Mesenteric Artery Intervention : Catheter-Based Therapy for Chronic Mesenteric Ischemia

Prevalence

The prevalence of mesenteric arterial stenoses is much more common than is the clinical manifestation of chronic mesenteric ischemia (CMI), likely due to the rich vascular communication among the three mesenteric vessels. CMI is twice as common in women than men. Asymptomatic mesenteric stenosis was documented angiographically in 40% of patients with an abdominal aortic aneurysm, 29% with aortoiliac obstructive disease, and in 25% of patients with peripheral arterial disease of the lower extremities. In a healthy group of elderly individuals (>65 years) ultrasound imaging found a 17.5% prevalence of asymptomatic (>70%) stenosis of at least one mesenteric artery. Symptomatic CMI is uncommon, accounting for less than 2% of all atheromatous revascularization procedures, and it is usually the consequence of atherosclerotic disease involving aorto-ostial stenosis of the celiac, superior mesenteric, and/or inferior mesenteric arteries often in the context of concomitant atherosclerotic disease of the aorta.

Etiology

Classical teaching suggests that CMI occurs when only one of three mesenteric arteries (celiac, superior mesenteric, and inferior mesenteric) remains patent due to the rich collateral supply and the most commonly intervened on vessel is the superior mesenteric artery. Causes of CMI include vascular conditions such as fibromuscular dysplasia, Takayasu disease, Buerger disease, radiation and autoimmune arteritis, and aortic dissection, but atherosclerosis is the predominant (>95%) cause of clinical mesenteric arterial stenosis. The median arcuate syndrome, also called the celiac axis compression syndrome, can occur if the origin of the celiac trunk arising from the aorta is extrinsically compressed by the arcuate ligament of the diaphragm. This can cause significant, sometimes critical, stenosis of this vessel.

Natural History

The natural history of asymptomatic mesenteric artery stenosis is that clinical symptoms do not develop in the majority of patients. Abdominal angiography was performed in 980 patients, demonstrating >50% stenosis of at least one mesenteric artery in 82 patients. After 2.6 years of follow-up, CMI developed in only 4 (4.9%) of the 82 patients, and these individuals all had involvement of all three mesenteric arteries.

The natural history of patients with symptomatic CMI is that between 20% and 50% of patients will progress to develop acute mesenteric ischemia. The remaining patients continue to suffer chronic postprandial abdominal pain, weight loss, and emaciation.