Chronic Mesenteric Ischemia

Aka: Chronic Mesenteric Ischemia, Abdominal Angina, Intestinal Angina

1. See Also
   1. Mesenteric Ischemia
2. Epidemiology
   1. Age: 60 years is mean age of diagnosis
   2. Gender predominance: Female (by ratio to 3:1)
3. Causes
   1. Diffuse atherosclerotic disease in 95% of cases
      1. All major mesenteric vessels (SMA, IMA, Celiac Artery) with stenosis or Occlusion
   2. Other causes
      1. Radiation Therapy
      2. Malignancy
      3. Fibromuscular dysplasia
      4. Vasculitis (often involves smaller vessels)
         1. Takayasu Arteritis
         2. Giant Cell Arteritis
         3. Polyarteritis Nodosa
         4. Systemic Lupus Erythematosus
         5. Thromboangiitis Obliterans
4. Risk Factors
   1. Cardiovascular Risk Factors
   2. Tobacco Abuse (75-80%)
5. Symptoms
   1. Symptoms are typically present for 4 -6 months at presentation
      1. Diagnosis is often delayed as much as 18 months
   2. Postprandial, diffuse Abdominal Pain
      1. Crampy, Abdominal Pain
      2. Pain is typically diffuse and poorly localized, or periumbilical
   3. Associated findings
      1. Weight loss of 15-25 pounds
      2. Nausea
6. Signs
   1. Abdominal bruit (60-90%)
   2. Fecal Occult Blood Testing (10%)
7. Labs
   1. See Mesenteric Ischemia
   2. Malnutrition Labs in Chronic Mesenteric Ischemia
      1. Anemia
      2. Leukopenia or Lymphopenia
      3. Hypoalbuminemia
8. Imaging: Diagnosis
   1. See Mesenteric Ischemia
   2. CT Abdomen and CT Angiography
      1. First-line study in most cases
      2. Occlusion of 2 major visceral arteries with significant stenosis of the third
   3. Angiography (gold standard)
   4. Contrast-Enhanced MRA Abdomen
      1. Contrast-Enhanced MRA is the best modality to fully evaluate for abdominal vascular disease
   5. Mesenteric Duplex Ultrasound
9. Management
   1. See Mesenteric Ischemia
   2. Medical Short-Term Measures while pending surgical management
      1. Bowel Rest
      2. Tobacco Cessation
      3. Perioperative Intra-arterial directed papaverine (vasodilator) to prevent arterial spasm
      4. Nitroglycerin as needed
      5. Anticoagulants (Heparin, Warfarin)
   3. Surgical (Vascular Surgery, Endovascular procedures)
      1. Indicated in all patients with Chronic Mesenteric Ischemia unless surgical risk outweighs benefit
      2. Endovascular techniques are preferred for high-risk surgical candidates (esp. short Life Expectancy)
         1. Angioplasty with stenting has best outcomes
         2. Lower morbidity and mortality than open procedures
         3. Initial symptom relief in 95% of cases
         4. Restenosis occurs in 20-40% patients (with up to half requiring repeat intervention)
      3. Open revascularization is preferred for patients who can withstand more invasive surgery (esp. younger patients)
         1. Lower restenosis rates than with endovascular procedures
         2. Long-term symptomatic relief
         3. Procedures
            1. Resection of necrotic bowel
            2. Transaortic Endarderectomy (Celiac Artery or SMA)
            3. Anterograde bypass (from supraceliac aorta)
            4. Retrograde bypass (from infrarenal aorta or common iliac artery)
      4. References
         1. Oderich (2009) Ann Vasc Surg 23(5): 700-12 [PubMed]
         2. Cai (2015) Ann Vasc Surg 29(5): 934-40 [PubMed]
10. References
    1. Fraboni (2012) Board Review Express, San Jose
    2. Kern and Gilley-Avramis (2022) Crit Dec Emerg Med 36(11) 21-8
    3. Mastoraki (2021) World J Gastrointest Pathophysiol 7(1): 125-30 [PubMed]