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Online ISSN 1827-1847
Wyers M. C., Zwolak R. M.
Section of Vascular Surgery Dartmouth Hitchcock Medical Center Lebanon, NH, US
This review summarizes the current options for and results of endovascular treatments of chronic and acute mesenteric ischemia. Conventional operative approaches for mesenteric revascularization pose many technical challenges and carry a significant risk of morbidity and mortality. Less invasive treatments for mesenteric ischemia are appealing for these systemically ill patients. Mesenteric stenting has become a viable treatment option for patients with chronic mesenteric ischemia (CMI), especially for more nutritionally bereft patients or patients judged, for other reasons, to be at high operative risk. For patients with chronic symptoms, percutaneous mesenteric stenting is initially efficacious but does not provide the durability of mesenteric bypass surgery. Therefore close clinical and duplex ultrasound follow-up is advisable. Patients with recurrent, chronic symptoms who remain poor operative candidates can usually be retreated safely with endovascular means. Others advocate mesenteric stenting as a bridge for extremely malnourished patients to gain some weight before subjecting them to an operative bypass. Endovascular treatments for patients with acute mesenteric ischemia (AMI) have some significant limitations. Catheter-directed vasodilator administration is appropriate and recommended for the small subset of acutely ischemic patients with non-occlusive mesenteric ischemia. Successful reports of percutaneous thrombectomy or thrombolysis of an acute mesenteric embolus or thrombotic occlusion do exist but cannot be considered the primary mode of therapy. In the majority of patients with acute ischemia, these catheter based treatments do not replace or prevent the need for a thorough laparotomy and inspection of the intestines. They can also be time consuming and delay complete revascularization. More recently a new hybrid treatment option for AMI caused by terminal thrombosis of a diseased superior mesenteric artery has been introduced, that involves retrograde arterial stenting performed during celiotomy.
The Achilles heal with all forms of mesenteric stenting is the relatively high rate of recurrent stenosis. Duplex ultrasound and close clinical surveillance is highly advisable. Fortunately, most recurrent stenoses can be safely redilated or restented but some patients may eventually require operative bypass for recurrent symptoms.