemic disease is an unusual cause of chronic abdominal pain. We present our experience from open surgical treatment of patients with this rare disease followed by a short review of the literature. During the period 2006-2008, three patients were referred to our department with clinical and radiological findings of chronic mesenteric ischemic disease. In all patients, at least 2 out of 3 splachnic vessels (celiac artery, superior and inferior mesenteric artery) were occluded, with severe stenosis of the third. Open surgical revasculation was performed in all patients, using autologous or synthetic (Dacron) bypass grafts. Graft patency was examined with triplex ultrasound studies at 3, 6 and 12 months postoperatively and/or follow up CT angiography. All patients had patent grafts during the follow up period and have regained their normal body weight. Immediate and late results, technical details and controversies in open surgical revasculation for chronic mesenteric ischemic disease are reviewed. In conclusion open surgical revasculation for chronic mesenteric ischemic disease is a technically challenging procedure with good results in patients younger than 70 years old , with long occlusions of the splachnic vessels and severe calcification of the vessel wall.

Introduction: Doppler transabdominal ultrasound is a validated screening test for chronic mesenteric ischaemia, but gas and obesity are limitations. Endoscopic ultrasound has been proposed as a comprehensive test to evaluate chronic upper abdominal pain and is capable of Doppler measurement. We aim to evaluate the accuracy of Doppler endoscopic ultrasound (D-EUS) as a single screening test to rule out chronic mesenteric ischaemia in patients with abdominal pain and compare it with Doppler transabdominal ultrasound (D-TUS)., Methods: We enrolled all patients ≥50 years with chronic upper abdominal pain and vascular risk referred for endoscopic ultrasound. All were scheduled for D-EUS and D-TUS plus a confirmatory test if one of the previous resulted positive. We estimated the accuracy of both techniques comparing them using McNemar test., Results: 68 patients completed the study. Fifty-three (78%) underwent D-EUS, D-TUS, and a confirmatory test. Fifteen (38%) underwent follow-up after negative results. Three (4%) in the D-EUS group and 14 in the D-TUS (21%) were excluded due to artefacts. D-EUS presented a sensitivity of 63%, specificity of 84%, whilst D-TUS presented a sensitivity of 80% and a specificity of 78%. Specificity of D-EUS was not significantly different to D-TUS., Conclusions: These results support the role of Doppler endoscopic ultrasound to exclude chronic mesenteric ischaemia as cause of chronic abdominal pain., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare the short-term and medium-term result of stent implantation with pharmaceutical thrombolysis in patients with acute superior mesenteric artery occlusion., Methods: From January, 2004 to December, 2008, thirty-five patients diagnosed acute superior mesenteric ischemia, 12 patients treated with stent implantation (interventional therapy group) and 23 patients with pharmaceutical thrombolysis (thrombolytic therapy group). Interventional therapy group treated with balloon dilatation and stent implantation assisted with anticoagulation, antiplatelet and vascular dilation agents. Thrombolytic therapy group used urokinase combined with anticoagulation, antiplatelet and vascular dilation agents. All patients had taken clopidogrel and aspirin orally after discharged and followed up. The clinical effects of both groups were evaluated separately and the Fisher exact test was used to analysis the significant differences., Results: In the 23 cases of thrombolytic therapy group, 7 cases was effective, 16 cases was ineffective (7 cases aggravated or died, 9 cases turn to surgical operation). In the 12 cases of interventional therapy group, 10 cases treated with stent implantation (1 case died of acute cardiac infarction 3 days after interventional operation), 2 cases failed in recanalizing. All patients were followed up after discharged (range 1 - 48 months, mean 15 ± 12 months), 1 case in thrombolytic therapy group was stable, 6 cases died of the recurrence of acute superior mesenteric artery occlusion; 7 cases in interventional therapy group was stable, 1 case died of acute cardiac infarction 20 months after interventional operation (intestinal ischemia not appeared), 1 case had intestinal ischemia reoccurred and recovered by superior mesenteric artery thrombolysis., Conclusions: In the treatment of acute superior mesenteric ischemia, stent implantation was obviously superior to pharmaceutical thrombolysis in improving intestinal ischemia and survival, therefore it could provided a reliable choice for the patients who had not appeared intestinal necrosis.

