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Chronic Mesenteric Ischemia: Diagnosis and Intervention
Key Points
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Atherosclerotic stenoses commonly involve the major mesenteric arteries (celiac, superior mesenteric, and inferior mesenteric) but rarely cause symptomatic mesenteric ischemia because of the excellent collateral circulation that interconnects the visceral vascular beds.
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The classic presentation is postprandial abdominal pain with weight loss. Patients with functional bowel complaints rarely have significant weight loss.
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Patients with suspected chronic mesenteric ischemia (CMI) commonly have atherosclerosis involving other vascular territories such as coronary artery disease, stroke, renovascular disease, or lower extremity atherosclerotic disease.
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Symptomatic mesenteric ischemia usually results from significant stenosis affecting two or more vessels. Single-vessel disease of the mesenteric circulation is a rare cause of symptomatic mesenteric ischemia but may occur after an abdominal surgery that interrupts the collateral circulation.
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Noninvasive testing with computed tomographic angiography is the preferred screening test in patients with suspected CMI.
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An endovascular-first strategy with stents has largely replaced open surgery as the initial treatment for this disease.
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Angiographic restenosis after stenting approaches 40%, but the clinical recurrence rate appears to be about 1 in 5 patients, so careful clinical and noninvasive follow-up is warranted.
Background
Although the most common vascular disorder involving the intestines is ischemia, the clinical syndrome of chronic mesenteric ischemia (CMI), or chronic intestinal ischemia, is very unusual. Other etiologies associated with this uncommon syndrome include fibromuscular dysplasia, Buerger disease, and aortic dissection, but atherosclerosis is by the far the most frequent cause. Atherosclerotic disease of the aorta with associated aorto-ostial stenosis of the visceral vessels is a relatively common angiographic finding but an infrequent clinical problem.
In a population-based prevalence study of mesenteric artery stenosis, 553 healthy Medicare beneficiaries were screened with abdominal ultrasound for evidence of mesenteric disease. In 17.5% of the total cohort, there was significant narrowing of a mesenteric vessel (>50% diameter stenosis), and more than 97% of these cases represented isolated celiac artery narrowing. There was no correlation with age, race, gender, or body mass index and the presence of mesenteric artery stenosis. Only 1.3% of the patients had involvement of more than one mesenteric vessel.
Another natural history study reported on a group of 980 asymptomatic patients with mesenteric ischemia who were monitored clinically. Only three patients eventually developed symptoms, each with three mesenteric vessels severely affected. The most likely explanation for the infrequent occurrence of CMI in clinical practice is the redundancy of the visceral circulation, which has multiple interconnections between the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA).
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