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Chronic Visceral Ischemia. Hallmarks Abdominal pain after eating (15-20 min) Abdominal pain after eating (15-20 min) Mikkelsen - Intestinal angina Mikkelsen.

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Presentation on theme: "Chronic Visceral Ischemia. Hallmarks Abdominal pain after eating (15-20 min) Abdominal pain after eating (15-20 min) Mikkelsen - Intestinal angina Mikkelsen."— Presentation transcript:

1 Chronic Visceral Ischemia

2 Hallmarks Abdominal pain after eating (15-20 min) Abdominal pain after eating (15-20 min) Mikkelsen - Intestinal angina Mikkelsen - Intestinal angina Abdominal pain post food ingestion Abdominal pain post food ingestion Increasing frequency and severity Increasing frequency and severity Changes in types, amounts and frequency of food eaten Changes in types, amounts and frequency of food eaten 90% pts. Have lost weight (29 lbs.) 90% pts. Have lost weight (29 lbs.) 75% have an abdominal bruit 75% have an abdominal bruit

3 Historical Perspectives Described Baccelli Described Baccelli Conner Misdiagnosed abdominal pain Conner Misdiagnosed abdominal pain Dunphy (Peter Bent Brigham Hospital) Precursor to fatal intestinal necrosis Dunphy (Peter Bent Brigham Hospital) Precursor to fatal intestinal necrosis Mikkelson 1957 proposed treatment Mikkelson 1957 proposed treatment 1958 Shaw and Maynard - first successful TEA of the SMA 1958 Shaw and Maynard - first successful TEA of the SMA

4 Epidemiology 4:1 - Female:male 4:1 - Female:male 60.7 y/o +/- 10 years 60.7 y/o +/- 10 years 16% do not have classic symptoms 16% do not have classic symptoms nausea, vomiting, diarrhea, constipation nausea, vomiting, diarrhea, constipation 17.4 mo. +/ mo delay in diagnosis 17.4 mo. +/ mo delay in diagnosis 50% have had some form of abdominal operation 50% have had some form of abdominal operation

5 Etiology Near 100% have occlusion or high grade stenosis of the SMA Near 100% have occlusion or high grade stenosis of the SMA 70% have disease of all 2-3 mesenteric vessels 70% have disease of all 2-3 mesenteric vessels 20-30% have disease of the SMA or celiac alone ???? 20-30% have disease of the SMA or celiac alone ???? Atherosclerosis Atherosclerosis FMD, Arteritis, Median arcuate ligament FMD, Arteritis, Median arcuate ligament

6 Incidence 6-10% Unselected autopsy patients have significant atherosclerosis of visceral arteries 6-10% Unselected autopsy patients have significant atherosclerosis of visceral arteries % on Aortogram % on Aortogram

7 Diagnosis Biplanar aortography Biplanar aortography MRA MRA CT scan with IV contrast CT scan with IV contrast Duplex ultrasonography Duplex ultrasonography Other Other Upper GI, Endoscopy Plain films Upper GI, Endoscopy Plain films 33% present for other Vascular dz. manifestations 33% present for other Vascular dz. manifestations

8 MRA 2D-TOF MRA coronal plane 2D-TOF MRA coronal plane Splenic artery, trunks of SMA and Renal artery Splenic artery, trunks of SMA and Renal artery NOT GOOD FOR: NOT GOOD FOR: Hepatic artery, gastroduodenal artery, SMA branches Hepatic artery, gastroduodenal artery, SMA branches Kumamoto Japan, 1995 Kumamoto Japan, 1995

9 MRA (plus) Gadolinium enhanced MRA Gadolinium enhanced MRA 65 patients/14 positive MRA 65 patients/14 positive MRA 12 Angio alone/2 Surgery alone 12 Angio alone/2 Surgery alone 6 patients had mesenteric ischemia 6 patients had mesenteric ischemia Stenosis/occlusion of the Celiac in 7 pts. Stenosis/occlusion of the Celiac in 7 pts. Stenosis/occlusion of the SMA in 6 pts. Stenosis/occlusion of the SMA in 6 pts. 100% sensitive/95% specific; 100% sensitive 100% sensitive/95% specific; 100% sensitive 1997, University of Michigan 1997, University of Michigan 1998, Universitat Heidelberg 1998, Universitat Heidelberg

