Mesenteric arterial ischaemia: diagnosis and therapeutic options

Abstract

Ischaemia of the bowel may arise from a number of causes affecting the arterial and venous compartments of the vascular tree. This article addresses the causes and consequences of arterial obstruction, which may compromise the supply of oxygenated blood to the bowel. These events may occur as an acute phenomenon, or they may present in a chronic fashion. The therapeutic options available to treat this condition are largely dependent on the mode of presentation and the amount of time that is available before irreversible damage occurs to the bowel integrity. In the acute phase, the viability of the bowel is in doubt, and this necessitates an open operative approach to assess the amount of bowel infarction which has already occurred. A variety of operative procedures are then available to limit this bowel loss and to secure the viability of the remaining bowel. In the more chronic phase there are alternative, less invasive procedures that may be appropriate for the patient, who may have suffered a prolonged period of undernourishment and dehydration. In such cases the immediate bowel viability is not in doubt, but the medium/long-term survival is compromised. Treatment options appropriate to each clinical scenario are discussed, along with the major technical issues associated with these treatments. A team approach to the most appropriate management plan is stressed, and the published outcomes reviewed.

Chronic atherosclerotic mesenteric ischemia (CMI)

“…28 Ischemic colitis is frequently diagnosed by histology following biopsy during bowel endoscopy. 29 Intra-arterial digital subtracted angiography is still considered the diagnostic gold standard even if multi-slice CT reconstructions offer a better three-dimensional understanding of the vessel anatomy, especially for planning the interventional access.…”

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“…Anastomosis between superior pancreaticoduodenal artery (from celiac artery) and inferior pancreaticoduodenal artery (from superior mesenteric artery) is one of the important collateral channels [7,8]. Treatment options available include surgical bypass grafting [9] and percutaneous trans luminal angioplasty and stenting [10,11].…”

Triple-vessel mesenteric ischaemia presenting with gastric ulceration

“…The average age of patients are in the seventh decade with a significant female predominance and is nearly exclusively caused by mesenteric atherosclerosis [2,3]. Other rare causes which may affect large or small arteries supplying the gut include neurofibromatosis, fibromuscular hyperplasia, visceral artery dissection, radiation therapy, connective tissue disease and cocaine abuse [4]. Atherosclerotic disease of the coeliac trunk and mesenteric vessels is common, hence angiographic evidence of partial or complete occlusion of these vessels is only of significance in association with relevant symptoms or signs [2,4].…”