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Review
. 2018 Jul;34(3):217-223.
doi: 10.1159/000490318. Epub 2018 Jun 18.

The Ongoing Challenge of Acute Mesenteric Ischemia

Bernd Luther  1 , Apostolos Mamopoulos  2 , Christian Lehmann  3 , Ernst Klar  4
Affiliations
Review

The Ongoing Challenge of Acute Mesenteric Ischemia

Bernd Luther et al. Visc Med. 2018 Jul.

Abstract

Background: The lethality of acute mesenteric ischemia (AMI) remains quite high with 50-70%. The main reasons for that are the fact that AMI is rarely taken into consideration by the differential diagnosis of acute abdomen, the time-consuming diagnostic process, and the lack of a standardized therapeutic concept. The present interdisciplinary review aims to increase awareness among physicians and to help improve clinical outcomes.

Methods: This clinical therapeutic review is based on author expertise as well as a selective literature survey in PubMed based on the term 'mesenteric ischemia', combined with the terms 'arterial', 'clinical presentation', 'diagnosis', 'therapy', 'surgery', and 'interventional radiology'. Based on these search results as well as on the guidelines of the German Society of Vascular Surgery, the American College of Cardiology, and the American Heart Association, we present an interdisciplinary treatment concept.

Results: AMI is a vascular emergency that can be successfully treated only within the first hours after the onset of symptoms. Computed tomography angiography is the diagnostic method of choice. Intensive care unit treatment can prevent the occurrence of multiple organ failure. Treatment primarily consists of the revascularization of the mesenteric arteries. Endovascular techniques should be given priority, whereas signs of peritonitis or a central arterial occlusion with high thrombus load primarily require a surgical approach in order to save time and increase patient safety. Additional bowel resections can play a significant role in the treatment of intestinal sepsis.

Conclusion: Prompt and goal-oriented diagnosis and consistent treatment of AMI within 4-6 h from the onset of symptoms can be decisive for the reduction of AMI-associated lethality. In order for this to happen, a standardized concept of emergency treatment needs to be implemented.

Keywords: Acute mesenteric ischemia; Emergency procedure; Endovascular mesenteric reconstruction; Ischemic bowel disease; Surgery of mesenteric arteries.

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Figures

Fig. 1
Fig. 1
Clinical course and treatment of acute mesenteric ischemia (according to [30]).
Fig. 2
Fig. 2
Correlation between lethality and duration of intestinal ischemia according to Paes et al. [6] (1990) (----) and Walter et al. [7] (1992) (----) (according to [3]).
Fig. 3
Fig. 3
Extensive stent-PTA of the superior mesenteric artery resulting in peripheral thrombus dislocation. Clinical course: persistent acute mesenteric ischemia with fatal outcome.
Fig. 4
Fig. 4
a, b Implantation of 5 mm stents in the superior mesenteric artery und celiac artery. c, d Reocclusion of both stents 4 weeks later with acute mesenteric ischemia. e Open reconstruction with an aorto-celiac bypass and aortic reinsertion of the superior mesenteric artery. Outcome: recovery.
Fig. 5
Fig. 5
Diagnosis and treatment algorithm of acute mesenteric ischemia. NOMI = Non-occlusive mesenteric ischemia.
See this image and copyright information in PMC

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