Acute Mesenteric Ischemia

Microsoft Word - collective review Definition : (1)
acute mesenteric ischemia (AMI) 1 1000 hospital admission 1-2 100 abdominal pain (2, 3)
atherosclerosis
morbidity mortality mesenteric ischemia 30 (4, 6) 60- 80 % (2, 6, 7-9)
History - AMI Beneviene 15 AMI literature 1815 report Guy’s hospital London (10, 11)
- 1875 Litten pathophysiology AMI ligate superior mesenteric artery (SMA) (12)
- 1895 Elliot mesenteric venous thrombosis (MVT) 1936 (13)
- 1958 Ende nonocclusive mesenteric ischemia (NOMI) New England Journal of Medicine infarction of the bowel in cardiac failure (14)
- 1940 mesenteric vein thrombosis heparin(15)
- 1950 Klass SMA embolectomy bowel resection heart failure autopsy bowel (16)
- 1975 Shaw Rutledge successful embolectomy bowel resection (17)
- 1958 SMA revascularization SMA thrombosis (18)
- 1970 angiogram AMI Anatomy Blood supply 3 vessels celiac axis, SMA IMA 1. Celiac vessels foregut supply stomach second
part of duodenum aorta aorta aorta T12-L1 1-2 cm. branch 3 branch left grastric artery, common hepatic artery splenic artery
2. SMA midgut second part of duodenum 2/3 transverse colon aorta 45 emboli SMA aorta L1-L2 celiac axis 1-3 cm. branch inferior pancreaticoduodenal artery, middle colic artery, jejunoileal artery, right colic artery ileocolic artery
3.IMA hindgut 2/3 transverse colon rectum aorta aortic bifurcation 3 cm SMA 5-8 cm. aorta L3 branch left colic artery, sigmoid artery superior hemorrhoidal artery
splanchnic collateral circulation (19)
1 splanchnic collateral circulation Splanchnic collateral circulation 1. systemic-splanchnic collaterals 1.1 CA-systemic : phrenic-esophageal vessels 1.2 IMA-systemic : superior-middle-inferior hemorrhoidal vessles 2. primary splanchnic collaterals 2.1 CA-SMA : pancreaticoduodenal arcade and arc of Buhler 2.2 SMA-IMA : arc of Riolan and marginal artery of Drummond 3. secondary splanchnic collaterals 3.1 CA:dorsal pancreatic-anteriorsuperior pancreaticoduodenal- gastroduodenal arteries, right-left epiploic arteries(arc of Barkow) and right-left gastroepiploic arteries 3.2 SMA : jejunal-ileal arterial arcades and right-middle colic artery (marginal artery of Drummond) 3.3 IMA:marginal artery and sigmoid arterial arcades 4. tertiary splanchnic collaterals 4.1 intramural vessels
Pathophysiology
Splanchnic circulation 25 % cardiac output 35% cardiac output post prandial 70% mesenteric flow mucosa submucosa muscle serosa (20, 21)
factor intestinal blood flow intrinsic
factor (metabolic and myogenic factor) extrinsic factor (neural and hormonal factor)
Intrinsic factors 1. metabolic factor - oxygen supply GI tract splanchnic circulation imbalance oxygen demand supply metabolite hydrogen, potassium, carbonmonoxide, adenosine vasodilatation hyperemia splanchnic blood flow 2.myogenic factor - arteriolar wall tension receptor intestine splanchnic blood flow perfusion pressure hypotension arteriolar wall tension maintain splanchnic blood flow Extrinsic factors 1.neural factor – 2 receptors alpha beta adrenergic receptor alpha receptor splanchnic vasoconstriction beta receptor splanchnic vasodilatation 2.hormonal factor – exogenous endogenous humoral factor splanchnic blood flow (22)
2 physiologic and pharmacologic factors regulating mesenteric blood flow (extrinsic regulatory systems)
15 villi 3 mucosa 6 transmural necrosis mucosa serosa(8, 23)
2 collateral circulation splanchnic autoregulation
systemic inflammatory response syndrome (SIRS) mediator cytokine, platelet activating factor, tumor necrosis factor splanchnic circulation
reperfusion injury splanchnic shock cardiac arrest, multiple organ failure (MOF) reperfusion oxygen ischemic circulatation oxygen free radical O2, H2O2, OH local systemic tissue lipid peroxidation cell membrane denature intracellular macromolecule (19) bacterial invasion bacterial translocation endotoxemia bacteremia (24) Etiology AMI 4 mesenteric arterial emboli, mesenteric arterial thrombosis, nonocclusive mesenteric ischemia mesenteric venous thrombosis Mesenteric arterial embolism AMI 40-50 % case emboli cardiac source MI, atrial tachyarrhythmia, endocarditis, cardiomyopathy, ventricular aneurysm, valvular disorder, intracardiac shunt right to left shunt paradoxical emboli catheter intervention precipitate emboli embolism
