schiro mesenteric ischemia - baptist health south...
TRANSCRIPT
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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
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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
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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.
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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
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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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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.
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6/28/2016
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Transhepatic Portogram
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12mm Self-Expanding Stent
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Post Stent
102
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Post Stent
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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!