Introduction: Messenger RNA (mRNA) changes in the small intestine in response to acute mesenteric ischaemia (AMI) could offer novel diagnostic possibilities, but have not been described. The aim was to characterize the mRNA response to experimental AMI., Materials and Methods: Twelve pigs underwent catheterisation of the superior mesenteric artery with injection of polivinylalcohol embolisation particles or sodium chloride. Laparotomy and intestinal tissue sampling were performed. Microarray analysis was performed using the GeneChip(®) whole porcine genome array., Results: Seven down-regulated cellular pathways were associated with protein, lipid and carbohydrate metabolism. Seventeen up-regulated pathways were associated with inflammatory and immunological activity, regulation of extracellular matrix and decreased cellular proliferation. Thrombospondin (THS), monocyte chemoattractant protein 1(MCP-1) and gap junction alpha 1(GJA-1) were consistently up-regulated in all embolised pigs. Genes encoding earlier proposed biomarkers for AMI were up-regulated, such as lactate dehydrogenase and creatine kinase, or down-regulated, such as intestinal fatty acid binding protein and glutathione S-transferase., Conclusion: This study describes the intestinal tissue response on a gene expression level to AMI. THS, MCP-1 and GJA-1 were consistently up-regulated by ischaemia, whereas earlier proposed biomarkers for AMI were not. Gene expression may not be directly linked to the use of the corresponding proteins as potential clinical biomarkers., (Copyright © 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

A common celiomesenteric trunk (CMT) is one of the several anatomic variations in the mesenteric circulation and occurs when the celiac and superior mesenteric arteries originate from a single common trunk. Because of its rarity, few lesions of the CMT have been reported. We herein present a case of atherosclerotic stenosis of the CMT of an 81-year-old female who presented with symptoms of mesenteric angina. To our knowledge, this represents the first reported case of endovascular treatment of CMT stenosis.

Abdominal angina refers to abdominal pain in which perfusion to digestive tissues has been compromised, usually due to mesenteric atherosclerosis. Pathology can progress to necrosis of vital viscera, sepsis, or even death. Practitioners need to be aware of this serious medical condition, especially in the ever-growing elderly population.

Unlabelled: To review 20 years of literature on chronic mesenteric ischemia (CMI), examining its complex clinical presentation and comparing open and endovascular treatment options., Methods: The PubMed and EBSCOHost electronic databases were queried to identify English-language articles published over the last 20 years. Scrutiny of the retrieved articles identified 1939 patients (mean age 65 years). Of these, 1163 patients underwent open surgery: 714 between 2000 and 2009 and 449 between 1990 and 1999. Of the 776 patients undergoing endovascular repairs, the majority (684) were performed between 2000 and 2009; 92 patients were treated between 1990 and 1999. Data were entered in an electronic database and were pooled for categorical analysis., Results: No major differences were seen among open surgeries or among endovascular surgeries performed when comparing the 2 time periods. On comparing open and endovascular surgeries performed between 2000 and 2009, symptom improvement was 2.4 times more likely after open compared to endovascular surgery (95% CI 1.5 to 3.6, p<0.001). Five-year primary patency and 5-year assisted primary patency were 3.8 (95% CI 2.4 to 5.8, p<0.001) and 6.4 (95% CI 1.3 to 30.1, p = 0.02) times greater in the open group. Freedom from symptoms at 5 years was 4.4 times greater for open versus endovascular (95% CI 2.8 to 7.0, p<0.001). The complication rate for open versus endovascular surgery was 3.2 times greater (95% CI 2.5 to 4.2, p<0.001). The difference in mortality was not statistically significant (p = 0.75)., Conclusion: Our data demonstrate that open revascularization surpasses endovascular procedures in long-term vessel patency and control of symptoms. Patients undergoing open procedures do, however, develop increased complications perioperatively. The preferred revascularization approach used in treating this condition should be tailored to the anatomy and physiology of each patient.