(7,8 )
mesenteric arterial embolism lodge SMA SMA aorta oblique angle emboli lodge 3-10 cm. origin SMA (distal middle colic artery) 50% SMA 35% origin SMA 15% (2,25-27)
1/3 SMA emboli embolic event SMA emboli proximal jejunum
small bowel proximal jejunum
1 common site SMA embolism thrombosis
2. Mesenteric arterial thrombosis 20-25% (7,9) underlying atherosclerosis 80% chronic mesenteric ischemia intestinal angina (29)
mesenteric arterial thrombosis origin SMA(30)
infarction visceral artery collateral branch SMA thrombosis duodenum transverse colon 3. NOMI
20% AMI (31,32) low cardiac output status mesenteric vasocontriction hypovolumia, decreased cardiac output, hypotension, vasopressor drugs digitalis, ergot alkaloid, cocaine (33-35)
decrease mesenteric flow vascular smooth muscle contraction somatostatin, beta blocker, norepinephrine dopamine (high dose) (36)
4.Mesenteric venous thrombosis
10% AMI 2 Primary MVT Secondary MVT MVT 80-90% MVT secondary MVT (1) hypercoagulable state : protein C, S deficiency, factor V
leiden mutation, antithrombin III deficiency (2) hyperviscosity syndrome : myeloproliferative disorders,
polycythemia vera, sickle cell disease (3) intraabdominal inflammation and sepsis (4) abdominal trauma (5) venous hypertension (6) iatrogenic 2 acute MVT 4
chronic MVT 4 30-60 increased portal and SMV pressure increased hydrostatic pressure luminal fluid sequestration and bowel wall edema hypovolumia and hemoconcentration pressure compromised blood supply
thrombosis hypercoagulable state branch SMV branch thrombosis cirrhosis, neoplasm operative injury SMV branch branch (27)
3 clinical profile of AMI (1,22)
Incidence (%)
Thrombosis 20-25 Elderly Intestinal angina Systemic atherosclerosis
Very high
Embolism 40-50 Elderly N0 Recent MI Congestive heart failure Arrhythmia Rheumatic fever
High
NOMI 20 Elderly No Cardiogenic shock Cardiopulmonary bypass Vasopressor agents Sepsis Burn Pancreatitis
Highest
Lowest
Diagnosis AMI intestinal infarction sign symptom specific high index of suspicion (2,30) hallmark severe abdominal pain out of proportion of examination (37)
Clinical presentation 85% colicky pain (60%) , diarrhea (32%), LGIB bleeding diarrhea bowel infarction (27)
1. SMA embolism collateral circulation classic triad
(1) severe abdominal pain (2) gut emptying (vomiting, diarrhea or both) (3) underlying cardiac disease
source of embolism cardiac disease 2. SMA thrombosis abdominal angina
30-50% (26,27)
mesenteric arterial embolism thrombosis 70- 80 CAD, PAD, arrhythmia atherosclerotic disease mesenteric arterial emboli thrombosis
3. NOMI AMI ICU respiratory distress, hypotension vasopressor drugs cardiopulmonary bypass hemodialysis embolism NOMI 20-25% gastrointestinal bleeding (38)
4. MVT AMI AMI
75% onset 48 9% 24 onset 50% personal family history deep vein thrombosis pulmonary embolism (39)
Laboratory Investigation
Laboratory investigation acute mesenteric ischemia lab sensitivity specificity Lab (19)
WBC > 15,000 (75-90%) Neutrophilia with shift to the left (60%) Metabolic acidosis (50%) Hyperamylasemia (25%) Hemoconcentration, elevate serum lactate (30%) Elevate serum phosphate, ALP, creatine kinase (10%) Azotemia, hypoxia and bacterimia D-dimer good negative predictive value 1.5 mg/l (40)
Intestinal FABP(intestinal fatty acid binding protein) enterocyte blood stream early intestinal injury kidney urine FABP (41)
Imaging study 1. Plain film rule out AMI gut obstruction, gallstone, perforating viscus AMI plain film normal 25% (42)
findings nonspecific small bowel distention, fluid- filled loops of bowel, thickened bowel loops, thickened fold, ground glass appearance film intestinal ischemia/infarction 25% mural thumbprinting (focal mural thickening sencondary to submucosal hemorrhage) rigid aperistalsis bowel loops muscle necrosis progress pneumoperitoneum, pneumatosis intestinalis portal vein gas ominious sign
