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 Visceral Ischemia

William R. Flinn, M.D., Bruce L. Gewertz, M.D., Leonard P. Krajewski, M.D.

Includes:

  • Chronic Visceral Ischemia
  • Acute Visceral Ischemia
  • Non-Occlusive Mesenteric Ischemia
  • Mesenteric Venous Occlusive Disease
  • Additional Important/Non-Core Cirriculum Topics:
  • Celiac/SMA Compression

I. Anatomy and Pathophysiology

1. To define the normal arterial and venous anatomy of the mesenteric circulation and to be familiar with the more frequently encountered anatomic variations.

2. To recognize the physiologic and pathophysiologic collateral circulation to the gastrointestinal tract that may develop in response to occlusive disease of the main mesenteric vessels.

3. To understand the high flow, low resistance physiology of normal mesenteric blood flow, recognize the neural, humoral (hormonal) and enteric ( intraluminal ) mechanisms of autoregulation , and understand the high degree of vasoreactivity of this arterial bed.

4. To understand the multiple etiologies of acute mesenteric ischemia including embolism, thrombosis, dissection, venous occlusion, trauma, and gut ischemia following aortic reconstruction

5. To understand the multiple possible etiologies of syndromes of chronic mesenteric ischemia including atherosclerosis, aneurysm, extrinsic compression syndromes, and other nonatherosclerotic arteriopathies .

6. To understand the clinical correllation of multiple visceral vessel involvement with the development of symptoms of chronic intestinal ischemia based upon an understanding of the compensatory collateral perfusion of the gut.

II . Diagnostic Evaluation

Acute Mesenteric Ischemia

1. To understand the characteristic initial signs and symptoms suggestive of acute mesenteric ischemia and how symptoms and physical findings may differ from other causes of the acute abdomen.

2. To define preexistent clinical conditions that may predispose to, or support the clinical diagnosis of acute mesenteric ischemia, e.g. atrial fibrillation, previous myocardial infarction (mesenteric embolism), severe cardiopulmonary dysfunction (non-occlusive ischemia), history of post- prandial pain and weight loss, known aortic dissection (mesenteric thrombosis), hypercoaguable states (mesenteric venous thrombosis).

3. To understand the parameters of initial serologic testing that characterize or may support the clinical diagnosis of acute mesenteric ischemia.

4. To define the indications for mesenteric arteriography (or other forms of visceral arterial imaging) in patients with suspected acute mesenteric ischemia and understand the technical aspects of the conduct of arteriography necessary to make an accurate diagnosis.

5. To define the characteristic arteriographic findings diagnostic of the major causes of acute mesenteric arterial ischemia; mesenteric thrombosis, mesenteric embolism, and non-occlusive mesenteric ischemia.

6. To define the appropriate diagnostic evaluation for suspected intestinal ischemia following aortic surgery.

7. To understand the usefulness of alternative imaging techniques (CT, MRI) for the diagnosis of acute mesenteric venous thrombosis.

Chronic Mesenteric Ischemia

1. To understand the characteristic signs and symptoms of chronic mesenteric ischemia and how other aspects of patients' history (e.g. previous aortic surgery) or physical examination (e.g. aortoiliac occlusive disease) may suggest the presence of associated visceral arterial occlusive disease.

2. To understand the limitations of standard gastrointestinal diagnostic testing modalities (e.g. GI endoscopy , contrast studies, CT, etc.) for diagnosis of chronic mesenteric ischemia.

3. To understand the usefulness of porto -mesenteric duplex ultrasound scanning for elective noninvasive evaluation of the major visceral vessels.

4. To define the indications for arteriography (or alternative vascular imaging studies) in patients with suspected chronic mesenteric ischemia and understand the arteriographic findings that are considered diagnostic of this condition.

5. To recognize the characteristic arteriographic findings in atypical causes of mesenteric arterial compromise including extrinsic compression and nonatherosclerotic visceral arterial disease.

III . Treatment

Acute Mesenteric Ischemia

1. To be familiar with techniques for surgical exposure of the main mesenteric vessels, to understand standard surgical options for revascularization following acute mesenteric embolism or acute mesenteric arterial thrombisis , and to understand surgical options for the management of intestinal necrosis when this has occurred.

2. To recognize the relationship of different anatomic patterns of gut infarction to the different causes of acute mesenteric ischemia when intestinal infarction is encountered unexpectedly at the time of laparotomy .

3. To understand the critical relationships between the extent of viable bowel (before and/or after successful revascularization) and the extent of resection of nonviable intestine, and the impact of these observations upon both the short and long-term prognosis for the patient.