An elderly woman developed chronic mesenteric ischemia (CMI) due to severe stenosis of the celiac artery and chronic total occlusion of the superior mesenteric artery (SMA). Stenting of the celiac artery resulted in resolution of CMI, but symptoms recurred 4 months later due to restenosis. We report successful sustained resolution of CMI after percutaneous retrograde revascularization of the SMA via the celiac artery., ((c) 2010 Wiley-Liss, Inc.)

Objectives: Significant comorbidities and an exhausted physiologic reserve lead to high mortality rates during operations for acute mesenteric ischemia. We present our experience with retrograde open mesenteric stenting., Methods/results: A total of 3 female patients (mean age = 74.1 years) with acute mesenteric ischemia underwent exploratory laparotomy. Operative technique included isolating the superior mesenteric artery for cannulation and retrograde endovascular angioplasty and stenting. One required small bowel resection. All 3 patients survived. Mean follow-up was 8.4 months (range: 1.2-16.6). All remain with a 100% primary patency rate., Conclusion: Retrograde open mesenteric stenting for acute mesenteric ischemia is a viable alternative to bypass.

Mesenteric vein thrombosis has a similar clinical course as arterial, although more prolonged. In the majority of cases conventional anticoagulant treatment should be used and is often successful. The duration should be at least 6 months. Thrombolysis has been used, both systemic and local, although only in small series. Surgery is indicated when there is peritonitis, when often bowel resection is necessary. Thrombectomy has been used infrequently., ((c) 2010. Published by Elsevier Inc.)

Endovascular treatment for chronic mesenteric ischemia is growing in popularity because of its lower periprocedural morbidity and mortality than open surgery. It is especially suitable for the high-risk surgical candidate and for those who have a poor nutritional state, although endovascular surgery may not be possible in patients with ostial occlusions or heavily calcified vessels. A positive response to angioplasty is helpful to secure a diagnosis in patients with slightly atypical symptoms. There are little data at present to suggest that primary stenting is better than angioplasty alone, but insertion of a stent may be valuable as a rescue procedure following dissection, vascular recoil, or thrombosis during angioplasty. The superior mesenteric artery is probably the most important vessel to treat but, where this is impossible, celiac or inferior mesenteric artery dilatation may have therapeutic benefit. However, there is some evidence at present favoring multiple, as opposed to single-vessel, angioplasty or stenting. Long-term patency is better after mesenteric bypass, which may be preferred in the younger and fitter patient. Treatment of the celiac artery compression syndrome is primarily surgical, but stent insertion may have a role as a secondary procedure where there is a residual stenosis after median arcuate ligament division., ((c) 2010 Elsevier Inc. All rights reserved.)

Rapid developments in preoperative noninvasive imaging as well as advanced endovascular techniques have made endovascular treatment of acute arterial mesenteric ischemia a feasible treatment option in many patients. Multidetector computed tomographic angiography will provide the diagnosis and guide treatment in most cases. The use of mechanical and aspiration embolectomy, sometimes in combination with thrombolytic therapy, is often successful in offering these very sick patients a good treatment option to open surgical revascularization. Underlying occlusive lesions can be treated in the same setting. Hybrid techniques using open abdominal exploration in combination with endovascular tools have the possibility of offering minimally invasive treatment to even more patients. Access to a hybrid operating room is very advantageous when performing these operations because it allows for performing both open and endovascular interventions in the same setting. A fixed angiographic system also minimizes radiation exposure and improves the imaging capabilities compared to a conventional, mobile C-arm. These tools must be used in conjunction with wise, careful clinical evaluation of the patient., ((c) 2010 Elsevier Inc. All rights reserved.)

