Use of fractional flow reserve in the assessment of chronic mesenteric ischemia

Abstract

Chronic mesenteric ischemia (CMI) is a rare condition that is usually the result of atherosclerotic obstructive disease affecting the mesenteric arteries. The classic triad of post-prandial pain, food aversion and weight loss is not always present, often leading to low clinical suspicion for CMI and underdiagnosis. Non-invasive evaluation for CMI usually starts with mesenteric arterial duplex scanning, followed by computed tomography angiography, magnetic resonance angiography or conventional angiography, the latter being the gold standard for establishing its diagnosis. However, angiography alone has been demonstrated in coronary and other vascular beds to be inaccurate in predicting the physiologic and hemodynamic significance of a certain subset of atherosclerotic stenoses. We present the case of a patient with risk factors and symptoms suggestive of CMI who underwent angiography. However, angiography was equivocal and invasive physiologic testing was required to confirm the diagnosis and guide revascularization.

The Use of Fractional Flow Reserve for Physiological Assessment of Indeterminate Lesions in Peripheral Artery Disease

“…Sadiq et al reported on a 67-year-old male, presented with acute myocardial infarction, requiring emergent coronary artery bypass graft (CABG) surgery due to severe multi-vessel coronary artery disease [16]. Due to disabling symptoms secondary to severe obstructive disease of the distal abdominal aorta and bilateral common iliac arteries, the patient underwent a peripheral intervention.…”

Functional Assessment of Intermediate Vascular Disease

“…There are just a few case reports for the probable significance of FFR in mesenteric disease [ 84 ]. The splanchnic circulation and its response to vasodilating stimuli is poorly understood and understudied.…”

Fractional Flow Reserve

“…Sadiq et al . [ 1 ] applied the FFR measurement in a CMI case, and demonstrated that the baseline resting pressure gradient of stenosis in SMA was 14 mmHg (FFR = 0.87), hyperemic pressure gradient was 37 mmHg (FFR = 0.65). After stenting, the FFR results became 0.95 and 0.85, which suggested a significant improvement postintervention.…”

“…Second, unlike the brief and transient changes in renal vasomotor tone, the flow is dynamic with routine postprandial hyperemia in the mesenteric arterial bed. [ 1 ] Thus, it is crucial to induce hyperemic condition in measuring a FFR in the mesenteric arteries, particularly in SMA, as hyperemic flow mimics the routine postprandial flow. Last but not least, the circulatory control of splanchnic perfusion is still poorly understood, so is the response to pharmacologic induced hyperemia in mesenteric arteries.…”

“…Recently, an interesting study was published, in which FFR was performed to diagnose and guide stenting in chronic mesenteric ischemia (CMI). [ 1 ] We herein highlighted, the implications and limitations of FFR from coronary artery to renal artery and mesenteric artery for future investigations, respectively.…”