Mesenteric vascular disease

Vascular surgery, Subject 4

I. Generalities

Mesenteric vascular disease may present as an acute life-threatening emergency or as a chronic

debilitating problem.

The involved arteries include: the celiac axis (CA), superior mesenteric artery (SMA) and inferior
mesenteric artery (IMA) arising from the anterior surface of the abdominal aorta.

II. Acute mesenteric ischemia

Generalities

- Its a surgical emergency with an 80% mortality rate.

- Classically, severe abdominal pain out of proportion to physical findings suggests the diagnosis. In
the early stages of acute mesenteric ischemia, these patients are often writhing in agony without
evidence of peritonitis.

- If diagnosis or treatment is delayed, transmural infarction of bowel results in peritoneal irritation and
more pronounced physical signs.

Etiology Acute occlusion of the mesenteric arteries may result from:

The usual site of distal embolization is the SMA,

generally several centimeters distal to the origin (at the
Embolization level of the middle colic artery). As with lower extremity
embolism, the source of embolism is usually the heart
(atrial fibrillation or myocardial infarction).

Sudden occlusion of pre-existing atherosclerotic

lesions of the visceral vessels may cause acute
mesenteric ischemia. Because mesenteric
atherosclerosis usually involves the origin of the
Thrombosis artery, thrombosis also begins at the origin of the
vessel. These patients will frequently admit to the
presence of pre-existing symptoms of chronic
mesenteric ischemia.

Nonocclusive Its due to states of low flow to the mesenteric arteries,

as seen in cardiogenic shock. It has been recognized
mesenteric in patients after cardiopulmonary bypass and in
patients requiring high doses of intravenous
ischemia vasoconstrictors and inotropes (e.g., epinephrine).
 Diagnosis and treatment

Saving these patients depends on a high index of suspicion and prompt diagnosis and treatment. All
patients suspected of acute mesenteric ischemia should have their cardiac status optimized while
being aggressively volume resuscitated and treated with broad-spectrum antibiotics.

- Angiography of the abdominal aorta and mesenteric arteries is performed if acute mesenteric
ischemia is suspected. Subsequent treatment is based on the arteriographic findings.

If embolus is found (usually involving the SMA), prompt surgical embolectomy is

performed. Subsequent anticoagulation is given, assuming a cardiac source.

If thrombosis is found (usually involving the origins of theCA and SMA), urgent
aortomesenteric bypass is performed. A prosthetic bypass is usually used, except in
the presence of bowel infarction (then, GSV is preferred).

The treatment of nonocclusive mesenteric ischemia involves direct arterial infusion

of vasodilators (i.e., papaverine or nitroglycerine) into the SMA. Supportive care to
optimize cardiac output and reverse the low-flow state is critical.

- Following embolectomy or reconstruction, the bowel is assessed for viability Overtly necrotic bowel
is resected. If marginal viability is present in the remaining bowel, it should be left in place. A second-
look laparotomy should be done in 24 hours to ensure viability of the residual bowel. Patients with
nonocclusive mesenteric ischemia who develop peritoneal signs should undergo laparotomy to rule
out necrotic bowel.

III. Chronic mesenteric ischemia

Results from slowly progressive stenosis/occlusion of the visceral vessels (CA, SMA, and IMA)
Atherosclerotic lesions generally involve the anterior abdominal aorta and the origins of these vessels.

Clinical presentation

- The triad of symptoms suggesting chronic mesenteric ischemia includes:

Postprandial abdominal pain, occurring in the epigastrium, generally 0.5-2 hours after a meal
"Food fear" resulting from the chronic association of eating with subsequent pain
Weight loss

Diagnosis The diagnosis of chronic mesenteric ischemia is suggested by the clinical triad noted
previously. Additional symptoms might include gastrointestinal dysmotility. Definitive diagnosis is often
delayed for up to 1-2 years, unless a high index of suspicion is maintained.
 - Duplex scanning of the visceral vessels Recently has been used to screen patients with suspected
chronic mesenteric ischemia. Elevated velocities within the CA and superior mesenteric vessels may
be seen.

- Arteriography is the most useful diagnostic study. Both anterior-posterior and lateral views of
the aorta must be used to visualize the origins of the visceral vessels. When symptoms occur, two of
the three vessels are usually occluded and the remaining one is highly diseased. A rich collateral
blood supply between the CA and SMA (pancreatoduodenal arcade) and the SMA and IMA (Riolan's
arch) may be seen.

- Computed tomography (CT) of the abdomen as well as upper and lower intestinal endoscopy, is
performed to rule out other causes for the patient's symptoms prior to recommending treatment of
mesenteric occlusive disease.

Treatment

- Surgery is recommended if severe mesenteric occlusive disease is found in a patient with the
clinical presentation noted previously. In well-selected patients, the results of surgery are excellent,
with 90% of patients cured of their symptoms.

Aortomesenteric bypass usually involving the CA and SMA, is performed with a short
prosthetic graft. The bypass can be constructed in an antegrade format from the supraceliac
aorta or a retrograde approach from the infrarenal aorta or iliac system.

Transaortic mesenteric endarterectomy directly removes the atherosclerotic lesions

from the aorta and origins of the mesenteric vessels, restoring patency without prosthetic
grafting.

IV. Mesenteric venous thrombosis

It may present more insidiously than acute mesenteric ischemia. Typically, it causes progressive
abdominal pain and distention and may be confused with intestinal obstruction.

Etiology It is frequently associated with hypercoagulable states, including patients with a neoplasm
or hematologic abnormality.

Diagnosis It is suggested by CT scan that reveals concentration of contrast in the wall of the
mesenteric vein without luminal flow.