Mortality related to acute mesenteric arterial occlusion remains very high. Patient survival is dependent on prompt recognition and revascularization before ischemia progresses to intestinal gangrene. Biphasic computed tomography angiography has surpassed angiography as the diagnostic test of choice due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia. Unlike chronic mesenteric ischemia, the treatment of acute arterial mesenteric ischemia, either embolic or thrombotic, remains largely surgical. This is due to the emergent need for revascularization combined with a careful evaluation of the intestines. Endovascular techniques remain useful, however, and can save precious time in the treatment of these challenging patients if integrated into a treatment pathway combined with definitive surgical treatment. A new hybrid endovascular-surgical treatment for the treatment of acute mesenteric thrombosis is described., ((c) 2010 Elsevier Inc. All rights reserved.)

Treatment of chronic mesenteric ischemia has evolved during the last 2 decades. Endovascular treatment has first emerged as an alternative to bypass in the elderly or higher-risk patient, but has become the primary modality of treatment in most patients with suitable lesions, independent of their surgical risk. Open mesenteric revascularization with bypass or (rarely) endarterectomy still has an important role in the treatment of patients with more extensive disease, including long-segment or flush occlusions, small vessel size, multiple tandem lesions, and severe calcification. Our preference for open reconstruction in good-risk patients with multivessel disease is a supraceliac aorta to celiac and superior mesenteric artery (SMA) bypass, whereas an iliac artery to SMA bypass or, occasionally, an infrarenal aortic to SMA bypass is used in the higher-risk group. In this article, we summarize the selection criteria, techniques, and outcomes of open mesenteric reconstruction in the endovascular era., ((c) 2010 Elsevier Inc. All rights reserved.)

The overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö, Sweden was estimated at 12.9/100,000 person-years. Autopsy rate was 87%. Acute superior mesenteric artery (SMA) occlusion (embolus/thrombus ratio = 1.4), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI) were found in approximately 68%, 16%, and 16%, respectively. Acute SMA occlusion was found to be more common than ruptured abdominal aortic aneurysms. The incidence increased exponentially with age, equally distributed among men and women after adjusting for age and gender in the population. Thrombotic occlusions were located more proximally than embolic occlusions and intestinal infarction was more extensive, whereas patients with embolus had a higher frequency of acute myocardial infarction, and had cardiac thrombi in 48% and synchronous emboli in 68% of the patients. The proportion of patients with symptoms inherent with chronic mesenteric ischemia prior to onset of acute thrombotic occlusion has been reported to occur in 73%. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal NOMI. MVT is either caused by thrombophilia, direct injury, or local venous congestion or stasis. Multidetector row computed tomography with intravenous contrast enhancement and imaging in the arterial phase for suspicion of acute SMA occlusion and imaging in the venous phase for MVT has become the diagnostic method of choice. In-hospital mortality is highest for NOMI, lower for acute SMA occlusion, and lowest, around 20%, for MVT., ((c) 2010 Elsevier Inc. All rights reserved.)

Chronic mesenteric ischemia (CMI) remains a well-described disease process that is difficult to diagnose. Since its initial description more than a century ago, a myriad of diagnostic and treatment modalities have been applied to ameliorate the classic symptoms of postprandial abdominal pain and weight loss. It is estimated that mesenteric occlusive disease affects approximately 1% to 18% of the population, with a majority of these patients manifesting no symptoms of CMI. While associated with a small prevalence, the potential economic impact of this disease process, with the increasing age of the population and the catastrophic outcomes associated with no treatment, is significant. The primary etiology of CMI is atherosclerotic occlusive disease involving the ostia of the mesenteric arteries. Several studies have investigated the pathophysiology of the postprandial abdominal pain associated with ischemia focusing on transport mechanisms, claudication of the intestinal musculature, and ischemia of the visceral nerves. The process of diagnosing CMI involves assimilation of the presentation, typical history and physical examination findings, and results of imaging modalities. At the end of this diagnostic process, the decision to offer a patient surgical intervention is primarily based on symptomatology and results of duplex and other imaging modalities. There are specific criteria for which to offer symptomatic patients interventions. Patients who are asymptomatic do not need to undergo revascularization, which may disrupt collateral arterial circulation to the mesentery. They should be followed conservatively., ((c) 2010 Elsevier Inc. All rights reserved.)