10 MRA (plus-plus) Gadolinium enhanced MRA (before and after caloric stimulation) Gadolinium enhanced MRA (before and after caloric stimulation) 10 Healthy volunteers (28 second breath hold) 10 Healthy volunteers (28 second breath hold) Fasting (6 hours)/Fed 475 kcal meal Fasting (6 hours)/Fed 475 kcal meal SMA flow ml/min/kg SMA flow ml/min/kg SMV flow ml/min/kg SMV flow ml/min/kg Clearly enhances distal vessels better Clearly enhances distal vessels better 1998, University Hospital Zurich 1998, University Hospital Zurich

11 Duplex Scanning Celiac and SMA have an anterior position Celiac and SMA have an anterior position Hampered by: bowel gas,obesity Hampered by: bowel gas,obesity Used best in: Normal subjects, response to stimuli, Postoperative evaluation Used best in: Normal subjects, response to stimuli, Postoperative evaluation SMA - reversed flow in early diastole (high resistance) in fasting state (Not true in celiac) SMA - reversed flow in early diastole (high resistance) in fasting state (Not true in celiac) SMA PSV cm/sec/PDV cm/sec - higher PDV in the celiac SMA PSV cm/sec/PDV cm/sec - higher PDV in the celiac

12 SMA and Celiac Hemodynamics 15 min - 90 min post meal 15 min - 90 min post meal SMA increase in PSV> SMA Celiac >> SMA

13 Collateral Circulation SMA Occlusion SMA Occlusion Hepatic to GDA Hepatic to GDA Superior pancreaticoduodenal to inferior pancreatic Superior pancreaticoduodenal to inferior pancreatic

14 Collateral Circulation Celiac occlusion Celiac occlusion Reverse flow Reverse flow IMA to SMA IMA to SMA Meandering mesenteric Meandering mesenteric Mid colic to ascending colic branch Mid colic to ascending colic branch Iliac to IMA Iliac to IMA Sup/Inf Hemorrhoidal Sup/Inf Hemorrhoidal

15 Duplex Scanning 80 patients (Total) 80 patients (Total) n=9 SMA stenosis > 70% n=9 SMA stenosis > 70% PSV > 275 cm/sec, no postprandial scanning necessary PSV > 275 cm/sec, no postprandial scanning necessary 89% sensitivity 89% sensitivity PSV 20% PSV 20% 100 % specificity that SMA dz. Is not present 100 % specificity that SMA dz. Is not present 1995, Oregon Health Sciences (Porter) 1995, Oregon Health Sciences (Porter)

16 Intervention Indications Symptomatic patients with appropriate biplanar angiography Symptomatic patients with appropriate biplanar angiography Negative wokup for other sources of pain Negative wokup for other sources of pain Asymptomatic patients at time of aortoiliac reconstruction with SMA stenosis/occlusion Asymptomatic patients at time of aortoiliac reconstruction with SMA stenosis/occlusion SMA alone - ? Retrograde bypass SMA alone - ? Retrograde bypass SMA and celiac - Supraceliac bypass SMA and celiac - Supraceliac bypass

17 Intervention (What to revascularize) Late recurrence 26.5% (n=56 pts) Late recurrence 26.5% (n=56 pts) 11% with complete revascularization 11% with complete revascularization 29% with 2/3 revascularization 29% with 2/3 revascularization 50% with 1/3 revacularization 50% with 1/3 revacularization Mayo Clinic 1981 (Hollier) Mayo Clinic 1981 (Hollier) Similar results 1 or 2 arteries, as long as SMA revascularized Similar results 1 or 2 arteries, as long as SMA revascularized UCSF (Reilly), Oregon Health Sciences (Porter) UCSF (Reilly), Oregon Health Sciences (Porter)

