Endovascular treatment of abdominal ischemic syndrome

Abdominal angina is defined as the postprandial pain that occurs in individuals with sufficient mesenteric vascular occlusive disease such that blood flow cannot increase enough to meet visceral demands. The mechanism is believed to be similar to the angina pectoris that occurs in individuals with coronary artery disease or the intermittent claudication that accompanies peripheral vascular disease, as depicted in the image below.

The superior mesenteric artery and inferior mesenteric artery share collateral circulation near the splenic flexure of the colon. When dilated, this vessel is termed the meandering mesenteric artery. As seen on an angiogram, this is a sign of chronic mesenteric ischemia.

Intestinal ischemia results from the mismatch of oxygen supply to and oxygen consumption by the gastrointestinal tract owing to reduced blood flow. The decreased blood flow results from narrowing of the mesenteric vessels, which can be can be secondary to a thrombus or embolus. The most common cause of abdominal angina is atherosclerotic vascular disease. The occlusive process commonly involves the ostia and a few proximal centimeters of the mesenteric vessels. Aortoiliac occlusive disease frequently coexists and may be the cause of the ostial lesions.

The classic description of intestinal angina is abdominal pain that is out of proportion with physical examination.

The hallmark of this condition is disabling midepigastric or central abdominal pain that develops 10-15 minutes after eating. The pain gradually increases in intensity, reaches a plateau, and then slowly decreases in intensity several hours after eating. Some patients have associated motility disturbances such as diarrhea or constipation, bloating, or vomiting.

Therapeutic Options. There are basically two approaches for the treatment of CMI: surgery and endovascular recanalization. Endovascular recanalization includes percutaneous transluminal angioplasty (PTA) with or without stent placement of one or more mesenteric arteries. Treatment of symptomatic CMI is necessary to prevent acute mesenteric ischemia, which may cause bowel infarction and death. Asymptomatic disease does not constitute an indication for treatment, although prophylactic treatment may be necessary in cases of planned abdominal surgery because of probable loss of collaterals during surgery. Classic surgery includes procedures such as endarterectomy, aortomesenteric and/or celiac bypass grafting. However, the perioperative mortality can be high, reaching 17% and the major complications rate is high, ranging between 15 and 35%.

Дата добавления: 2015-10-26