Objective: To evaluate the application of multi-detector row CT (MDCT) and CT angiography (CTA) for detecting early signs of acute bowel ischemia (ABI) in experimental porcine models., Methods: Twelve pigs were assigned to four groups with 3 in each group. The digital subtraction angiography of superior mesenteric artery (SMA) and the embolization of branches of SMA with gelatin sponge and blood clot were performed by percutaneous transfemoral artery puncture and catheterization. MDCT pre- and post-contrast scanning in the arterial, venous and delay phase and CTA with three-dimensional reconstruction were carried out at pre-operation, 3 h, 6 h, 9 h, and 12 h after occlusion. The normal mesenteric vascular anatomy, arterial occlusion, mesentery and bowel changes, and dynamic change were evaluated., Results: ABI changes were identified pathologically in all the 12 experimental pigs, and the severity of ischemia increased over time after embolization. CTA showed all 57 embolized branches of SMA and 29 of 34 unoccluded arterial branches with 5 false-positive vessel occlusions. The sensitivity and specificity of CTA were 100% and 85.3%, respectively. Thin-slab maximum intensity projection (TSMIP) revealed the disappearance of distal comb-like vessel branches and brush-like vasa recta, which were clearly delineated in the normal bowel segments. Using this criterion, TSMIP correctly defined 23 of 24 ischemic bowel segments and all the 12 normal bowel segments with a sensitivity of 95.8% and a specificity of 100%., Conclusions: MDCT and CTA reliably define normal and occluded mesenteric vessels in the pig. It can easily detect ischemic bowel segment by identified early changes of ischemia. The early direct ischemic signs are occluded vessels, the disappearance of distal comb-like branches or brush-like vasa recta, and poor bowel enhancement. The early indirect sign is bowel dilatation with fluid collection.