A. B.
2 A. mural thumbprinting and B. pneumatosis intestinalis
2.CT Scan CT scan of abdomen acute abdominal
pain AMI CT nonspecific sensitivity
specificity CT scan 64-82% 92% (43)
MVT CT sensivity > 90% diagnostic test of choice (44)
spiral CT scan multiple detector multiple row of detector faster gantry rotation three dimension accuracy conventional CT scan angiogram CT scan angiogram thrombus embolism peripheral branch AMI CT 30% (26,37)
CT findings AMI Bowel wall thickening, luminal dilatation, fluid-filled bowel loops,
increase attenuation of mesenteric fat, lack of bowel wall enhancement, splanchnic vascular occlusion
signs progress pneumatosis intestinalis, portal venous gas, pneumoperitoneum
MVT CT scan findings enhance peripheral vascular rim central area of low density, enlargement of SMV, thickened bowel wall and dilatation of collateral thick mesentery
3 A.enlarged SMV with central lucency in the lumen, representing the
thrombus. The vein wall is sharply defined with a rim of increased density surrounding the thrombus (arrows). B, Abdominal CT with contrast agent shows thickening and persistent enhancement of the bowel wall (white arrows), and dilated collateral vessels within a thickened mesentery (black arrows).
3.Angiogram (1) mesenteric arterial emboli thrombosis (2) Evaluation of NOMI (3) Road map revascularization (4) Catheter intervention angiogram gold standard AMI sensitivity specificity 74-100% 100% (26,37) angiogram AMI angiogram angiogram biplanar view anteroposterior (AP) lateral view AP view peripheral collateral branch lateral view origin angiogram finding AMI (19)
4 Angiographic findings of acute mesenetric ischemia Type Embolism Thrombus NOMI MVT
Location - 15%SMA origin , 50% middle colic artery , 25% ileocolic artery , 15% distal to ileocolic artery or distal SMA branches 1-2 cm from SMA orifice Diffuse involvement in multiple sites of SMA or SMA branches SMV or portal vein Rarely IMV
Specific findings - sharp, rounded filling defects (meniscus signs) - extensive, irregular mesenteric obstruction - planar vascular defect - stenosis of origins of multiple SMA branches - alternate spasm and dilatation of intestinal branches (string of sausage/beads sign) - impaired intramural filling - spasm of mesenteric arcades -no found embolus/thrombus thrombus in the SMV
Other findings - poor contrast flow below obstruction - collaterals uncommon - minimal atherosclerosi - multiple lesions - collaterals common -extramesenteric atherosclerosis - slowed mesenteric flows - aortic reflux of contrast during injection -reflux of contrast into the aorta -prolonged arterial phase with accumulation of contrast and thickened bowel walls -extravasation of contrast into bowel lumen, and filling defect in the portal vein or complete lack of venous phase
4 A.SMA embolism occlude at origin of ileocolic artery and vasoconstriction distal to emboli B.angiogram postembolectomy with papaverine infusion , vasodilatation is seen
5 angiogram intermittent spasm and dilatation of vessels “string of sausages” in NOMI 4.MRI CT intestinal ischemia
three dimension gadolinium enhanced MRA vessels MRI detect small thromboembolism mesenteric vessels improve oxygen desaturation SMV real time observation of intestinal hypomotility of ischemic segment further study (45)
5.Duplex ultrasound AMI ultrasound abdominal distention distend and dilated bowel loops operator dependent sensitivity 70-89% specificity 92-100% (37)
Duplex ultrasound complete occlusion of main SMA peripheral located thrombi or emboli
