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Nejm 2016 Mesenteric Ischemia
Nejm 2016 Mesenteric Ischemia
Review Article
Mesenteric Ischemia
Daniel G. Clair, M.D., and Jocelyn M. Beach, M.D.
M
esenteric ischemia is caused by blood flow that is insuffi- From the Cleveland Clinic Lerner College
of Medicine of Case Western Reserve
cient to meet the metabolic demands of the visceral organs. The severity
University (D.G.C.) and the Department
of ischemia and the type of organ involved depend on the affected vessel of Vascular Surgery, Heart and Vascular
and the extent of collateral-vessel blood flow. Institute, Cleveland Clinic (D.G.C., J.M.B.)
— both in Cleveland. Address reprint re-
Despite advances in the techniques used to treat problems in the mesenteric
quests to Dr. Clair at the Department of
circulation, the most critical factor influencing outcomes in patients with this Vascular Surgery, Cleveland Clinic, 9500
condition continues to be the speed of diagnosis and intervention. Although mes- Euclid Ave., Desk F30, Cleveland, OH
enteric ischemia is an uncommon cause of abdominal pain, accounting for less 44195, or at claird@ccf.org.
than 1 of every 1000 hospital admissions, an inaccurate or delayed diagnosis can N Engl J Med 2016;374:959-68.
DOI: 10.1056/NEJMra1503884
result in catastrophic complications; mortality among patients in whom this con-
Copyright © 2016 Massachusetts Medical Society.
dition is acute is 60 to 80%.1-3
This article highlights the pathophysiological features, diagnosis, and treat-
ment of ischemic syndromes in the foregut and intestines. The goal of this review
is to improve the understanding and management of this life-threatening disorder.
Pathoph ysiol o gy
Mesenteric Circulation
The mesenteric circulation is extremely complex.
Three primary vessels — the celiac artery, supe-
rior mesenteric artery, and inferior mesenteric
artery — interconnect through collateral net-
works between the visceral and nonvisceral cir-
culations. These interconnections ensure that
the loss of a single vessel does not lead to cata-
strophic malperfusion of the viscera.
The acute occlusion of a single vessel (typi-
cally the superior mesenteric artery) in acute B
mesenteric ischemia can result in profound ische-
mia caused by the loss of blood flow through
this key vessel and its collateral vascular net-
work. In contrast, in patients with chronic mes-
enteric ischemia, additional collateral networks
develop over time; symptoms often do not ap-
pear until occlusion of two or more primary
vessels occurs.
A B
C D
Figure 2. Imaging Studies in a Patient with Chronic Mesenteric Ischemia, a Celiac Stent, and Occlusion of the Superior
Mesenteric Artery.
Duplex ultrasonographic and color Doppler images of occlusion of the superior mesenteric artery at the origin
(Panel A) and reconstitution of flow in the proximal superior mesenteric artery distal to the occlusion (Panel B) are
shown. High velocities (peak systolic velocity, 594 cm per second [plus sign]; end-diastolic velocity, 181 cm per sec-
ond) indicate severe stenosis. A sagittal CTA image (Panel C) shows prior celiac stenting, occlusion of the superior
mesenteric artery at the origin (arrow), and distal reconstitution. The severe atherosclerotic disease and calcifica-
tion of the aorta and visceral vessels are characteristic of patients with chronic mesenteric ischemia. An angiogram
(Panel D) was obtained after endovascular treatment of the occlusion in the superior mesenteric artery with a covered
balloon-expandable stent. Restoration of antegrade flow in the superior mesenteric artery is evident, with filling of
the distal branches.
critical for timely diagnosis and treatment. In cords and the results of the examination for any
contrast to other vascular disorders, mesenteric evidence of other atherosclerotic and vascular
ischemia primarily affects women; more than diseases, including peripheral artery, cerebrovas-
70% of persons with this disorder are female.11 cular, coronary artery, and renovascular disease.