Purpose: Open revascularization in patients with chronic mesenteric ischemia (CMI) is considered the gold standard. Percutaneous transluminal angioplasty and stenting (PTAS) is often reserved for patients not suitable for open revascularization. In our institute, endovascular revascularization is the first-choice treatment. The purpose of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive patients with CMI at a single tertiary vascular referral center., Methods: A retrospective review was performed of all consecutive patients with CMI who underwent PTAS from July 2001 to July 2008. Only symptomatic patients treated for atherosclerotic CMI were included. Patency was evaluated using computed tomography angiography (CTA). Kaplan-Meier curves were used to calculate patency rates of the treated mesenteric arteries., Results: Sixty mesenteric arteries (30 celiac trunks, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Major morbidity was 4%. After dissection of the superior mesenteric artery (n = 1) and brachial artery (n = 1), respectively, both patients underwent endarterectomy and patch plasty. In three arteries, the lesion could not be crossed endovascularly and they were deemed immediate intention-to-treat failures. The initial technical success rate was 93%. No 30-day mortality was observed. Median follow-up was 25 months. During follow-up, 2 patients died from intestinal ischemia. Complete symptom relief was achieved in 78% of patients. Primary 1- and 2-year patency rates were 86% +/- 5% and 60% +/- 9%, respectively; primary-assisted patency rates were 88% +/- 5% and 79% +/- 7%, respectively. During follow-up, 6 patients underwent open revascularization due to failure of PTAS., Conclusion: The initial technical success rate of PTAS as first-choice treatment of CMI is >90%. The 2-year primary patency rate dropped to 60%, but symptomatic in-stent stenoses could often be treated successfully with renewed endovascular techniques. Including one conversion, 14% of patients needed open revascularization during follow-up., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Endovascular therapy for chronic mesenteric ischemia (CMI) has been increasingly utilized. Early outcomes compare favorably with open mesenteric bypass--the current gold standard. The goal of this study is documentation of intermediate-term anatomic and functional outcomes of endovascular mesenteric revascularization for symptomatic CMI., Methods: This is a retrospective review of all patients undergoing endovascular treatment of symptomatic CMI from July 2002 to March 2008. Study endpoints included periprocedural mortality, major morbidity, patency, symptomatic recurrence, and survival. Endpoints were analyzed using actuarial methods., Results: Sixty-six mesenteric arteries (78.8% stenotic/21.2% occluded) were treated in 49 patients. One or more vessels were treated in each case; however, four mesenteric artery total occlusions (3 SMAs/1 IMA) could not be crossed. Initial symptom relief was noted in 89.8% (n = 44) with no change in 5 patients. Single-vessel treatments were performed in 32 patients (65.3%) and two-vessel interventions in 17 (34.7%). The 30-day mortality rate was 2.0% (n = 1). Major complications occurred in 8 patients (16.3%). The mean follow-up duration was 37.4 +/- 2.98 months (range, 0-66). Restenosis on follow-up imaging occurred in 64.9% (n = 24) of the 37 patients who had radiographic surveillance at a mean follow-up interval of 8.5 +/- 1.9 months and was diagnosed most often by Duplex scan or computed tomographic angiography (CTA). Fourteen patients (28.6%) developed recurrent symptoms with 13 requiring a reintervention. Actuarial 36-month freedom from symptomatic recurrence was 60.9% +/- 9.4%. Two-vessel treatment was protective against symptom recurrence (P = .0014) and reintervention (P = .0060) by univariate analysis. A total of 19 reinterventions were required in 14 patients (28.6%) at a mean of 17 months from the original treatment. Primary patency at 36 months was 63.9 +/- 8.5%. Actuarial survival at 48 months was 81.1% +/- 6.1% with no CMI-related deaths in the study cohort., Conclusion: Intermediate (3-year) follow-up indicates that significant restenosis and symptom recurrence are common following the endovascular treatment of symptomatic CMI. Thirty percent of the cohort required a reintervention, one-third of which were conversions to surgical reconstruction. Similar to the surgical paradigm of two-vessel revascularization, endovascular treatment of multiple mesenteric arteries produced better outcomes. A first-line endovascular approach to patients with CMI is a reasonable clinical strategy, but close follow-up is mandatory., (Copyright 2010. Published by Mosby, Inc.)

In the period from 1984 to 2010 operations were made on 41 patients aged from 36 to 76 years with chronic ischemia of digestive organs (CIDO), infarction of the small intestine was determined in 7 of them mainly due to atherosclerotic injury of the celiac trunk (CT) and/or superior mesenteric artery (SMA). In 41 patients antegrade (15) or retrograde (26) shunting of CT and/or SMA were fulfilled with synthetic prostheses in combination with resection of the small intestine in 7 patients, with lethal outcome in 2 of them only. No prosthesis infection was noted. Lethality in early terms was 17.1% mainly at the early stage of the work. Observations during the period from one month to 24 years were followed up in 26 (63.4%) patients. Their state remains satisfactory, the shunts are patent. In treatment of patients with CIDO the antegrade and retrograde shunting of CT and/or SMA are shown to be effective methods.

Abdominal angina is an underrecognized cause of postprandial abdominal pain and weight loss. Diagnosis is often delayed and requires both a careful exclusion of more common causes and a high degree of clinical suspicion, based on the patient's age, the coexistence of multiple risk factors for atherosclerosis, and the presence of vasculopathy in other districts. Appropriate investigations include duplex ultrasound, traditional angiography, magnetic resonance angiography, computed tomography angiography, and tonometry. The purpose of this review is to discuss the pathophysiology and clinical presentation of chronic mesenteric ischemia and to suggest a diagnostic flowchart for this complex condition.

