Mesenteric Ischemia: A Minimally Invasive Approach

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Presentation transcript:

Mesenteric Ischemia: A Minimally Invasive Approach Danielle Pineda, MD April 7, 2017

Chronic Mesenteric Ischemia 11/22/2017

Rare Disease Accounts for less than 2% of all hospital admissions for GI conditions -But atherosclerosis of mesenteric vessels much more prevalent (usually asymptomatic)

11/22/2017 Rutherford 8th Edition

FOOD FEAR Pain after meals (30 mins on average) Weight loss Avoiding meals Pre-operative Necessities Endoscopy Colonoscopy CT scan Claudication: ischemic neuropathy involving small unmyelinated A delta and C sensory fibers and a local intramuscular acidosis from anaerobic metabolism enhanced by substance P 11/22/2017

Endovascular Approach Options

Technique Femoral or brachial approach Lateral position for C-arm Cross atherosclerotic lesion May need to pre-dilate with angioplasty and place sheath through stenosis Balloon-expandable Stent versus stent graft SMA preferential vessel although can also treat celiac/IMA in higher risk patients 11/22/2017

Complications Cardiac events (patients high risk secondary to atherosclerosis) GI bleeding Embolus/dissection leading to bowel ischemia Access related problems (especially brachial) Renal failure 11/22/2017

Hybrid Approach Midline laparotomy Micropuncture access of the SMA Cross stenosis/occlusion in retrograde fashion Balloon expandable stent or stent graft Transverse closure or patch closure 11/22/2017

11/22/2017

Acute Mesenteric Ischemia 11/22/2017

Multiple Causes Arterial emboli Arterial thrombosis 40-50% of cases Intracardiac mural thrombus, endocarditis, proximal thoracic aortic aneurysms Arterial thrombosis 20-35% of cases Preexisting atherosclerosis – acute on chronic picture Nonocclusive Mesenteric Ischemia Mesenteric Venous Thrombosis

Signs and Symptoms Pain out of proportion to exam Pneumatosis on CT scan Elevated WBC, lactate 11/22/2017

Endovascular Approach Options

Mechanical Thrombolysis Usually reserved for high risk surgical patients if no bowel ischemia suspected Risk of embolus to distal SMA branches could precipitate bowel ischemia Angioplasty and Stent Used in situations when patient has acute on chronic disease in conjunction with mechanical thrombolysis or in retrograde approach as discussed

Case 1 80 yo F with history of supraceliac aorta to celiac and SMA bypass Represents with weight loss and post-prandial pain 11/22/2017

Celiac artery stenosis Occluded bypass Celiac artery stenosis 11/22/2017

11/22/2017

Questions???