unusual origin of target vessels poor correlation flow parameter severity bowel ischemia duplex ultrasound (45) duplex USG second line study
Treatment AMI iv fluid resuscitation
underlying hypovolumia hypotension mesenteric vasocontriction resuscitation propagation clot reperfusion injury
invasive monitoring PA catheter O2 100% intubation
broad spectrum antibiotic bacteremia bacterial translocation compromised bowel mucosa vasopressor drug mesenteric vasoconstriction dopamine low dose mesenteric vasodilatation high dose mesenteric vasoconstriction vasopressor drug NPO NG decompression luminal pressure perfusion pressure risk aspiration
foley catheter monitor urine anticoagulant heparin controversy
AMI heparin sign bowel infarction (46)
delay heparin sign bowel infarction (47) delay 48 risk hemorrhage damage bowel (25)
anticoagulant thrombus propagation systemic
hypocoagulable state preoperative anticoagulant postoperative heparinization emboli recurrence
rate emboli branch thrombosis revascularization anticoagulant (1) anticoagulant MVT drug of choice
AMI angiogram iv glucagon 1 ug/kg/min titrate to 10 ug/kg/min vasospasm angiogram catheter SMA infuse vasodilator drug papaverine papaverine phosphodiesterase inhibitor mesenteric blood flow marginal bowel perfusion bowel salvage, dose 30-60 mg/hr 8-24 angiogram re-evaluation re-evaluation flush papaverine NSS 30
vasodilator drug recommend emboli NOMI SMA thrombosis mesenteric vasospasm treatment (2,8,22,30) hard data support routine papavarine SMA emboli , outcome (37)
Specific management AMI
1. sign of peritonitis 2. peritonitis angiogram 3. peritonitis SMA emboli or thrombosis >
NOMI ( 19) surgical management restore blood flow resect dead
bowel preparation skin nipple long midline
incision bowel esophagus rectum ischemic infarct segment mesenteric arterial thrombosis small bowel spare stomach, duodenum distal colon mesenteric arterial emboli spare proximal jejunum NOMI pulse venous thrombosis MVT marked edema of intestine, mesenteric cyanotic discolorization of bowel wall pulse mesenteric artery (1) MVT colon collateral circulation restore mesenteric flow ischemic segment resection
1. SMA emboli SMA emboli (37)
(1) peritonitis (2) partially complete occlusion (3) emboli ileocolic artery ileocolic artery major emboli minor emboli major SMA emboli embolectomy expose
SMA retract small bowel transverse colon ligament of trietz renal vein SMA pulse emboli thrombosis emboli transverse arteriotomy fogarthy catheter No.3-4 proximal SMA, No.2 distal SMA establish mesenteric flow bypass arteriotomy primary closure venous patch or graft patch angioplasty arterial stenosis
SMA embolectomy 12 intestinal viability 100% SMA embolectomy 12 24 intestinal viability 56% 24 intestinal viability 18% (37)
minor with partially occlude emboli endovascular therapy
Algolithm 1 SMA embolism (37)
2.SMA thrombosis aortomesenteric bypass aortomesenteric bypass 2 antegrade retrograde bypass Antegrade bypass revascularization supraceliac aorta
SMA SMA atherosclerosis infrarenal aorta
Retrograde bypass inflow infrarenal aorta common iliac artery vein graft prosthetic graft prosthetic graft kink vein graft contamination bowel resection (19,48) antegrade retrograde bypass
5 Comparision of antergrade and retrograde bypass (19)
Antegrade Retrograde Advantages Disadvantages
Disease – free inflow Reduced kinking Reduced compression Reduced turbulence Technical Exposure Renal ischemia
Relatives technical ease Familiar exposure Avoids renal ischemia Concomitant aortic replacement Disease inflow Graft position/length Kinking