The physician should assess the patient’s re- In addition, other pulmonary and cardiovascular
teric ischemia as was initially hoped. Despite the flow. More ominous pathological findings, in-
many investigations conducted to date, no clini- cluding pneumatosis, free intraabdominal air,
cally useful biomarkers have been identified,18,19 and portal venous gas, may also be noted.27
probably owing to the hepatic metabolism of To determine whether mesenteric ischemia is
complex proteins secreted by the intestine.8 present, CTA should be performed with the use
Tests for markers of nutritional status, such as of intravenous contrast material and reconstruc-
albumin, transthyretin, transferrin, and C-reac- tion of images should be achieved with thin
tive protein, are the only studies of value in axial images (1 to 3 mm). The sensitivity of CTA
cases of chronic mesenteric ischemia, since they is not as high for venous thrombosis as it is for
can be used to assess the degree of malnutrition arterial disease, but it can be improved with the
before revascularization is undertaken. use of two-phase imaging to enhance visceral
venous drainage.
Magnetic resonance angiography (MRA) is an
Di agnos t ic Im aging
attractive option that may provide information
Ultrasonography about flow and avoid the risks of radiation and
In the diagnosis of mesenteric vascular disease, use of contrast material that are associated with
duplex ultrasonography has a high degree of CTA. However, this test takes longer to perform
reliability and reproducibility, with both a sensi- than CTA, lacks the necessary resolution, and
tivity and a specificity of 85 to 90%.20-24 It is an can overestimate the degree of stenosis.12 Al-
effective, low-cost tool that is helpful in the though MRA techniques are evolving, currently
assessment of the proximal visceral vessels, al- CTA imaging is almost always the preferred
though the results can be limited more distally. choice, and the advantages of CTA outweigh any
The value of ultrasonographic testing is ex- risks associated with the use of this form of
tremely dependent on the skill of the technolo- imaging among patients with acute mesenteric
gist. In addition, adequate ultrasonographic im- ischemia.28
aging can be difficult to obtain in patients with
obesity, bowel gas, and heavy calcification in the Endoscopy
vessels. Adequate ultrasonographic assessment Endoscopy, which is often part of the investiga-
is often impossible in patients with acute mes- tion of abdominal pain, is most useful in diag-
enteric ischemia because of the length of the nosing conditions other than mesenteric ische
study and the abdominal pressure required; it is mia. These conditions include inflammatory and
therefore best reserved for the evaluation of pa- ischemic changes in the stomach and proximal
tients with chronic mesenteric ischemia (Fig. 2) small bowel, rectum, and right colon.29 How-
and for monitoring after intervention. ever, endoscopic examination does not reach the
majority of sections of the small bowel that are
Computed Tomographic and Magnetic most frequently involved in mesenteric ischemia.
Resonance Angiography This imaging technique is sensitive in identi-
Given its 95 to 100% accuracy,25 computed tomo- fying late changes, including infarction. How-
graphic angiography (CTA) has become the rec- ever, it lacks sensitivity and specificity in detect-
ommended method of imaging for the diagnosis ing more subtle ischemic changes.