Treatment

- Nonoperative treatment is anticoagulation (intravenous heparin) and treatment of the underlying

disorder.

- Celiotomy may be necessary if peritonitis develops, but 75% of patients can be treated
nonoperatively if the diagnosis is made promptly and appropriate treatment is given.

V. Others

Epidemiologa
 - Incidencia real desconocida
- Mxico 1 insuficiencia vascular mesentrica / 1000 ingresos hospitalarios
- Mortalidad 60-70%
- 1-4 / 1000 cirugas de urgencia

Isquemia mesentrica

- Oclusiva aguda:

Arterial embolia, trombosis mesentrica

Venosa thrombosis, estrangulacin

- Oclusiva crnica enfermedad ateroesclertica

- No oclusiva:

Arterial vasoconstriccn
Venosa

Perfil clnico de la isquemia mesentrica aguda

Incidencia Edad Sntomas Factores de riesgo Mortalidad

(%) anteriores

Trombosis 50 Ancianos Angina Ateroesclerosis sistmica Muy alta

intestinal

Embolia 25 Ancianos Ninguno Infarto de miocardio Alta

reciente

Isquemia 20 Ancianos Ninguno Choque cardiognico La ms alta

mesentrica Circulacin extracorprea
no oclusiva Agentes vasopresores
Sepsis
Quemaduras
Pancreatitis

Trombosis 5 Jvenes Trombosis Hipercoagulabilidad La ms baja

venosa asintomtica Hipertensin portal
mesentrica Inflamacin
Ciruga previa
Traumatismos

Isquemia oclusiva aguda

- Etiologa:

Embolia cardioarterial
Trombosis in situ (progresin de placa ateroesclertica)
- Otras causas:

Arteritis de Takayasu
Periarteritis nodosa
Tromboangeitis esclerosante
Compresin extrnseca

- Sitio ms frecuente origen MS y salida de clica media, clica derecha e ileoclica

- Fisiopatologa:

Oclusin de
arteria
mesentrica

Vaso-
espasmo
en todo el
lecho
mesentric Esfacelacin y
o ulceracin de la
mucosa

Hemorragia

- Ventana 6 horas (infarto, cianosis, gangrena, perforacin)

- Cuadro clnico:

Dolor abdominal desproporcionado sin relacin con datos fsicos

Dolor agudo, intenso, difuso, postprandial
Vmito
No responde a analgsicos
Evacuaciones con sangre sugerente de isquemia irreversible
Distensin abdominal (Signo tardo)

- Exploracin fsica: (Etapa tarda de la enfermedad)

Distensin abdominal
Ausencia de peristalsis
Datos de irritacin peritoneal

- Laboratorio:

Lactato srico elevado

Amilasa elevada
Isquemia avanzada tendencia a acidosis (corazn es el ms susceptible a la acidosis)
 Acidosis respiratoria retencin de CO2 por falla en la mecnica respiratoria.
Corrige mediante intubacin.

Acidosis metablica corrige con lquidos

Hemoconcentracin
Leucocitos normales

- Diagnstico:

Ultrasonido convencional engrosamiento de la pared, disminucin o ausencia de

peristalsis, gas en la vena porta

Ultrasonido Doppler estenosis grave de la AMS

Radiografa simple de abdomen imagen de doble riel, gas en sistema porta

Angio-TAC

Angiografa Gold standard. Permite la visualizacin de la oclusin y las colaterales. til

en la planeacin de la revascularizacin. Puede usarse para infusin de agentes teraputicos.

- Tratamiento: Revascularizacin (trombosis)

Tromboendarterectoma
Derivacin vascular con injerto

Reseccin intestinal valorar viabilidad del intestino mediante laparotoma exploradora

Sin necesidad de estudios previos pues el tiempo apremia

Se evala color, respuesta a la manipulacin
Fluorescena IV (50-60 seg) y se observa con lmpara UV en el transoperatorio

Isquemia mesentrica no oclusiva

- Cuadro clnico:

Progresin lenta
Dolor ausente en 20-24% de los casos
Inicio sbito de dolor
Vmito, diarrea acuosa
Signos de irritacin peritoneal
Hipotensin
Taquicardia infarto

- Laboratorio:

Leucocitosis
Trombocitopenia
 Hemoconcentracin
Acidosis metablica

- Diagnstico:

Arteriografa de contraste

Estrechamiento del origen de mltiples ramas de la AMS

Dilatacin alternada con estenosis de las ramas intestinales
Espasmo de las arcadas mesentricas
Defectos de llenado de los vasos intramurales

- Tratamiento:

Anticoagulacin heparina
Infusin vasodilatadores por catter papaverina, glucagn, nitroglicerina, nitroprusiato, pge
Exploracin quirrgica y reseccin del segmento necrtico
Laparotoma segunda mirada en un lapso de 24-48 horas

Isquemia visceral crnica

- Causa no ateromatosa compresin extrnseca de la arteria del tronco celiaco por fibras del
diafragma sndrome del ligamento arqueado interno

- Epidemiologa:

Ms comn en mujeres 4:1

Sexta o sptima etapa de la vida

- Datos clnicos:

Dolor sordo persistente, epigstrico y periumbilical

Angina intestinal 20 min despus de comer (incapacidad para aumentar el flujo de O2)
Relacin de dolor con los alimentos
Prdida de peso rpida (Signo fsico ms comn)
Sndrome de mala absorcin
Paciente delgado
Soplo en el epigastrio

- Diagnstico arteriografa con contraste

- Tratamiento revascularizacin mediante angioplasta

Arritmia causas

- Isquemia infarto
- Hipertensin auricular valvulopatas
- Fiebre reumtica