chronic mesenteric ischemia bypass 3 long term result recurrent graft failure AMI critical SMA (1)
patency vein graft 3 93% prosthetic graft 87% AMI restoration blood flow hyperkalemia acidemia hypotension ischemic reperfusion injury
6 Retrograde SMA bypass by prosthetic graft and vein graft
Algolithm 2 SMA thrombosis (37)
doubtful viability infarction revascularization bowel 30-45 definitive assessment of bowel viability (1) clinical judgement serosal color, visible arterial pulsation,
peristalsis, bleeding cut surface, mucosal hemorrhage clinical judgement sensitivity 78-91% specificity 82-91% (19,49)
(2) doppler USG operator dependent detect presence or absence flow sensitivity specificity 63% 88% (19)
(3) fluorescein test fluorescein 1 gm iv bowel under wood lamp nonviable bowel nonfluorescein > 5 mm sensitivity specificity 96% 99% perfusion fluorometer allergy fluorescein (50)
(4) surface oximetry PO2 bowel surface (PSO2) evaluate intestinal anastomosis
(5) Infrared photopletysmography plethysmography probe photoplethysmographic signal bowel bowel perfusion
(6) Laser doppler velocity blood flow doppler probe bowel perfusion
bowel viability nonviable segment resect primary anastomosis condition stable stoma
second look operation 24-36 questionable viable bowel intestinal anastomosis AMI second look operation laparoscopic abdominal observation second look operation (51)
3.NOMI splanchnic vasoconstriction alpha-agonist, digitalis vasopressor drugs vasodilator papaverine, tolazoline, glucagon, nitroglycerine, nitroprusside, prostaglandin E, phenoxybenzamine isoproterenal papaverine 60 mg intraarterial via angiogram catheter repeat angiogram reversal of vasoconstriction continue rate 30-60 mg/hr intraarterial papaverine mortality rate NOMI 70-90% 0-55% (37) catheter aorta hypotension papaverine 24 angiogram peritoneal sign negative Side effect cardiac arrhythmia hypotension (42)
iloprost synthetic derivative epoprostenol, prostacyclin analogue arterial vasodilator, fibrinolytic activity inhibit platelet aggregation iv SMA flow 60% blood pressure, improve intestinal mucosal, hypercarbia intramucosal pH, trial SMA infusion (42)
Algolithm 3 NOMI (37)
4.MVT peritonitis systemic anticoagulant warfarin hypercoagulable state secondary MVT 3-6 (26,52)
SMV thromboembolectomy rethrombosis MVT 1-3 clot main SMV portal vein (52)
thrombolytic therapy trial (42)
Algolithm 4 MVT (37)
Endovascular therapy multiple comorbid disease endovascular treatment AMI catheter directed thrombolysis , percutaneous transluminal angioplasty +/- stent percutaneous transcatheter thromboaspiration 1. catheter directed thrombolysis Jamieson and associate SMA embolectomy streptokinase thrombolytic therapy 8-12 clot lysis 4 peritonitis thrombolysis laparotomy partially occlude of emboli , clot in minor branch of SMA clot in major branch of SMA distal ileocolic artery (37)
2. percutaneous transluminal angioplasty +/- stent acute on top chronic mesenteric arterial thrombosis recurrent rate
3. percutaneous transcatheter thromboaspiration syringe aspirate clot large trial (53
Post operative care complication (1)
5 postoperative complication of revascularization
early post operative period cardiopulmonary system , metabolic abnormality broad spectrum antibiotics with anaerobic coverage 5 NG tube GI decompression early parenteral nutrition Results Mortality rate SMA emboli thrombosis 60% NOMI 70% severe underlying medical disease (19)
MVT mortality rate 20-50 % recurrent rate 13-30% 30 event (19,27,52)
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