Endovascular Treatment of Occlusive Superior Mesenteric Artery Disease

Historical Background

Traditionally, the preferred treatment to restore adequate blood flow to the visceral organs was open surgical bypass. This treatment resulted in significant morbidity and mortality rates, ranging from 12% to 33% and 2% to 15%, respectively. In 1980 Furrer and colleagues were the first to report a successful angioplasty of a superior mesenteric artery stenosis. The role of percutaneous mesenteric revascularization has since expanded and in most circumstances has become the initial treatment of choice for chronic superior mesenteric artery occlusive disease. A recent examination of a nationwide database in the period between 2000 and 2006 that included 5583 chronic mesenteric ischemia patients estimated that 69% of patients with chronic mesenteric ischemia were treated by percutaneous transluminal angioplasty with or without stent placement (PTA/S). Despite a higher proportion of elderly patients with medical comorbidities undergoing PTA/S, mortality and morbidity rates were 3.7% and 20%, respectively, compared with 13% and 38%, respectively, after surgical bypass. Admittedly, endovascular treatment is associated with lower long-term patency and a greater likelihood of repeat interventions.

Indications

Chronic mesenteric ischemia is usually related to atherosclerosis, with symptoms occurring over a period of weeks to months. Postprandial intestinal angina appears when perfusion of visceral organs fails to meet normal metabolic requirements. A dull, colicky pain typically starts within 15 to 30 minutes of food intake and can persist 5 to 6 hours. The abdominal pain is commonly misdiagnosed as another gastrointestinal disorder.

Food phobia results in malnourishment, with an average weight loss of 20 to 30 pounds. In addition, stenotic arteries harbor a risk of atherosclerotic plaque rupture and focal thrombosis or embolization, which can result in acute mesenteric ischemia and bowel infarction. One third of patients with multiple mesenteric vessel involvement and symptoms may progress to acute mesenteric ischemia and intestinal infarction, with a mortality rate of more than 50%. Nonatherosclerotic causes of chronic mesenteric ischemia include radiation arteritis, chronic aortic dissection, fibromuscular dysplasia, median arcuate ligament syndrome, or vasculitis, such as Takayasu disease, Buerger disease,and polyarteritis nodosum. Most symptomatic patients have an atherosclerotic occlusion or more than 70% stenosis of the superior mesenteric artery combined with occlusion or stenosis of at least one other mesenteric vessel. Symptomatic mesenteric artery stenosis is an indication for intervention. Endovascular therapy is the preferred initial approach in patients with chronic mesenteric ischemia, whereas open revascularization is reserved for early or late failures. In principle, PTA/S also allows correction of malnourishment should subsequent open revascularization be required.

The presence of an asymptomatic mesenteric artery stenosis is not automatically associated with subsequent acute or chronic mesenteric ischemia and is a frequent finding among elderly patients. Asymptomatic disease of the celiac axis or superior mesenteric artery may be safely observed, and prophylactic intervention is not warranted. However, in certain circumstances, a symptomatic patients with significant three-vessel disease may benefit from revascularization, particularly if aortic or colonic resection is planned. That type of surgery can compromise the collateral vascular network and result in acute mesenteric ischemia.