Background: The development of mesenteric venous thrombosis (MVT) does not necessarily require surgical intervention. The aim of this study was to assess the efficacy of avoiding early operative intervention, which can lead to significant sacrifice of the small bowel., Methods: Patients with MVT were identified using the inpatient registry for the years between 2003 and 2007. Each patient's past medical history, history of prior deep venous thrombosis or hypercoagulable state, clinical and biologic presentation, and computed tomography (CT) results were analyzed. The proportion of ischemic bowel observed on the CT scans was compared with the length of the bowel resected., Results: Nine patients were admitted for extensive MVT during the time period evaluated (six men, three women). All CT scans demonstrated signs of severe bowel ischemia, with a mean ischemic bowel proportion of 21% (range 5-45%). Four patients received medical management alone. Five patients underwent surgery. The mean admission time for these patients prior to the operation was 14.8 days (6-36 days). Surgery was required only in cases of intestinal perforation. The mean length of the bowel resections was 33 cm (20-45 cm). At 6 months after admission, none of the patients required parenteral nutrition. The mean follow-up evaluation period was 27 months (15-38 months). One patient died secondary to amyotrophic lateral sclerosis during the follow-up., Conclusions: Initial nonsurgical management comprised of inpatient observation on a surgical ward along with systemic anticoagulation must be considered an alternative treatment strategy for MVT. This strategy delays surgery and therefore avoids short bowel syndrome.

Chronic mesenteric ischemia (CMI) is a rare entity with potentially tragic consequences. Meanwhile, there is still no consensus regarding the most adequate treatment approach. The authors herein report a case of a 65-year-old woman with severe CMI as a result of an occlusion of both the celiac artery (CA) and superior mesenteric artery (SMA) and a significant stenosis of the inferior mesenteric artery (IMA) ostium. The patient was successfully treated by angioplasty and stenting of the IMA. Even though the usual approach for CMI is revascularization of the CA and the SMA, the present case demonstrates that IMA can have a central role in visceral circulation, and its endovascular revascularization can be the first treatment option in selected cases.

Chronic mesenteric ischemia is an uncommon disease in vascular surgery practice worldwide. Open revascularization remains the best treatment for low-risk patients due to durability and efficacy. Endovascular revascularization for chronic mesenteric ischemia was primarily indicated for elderly and higher-risk patients, but this has changed over the past 10 years due to development of more precise devices and lower morbidity and mortality rates despite the higher recurrence and restenosis rates. Our purpose was to summarize the data on endovascular and open revascularization for chronic mesenteric ischemia in a schematic tabular presentation.

The clinical syndrome of chronic mesenteric ischemia classically presents with a combination of involuntary weight loss, post prandial abdominal pain, and food fear. With occlusion or stenosis of the celiac and superior mesenteric arteries (SMA) collateral blood flow between mesenteric vessels is common and frequently act as the sole blood supply to the intestine. We present a rare case of chronic mesenteric ischemia in which the main blood supply to the celiac and SMA were collaterals coming off the right renal artery resulting in renal-splachnic steal. After an unsuccessful attempt to cannulate the SMA and celiac vessels it was possible to relieve this patient's symptoms with renal artery stenting.

Chronic mesenteric ischemia is a rare disorder that has traditionally been treated with open surgical revascularization (OR). Endovascular revascularization (ER) has recently gained popularity as an alternative modality of treatment; however, OR is still predominantly used. This study aimed at comparing the outcomes of these two treatment modalities. The literature was searched using the MEDLINE database through the PubMed search engine for relevant articles that compared the outcomes after OR and ER for chronic mesenteric ischemia. Review of the selected articles revealed that patients had lower postoperative mortality and morbidity, and shorter intensive care unit and hospital stay after ER. However, early and long-term symptomatic relief and significantly lower restenosis rate were characteristic of OR. Although no level 1 evidence governs the treatment of chronic mesenteric ischemia, the durability and efficacy of OR is such that this modality should remain the procedure of choice for patients who are fit or whose fitness could be improved before surgery. For unfit patients, or those with short life expectancy, ER is preferable owing to its minimally invasive nature and reduced postoperative mortality and morbidity. Randomized controlled studies are needed to compare the long-term durability and efficacy of ER to those of OR.