18 Interventions Transaortic endarterectomy Transaortic endarterectomy Antegrade bypass Antegrade bypass Retrograde bypass Retrograde bypass Vein patch angioplasty Vein patch angioplasty Interpostion graft Interpostion graft PTA PTA PTA/Stent PTA/Stent

19 Visceral Endarterectomy Blind retrograde fashion Blind retrograde fashion During acute ischemia in sick patient During acute ischemia in sick patient Distal SMA Distal SMA Incision through the origin of the SMA Incision through the origin of the SMA

20 Transaortic endarterectomy 50% of patients atheroma is around SMA/celiac orifice 50% of patients atheroma is around SMA/celiac orifice 10-20% had to have conversion to another procedure 10-20% had to have conversion to another procedure Medial visceral rotation Medial visceral rotation Combined aortic, renal and visceral repair Combined aortic, renal and visceral repair 14.6% peri-op mortality, 17% multiple complications 14.6% peri-op mortality, 17% multiple complications UCSF, 1991 (Cunningham) UCSF, 1991 (Cunningham)

21 Transaortic endarterectomy Usually works because lesions represent “overflow disease” Usually works because lesions represent “overflow disease” Distal disease (SMA) Distal disease (SMA) Vein patch angioplasty Vein patch angioplasty

22 Antegrade Bypass Lower morbidity (less extensive surgery) Lower morbidity (less extensive surgery) 95.8% 1 year/ 86% 5 year relief of symptoms 95.8% 1 year/ 86% 5 year relief of symptoms Slightly shorter ischemia times (26 vs. 30 min) Slightly shorter ischemia times (26 vs. 30 min) UCSF, 1991 (Cunningham) UCSF, 1991 (Cunningham)

23 Antegrade Bypass N=16 N=16 100% some component of organ failure 100% some component of organ failure 25% peri-op mortality of MODS 25% peri-op mortality of MODS University of Florida 1987 (Harward) University of Florida 1987 (Harward)

24 Antegrade Bypass Transabdominal Transabdominal Incise the arcuate ligament Incise the arcuate ligament Expose the aorta > 6cm proximal to the celiac axis Expose the aorta > 6cm proximal to the celiac axis Celiac artery proximal to its branches, common hepatic artery, SMA at or beyond the ligament of Trietz Celiac artery proximal to its branches, common hepatic artery, SMA at or beyond the ligament of Trietz Retropancreatic tunnel Retropancreatic tunnel

25 Retrograde Bypass (Infrarenal Aorta) More disease in the distal aorta More disease in the distal aorta IMA - easy prograde flow IMA - easy prograde flow SMA - must put the graft high on the aorta, and distally on the SMA SMA - must put the graft high on the aorta, and distally on the SMA Celiac - requires a long graft Celiac - requires a long graft Very prone to kinking, thrombosis, compression Very prone to kinking, thrombosis, compression *Note: Follow up studies have not shown this problem clearly *Note: Follow up studies have not shown this problem clearly

26 Retrograde Bypass (Infrarenal Aorta) Short vein graft vs. long vs. prosthetic Short vein graft vs. long vs. prosthetic All lengths can kink All lengths can kink Vein 500 ml/min max (SMA = 750 ml/min) Vein 500 ml/min max (SMA = 750 ml/min) Vein is preferential in cases of bowel necrosis Vein is preferential in cases of bowel necrosis

27 Retrograde Bypass (Infrarenal Aorta - Right Iliac junction) SMA alone SMA alone Dissect ligament of Treitz Dissect ligament of Treitz Graft comes through mesentery to anterior SMA wall Graft comes through mesentery to anterior SMA wall SMA and Celiac SMA and Celiac Bifurcated graft Bifurcated graft Celiac limb - Retropancreatic to hepatic artery Celiac limb - Retropancreatic to hepatic artery

28 PTA Poor surgical candidates Poor surgical candidates Furrer Furrer Poor results with “orificial” lesions Poor results with “orificial” lesions Symptomatic relief 80% at 3 year Symptomatic relief 80% at 3 year 5% mortality, 20% failure, 15 % - 50% need recurrent therapy 5% mortality, 20% failure, 15 % - 50% need recurrent therapy 40% recurrent sx at 1 year 40% recurrent sx at 1 year