4. To understand the relative usefullness of intraoperative techniques available for the assessment of intestinal viability at the time of surgical treatment for acute mesentertic ischemia.

5. To understand the pathophysiologic effects of intestinal reperfusion after surgical treatment of acute mesenteric ischemia and the impact of these effects on postoperative patient care.

6. To understand the role of early empiric re-exploration following surgical treatment of acute mesenteric ischemia.

7. To understand standard and alternative treatments for mesenteric venous thrombosis including the role of surgical treatment in the management of this disorder.

8. To understand the management of suspected acute gut ischemia occurring after aortic surgery.

9. To understand the therapeutic role of interventional non-surgical treatments in the management of all forms acute mesenteric ischemia, particularly in non-occlusive mesenteric ischemia.

Chronic Mesenteric Ischemia

1. To be familiar with all standard surgical techniques for direct, elective visceral revascularization and understand the importance of comprehensive revascularization in the surgical treatment of chronic intestinal ischemia.

2. To be aware of surgical alternatives for treatment of atypical or non-atherosclerotic visceral arterial occlusive lesions.

3. To understand the possible application of interventional, nonsurgical treatments for chronic visceral arterial occlusive lesions.

4. To understand the usefulness of noninvasive vascular testing for the follow-up of patients having visceral revascularization procedures.

References

1. Vascular Disease of the Gastrintestinal Tract - Pathophysiology , Recognition, and Management. Marston A, editor. Baltimore : Williams & Wilkins, 1986.

2. Flinn WR, Vogelzang RL eds., Visceral arterial disorders. In Strandness DE, Van Breda A, editors. Vascular diseases - surgical & interventional therapy. New York : Churchill Livingston, Inc. 1994:743 - 850.

3. Granger DN, Richardson PDI, Kvietys PR, et al. Intestinal blood flow. Gastroenterology, 1980; 78:837.

4. Clark ET, Gewertz BL. Intermittent ischemia accentuates intestinal reperfusion injury. J Vasc Surg 1991; 13:601.

5. Moneta GL, Cummings C, Yeager RA, et al. Mesenteric duplex scanning: a blinded prspective study. J Vasc Surg ; 1993; 17:79.

6. Nemcek AA, Vogelzang RL. Comprehensive visceral arteriography . In Strandness DE, Van Breda A, editors. Vascular diseases - surgical & interventional therapy. New York : Churchill Livingsston , Inc. 1994:763 - 774.

7. Kaleya RN, Sammartano RJ, Boley SJ. Aggressive approach to acute mesenteric ischemia. Surg Clin North Am 1992; 72:157.

8. Horgan PG, Gorey TF. Operative assessment of intestinal viability. Surg Clin North Am 1992; 72:143.

9. Morse SS, Clark RA. Management of nonocclusive and occlusive mesenteric ischemia. In Kadir S, editor. Current Practice of Interventional Radiology. Philadelphia : BC Decker 1991:394.

10. Harward TRS, Green D, Bergan JJ, et al. Mesenteric venous thrombosis. J Vasc Surg 1989; 9:328.

11. Stoney RJ, Cunningham CG. Chronic visceral ischemia. In Yao JST, Pearce WH, editors. Long term results in vascular surgery. Norwalk , Appleton & Lange. 1993:305.

12. Cunningham CG, Reilly LM, Rapp JH. Chronic visceral ischemia: three decades of progress. Ann Surg 1991; 214:276.

13. Hermreck AS, Thomas JH, Iliopoulos JI, Pierce GE. Role of supraceliac aortic bypass in visceral arterial reconstruction. Am J Surg 1991; 162:611.

14. McAfee MK, Cherry KJ, Naessens JM, et al. Influence of complete revascularization on chronic mesenteric ischemia. Am J Surg 1992; 164:220.

15. Calderon M, Ruel GJ, Gregoric ID, et al. Long - term results of surgical management of chronic intestinal angina. J Cardiovasc Surg 1992; 33:723.

16. Okuhn SP, Reilly LM, Bennett JB, et al. Intraoperative assessment ofrenal and visceral artery reconstruction: the role of duplex scanning and spectral analysis. J Vasc Surg 1987; 5:137.

17. McMillan WD, McCarthy WJ, Bresticker MR, et al. Mesenteric artery bypass: objective patency determination. J Vasc Surg 1995; 21:729.

18. Colapinto RF, McLoughlin MJ, Weisbrod GL. The routine lateral aortogram and the celiac compression syndrome. Radiology 1972; 103:557.

19. Golden DA, Ring EJ, Mclean GK, Friedman DB. Percutaneous transluminal angioplasty in the treatment of abdominal angina. AJR 1982; 139:247.

Posted June 2010