of visceral ischemic syndromes (Fig. 1 and 2).12,26
Images of the origins and length of the vessels Catheter Angiography
can be obtained rapidly, characterize the extent Catheter angiography, which was previously con-
of stenosis or occlusion and the relationship to sidered to be the standard method of diagnosis
branch vessels, and aid in the assessment of op- of mesenteric ischemia, has become a compo-
tions for revascularization. nent of initial therapy. Angiography with selec-
In addition to providing information about tive catheterization of mesenteric vessels is now
the vasculature, CTA can indicate potential used once a plan for revascularization has been
sources of emboli, other intraabdominal struc- chosen. Single or complementary endovascular
tures and pathologic processes, and abnormal therapies, including thrombolysis,30 angioplasty
findings such as the lack of enhancement or the with or without stenting,31 and intraarterial va-
thickening of the bowel wall and mesenteric sodilation,32 are then combined to restore blood
stranding associated with diminished blood flow. Angiography can also be used to confirm
the diagnosis before open abdominal explora- chronic mesenteric ischemia, in contrast, enteral
tion is undertaken.12 nutrition (as long as it does not cause pain) or
parenteral nutrition should be considered in or-
der to improve perfusion by means of mucosal
Ini t i a l C a r e a nd Ther a py
vasodilation and to provide nutritional and im-
Fluid and Electrolyte Management munologic benefits.39
Fluid resuscitation with the use of isotonic crys-
talloid fluids and blood products as needed is a T r e atmen t Op t ions
critical component of initial care. Serial moni-
toring of electrolyte levels and acid–base status Acute Mesenteric Ischemia
should be performed, and invasive hemody- Endovascular Repair
namic monitoring should be implemented ear- Endovascular strategies can theoretically restore
ly12; this is especially true in patients with acute perfusion more rapidly than can open repair and
mesenteric ischemia, in whom severe metabolic may thus prevent progression of mesenteric
acidosis and hyperkalemia can develop as a re- ischemia to bowel necrosis. Although the use of
sult of infarction.8 These conditions may create endovascular techniques is becoming more com-
the potential for rapid decompensation to a mon, the comparative data on the results with
systemic inflammatory response or progression the two approaches in patients with acute mes-
to sepsis. enteric ischemia are insufficient to show a clear
In patients with hemodynamic instability, it advantage of one approach over the other (Table
is imperative to carefully adjust fluid volume S1 in the Supplementary Appendix, available
while avoiding fluid overload and to use pressor with the full text of this article at NEJM.org).3,40,41
agents only as a last resort. The fluid-volume The largest review of endovascular interven-
requirement can be very high, especially after tions involved 70 patients with acute mesenteric
revascularization, because of the extensive capil- ischemia. Treatment was considered to be suc-
lary leakage; as much as 10 to 20 liters of crys- cessful in 87% of the patients, and in-hospital
talloid fluid may be required during the first 24 mortality was lower among those who under-
hours after the intervention.4 went endovascular procedures than among those
who underwent open surgery (36% vs. 50%).
Early Medical Therapy However, patients who presented with more
Heparin treatment should be initiated as soon as profound visceral ischemia may have been as-
possible in patients who have acute ischemia or signed to open revascularization. These and
an exacerbation of chronic ischemia. Vasodila- other data40,42 suggest that the use of endovascu-
tors may play a role in care, particularly in com- lar procedures for acute mesenteric ischemia is
bating persistent vasospasm in patients with becoming more common; the use of these pro-
acute ischemia after revascularization.9 Epithe- cedures increased from 12% of cases in 2005 to
lial permeability increases during acute mesen- 30% of cases in 2009.43 These data also show
teric ischemia as high bacterial antigen loads that this strategy may be most appropriate for
trigger inflammatory pathways,33,34 and the risk patients with ischemia that is not severe and
of bacterial translocation and sepsis increases.35 those who have severe coexisting conditions that
Antibiotics can lead to resistance and altera- place them at high risk for complications and
tions in bacterial flora; however, their use has death associated with open surgery.
been associated with improved outcomes in An acute occlusion can be treated with a com-
critically ill patients.36,37 In general, the high risk bination of endovascular strategies, with initial
of infection among patients with acute mesen- treatment aimed at rapidly restoring perfusion
teric ischemia outweighs the risks of antibiotic to the viscera, most often by means of mechani-
use, and therefore broad-spectrum antibiotics cal thrombectomy or angioplasty and stenting.
should be administered early in the course of Thrombolysis is safe and very effective as an
treatment. adjunct procedure to remove the additional bur-
Oral intake should be avoided in patients den of thrombus in patients without peritonitis,
with acute mesenteric ischemia, since it can ex- and it can be especially helpful in restoring per-
acerbate intestinal ischemia.38 In patients with fusion to occluded arterial branches. These tech-
those whose lesions are not amenable to endo- ploration should be performed if there is con-
vascular techniques. cern about the possibility of peritonitis.
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