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Chronic Visceral Ischemia

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Presentation on theme: "Chronic Visceral Ischemia"— Presentation transcript:

1 Chronic Visceral Ischemia

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

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

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

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

6 Incidence 6-10% Unselected autopsy patients have significant atherosclerosis of visceral arteries 14-24 % on Aortogram

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

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

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

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

11 Duplex Scanning Celiac and SMA have an anterior position
Hampered by: bowel gas,obesity 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 PSV cm/sec/PDV cm/sec - higher PDV in the celiac

12 SMA and Celiac Hemodynamics
15 min - 90 min post meal SMA increase in PSV<increase in PDV Celiac velocity not as fed state dependent Celiac responds before SMA Glucagon very similar to post fed state Vasopressin Decreased PSV and PDV Celiac >> SMA

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

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

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

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

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

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

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

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

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

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

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

24 Antegrade Bypass Transabdominal Incise the arcuate ligament
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 Retropancreatic tunnel

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

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

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

28 PTA Poor surgical candidates 1980 - Furrer
Poor results with “orificial” lesions Symptomatic relief 80% at 3 year 5% mortality, 20% failure, 15 % - 50% need recurrent therapy 40% recurrent sx at 1 year

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

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

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

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

33 Celiac Artery Compression Syndrome
Clinicopathologic condition vs. anatomic condition 80% female Disease: Reproducible postprandial pain, age 40-60, > 20 lb. Weight loss Anatomic: Atypical remitting pain, Psch d/o, substance abuse, >60 y.o., weight loss < 20 lb.

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

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

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

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

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


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