29 PTA Better outcome if oversized balloons used Better outcome if oversized balloons used Symptomatic relief not related to the pressure drop, may be related to overdilation Symptomatic relief not related to the pressure drop, may be related to overdilation Southampton Hospital 1988 (Odurny) Southampton Hospital 1988 (Odurny) Baylor 1996 (Allen) Baylor 1996 (Allen)

30 PTA with Stent 12 patients/3 celiac artery stenosis, 7 SMA stenosis, 1 aortomesenteric bpg occlusion, 2 SMA occlusions 12 patients/3 celiac artery stenosis, 7 SMA stenosis, 1 aortomesenteric bpg occlusion, 2 SMA occlusions 92% technical success 92% technical success 8% mortality despite technically successful procedure 8% mortality despite technically successful procedure Primary patency 74%, secondary patency 83% at 3 years Primary patency 74%, secondary patency 83% at 3 years Rhode Island 1999, (Sheeran) Rhode Island 1999, (Sheeran)

31 Evaluation of Intervention Patency Intra-op Duplex imaging Intra-op Duplex imaging Intra-op Electromagnetic flow measurement Intra-op Electromagnetic flow measurement Routine post-op angiogram Routine post-op angiogram Some consider madatory Some consider madatory

32 Peri-operative care Pre-operative TPN Pre-operative TPN Post-opertive TPN Post-opertive TPN “Revascularization syndrome” “Revascularization syndrome” Abdominal pain, tachycardia, leukocytosis, intestinal edema Abdominal pain, tachycardia, leukocytosis, intestinal edema

33 Celiac Artery Compression Syndrome Clinicopathologic condition vs. anatomic condition Clinicopathologic condition vs. anatomic condition 80% female 80% female Disease: Reproducible postprandial pain, age , > 20 lb. Weight loss Disease: Reproducible postprandial pain, age , > 20 lb. Weight loss Anatomic: Atypical remitting pain, Psch d/o, substance abuse, >60 y.o., weight loss 60 y.o., weight loss < 20 lb.

34 Evaluation Abdominal pain, abdominal bruit and appropriate arteriogram (> 50% lesion) Abdominal pain, abdominal bruit and appropriate arteriogram (> 50% lesion) Upper and lower GI series Upper and lower GI series HIDA HIDA ERCP ERCP Small bowel biopsy Small bowel biopsy Abdominal CT Abdominal CT Malabsorption studies Malabsorption studies UCSF 1985 (Reilly) UCSF 1985 (Reilly)

35 Interventions Decompression Decompression 53% remained asymptomatic 53% remained asymptomatic Decompression and dilation Decompression and dilation 76% remained asymptomatic 76% remained asymptomatic Reconstruction Reconstruction 76% asymptomatic 76% asymptomatic *Arteriogram: Asymptomatic patient -70% wide open celiac, Symptomatic - 75% celiac stenosis *Arteriogram: Asymptomatic patient -70% wide open celiac, Symptomatic - 75% celiac stenosis

36 TAKEHOME In the right hands most techniques are comparable In the right hands most techniques are comparable TEA - if multiple vessels need revascularization TEA - if multiple vessels need revascularization Antegrade vs. retrograde - depending on pts’ anatomy, concomminant procedures Antegrade vs. retrograde - depending on pts’ anatomy, concomminant procedures

37 TAKEHOME PTA PTA Fibromuscular disease Fibromuscular disease Poor operative risk patients Poor operative risk patients Older patients Older patients Stent ostial lesions Stent ostial lesions Necrotic bowel Necrotic bowel Vein bypass Vein bypass Direct thromboendartectomy Direct thromboendartectomy

38 TAKEHOME Median Arcuate Ligament Syndrome Median Arcuate Ligament Syndrome Be exhaustive in patient workup Be exhaustive in patient workup Asymptomatic disease in patients having infrarenal aortic surgery Asymptomatic disease in patients having infrarenal aortic surgery


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