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上腸間膜動脈閉塞症・上腸間膜静脈血栓症

著者: 錦織直人1) 一路会錦織病院

著者: 中島祥介2) 奈良県立医科大学 消化器・小児外科・乳腺外科学教室

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2022/10/26
参考ガイドライン:
  1. 日本循環器学会/日本血管外科学会:2022年改訂版 末梢動脈疾患ガイドライン(https://www.j-circ.or.jp/cms/wp-content/uploads/2022/03/JCS2022_Azuma.pdf)
患者向け説明資料

概要・推奨   

  1. SMA閉塞症の疫学と初期診断:発症頻度は毎年5.6~8.6人/10万人と低いが、死亡率は24~94%と予後不良で、生命予後の改善には早期診断・治療が求められる(推奨度1J)
  1. SMA閉塞症の血液検査所見:初期では血液検査で炎症所見の上昇を伴わない場合もある。
  1. SMA閉塞症の画像診断による確定診断:問診・理学的所見・血液検査は必須であるが確定診断に至ることは困難であり、確定診断には画像評価が必須である(推奨度1J)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
錦織直人 : 特に申告事項無し[2022年]
中島祥介 : 特に申告事項無し[2022年]
監修:杉原健一 : 講演料(大鵬薬品工業)[2022年]

改訂のポイント:
  1. 2022年改訂版 末梢動脈疾患ガイドラインに基づき、SMA閉塞症の診断と治療の内容を加えた。

病態・疫学・診察

疾患情報(疫学・病態)  
上腸間膜動脈(SMA)閉塞症:
  1. 上腸間膜動脈閉塞症とは、血栓、塞栓を原因として発症する腸管・腸間膜虚血症で致死的な腹部救急疾患である。
  1. 10万人に5.3~8.6人に発症し、腸間膜血管閉塞疾患の約7割を占め、塞栓症が約7割、血栓症が約3割と報告されている。
  1. 閉塞部位により腸管の虚血範囲は決定されるが、全小腸から右側結腸に及ぶ広範囲壊死を生じ得る。
  1. 死亡率は24~94%と高率である。広範囲な小腸壊死を生じると、いったん救命しても術後短腸症候群を来し、免疫能低下や静脈栄養離脱困難となる。また動脈塞栓症の場合、多発塞栓が高頻度であり注意を要する。死亡率は約2~9割と高率であり、大量腸切除後の短腸症候群が問題となることも多い。
 
  1. SMA閉塞症の疫学と初期診断:発症頻度は毎年5.6~8.6人/10万人と低いが[1]、死亡率は24~94%と予後不良で[2]、生命予後の改善には早期診断・治療が求められる(推奨度1J)
  1. 救命の第1のポイントは早期診断であり、急性腹症の患者において当疾患も念頭に鑑別診断にあたることが大切である。
  1. 病歴:突然に発症する激しい腹痛が主訴であることが多い。本疾患を念頭に鑑別診断を行わない限り、早期診断は困難である。また循環器系の基礎疾患を伴う場合も多く、既往症などの問診も重要である[3]
 
上腸間膜静脈(SMV)血栓症:
  1. 上腸間膜静脈(SMV)血栓症とは、何らかの原因により腸間膜静脈内に血栓が形成され、末梢側に伸展すると直静脈から壁内静脈が閉塞するとうっ血性腸管壊死が生じ、中枢側伸展では肝機能異常や門脈圧亢進を生じることである。
  1. 腸間膜血管閉塞疾患の5~15%と報告されている。死亡率は欧米で15~40%、わが国で8~17%と報告されている。また血栓の再発率は11~29%と高率であり、注意を要する。
  1. 何らかの原因により腸間膜静脈内に血栓が形成され、末梢側に伸展すると直静脈から壁内静脈が閉塞し、うっ血性腸管壊死が生じ、中枢側に伸展すると肝機機能異常や門脈圧亢進を生じる。
  1. 血栓の伸展速度や側副血行路の発達の程度が、症状・予後に関与する。急速に腸管壊死に至る「急性型」、側副血行路の発達により症状の乏しい「慢性型」、慢性型の経過中に血栓の増大により発症する「亜急性型」に分類される。
 
  1. SMV血栓症の疫学と初期診断:発症頻度は毎年1.8人/10万人と低いが[4]、死亡率は5~76%と予後不良で[5][6][7]、急性腹症の患者において当疾患も念頭に鑑別診断にあたることが大切である(推奨度1)
  1. 腹痛や嘔気・嘔吐など非特異的な症状であり早期診断が難しい場合が多く、診断に48時間以上要した症例が75~86%を占めたとの報告もある[8]
  1. 病歴:腹痛、嘔気・嘔吐、下痢・下血、腹部膨満などの非特異的な症状の場合が多く、血栓形成が緩徐な症例では側副血行路の形成で症状が乏しい場合もある。本疾患を念頭に鑑別診断を行わない限り、早期診断は困難である。
  1. 追記:初期では腸管膜の動脈の血流は保たれるが、静脈血栓により徐々にうっ血と虚血が進行し、最終的に動脈閉塞が生じ腸管壊死を来すと考えられる[9]
問診・診察のポイント  
SMA閉塞症:
  1. 初期には激烈な腹痛や下痢が出現し、進行すると腸管壊死より汎発性腹膜炎を来しショック状態に陥る。腹膜刺激症状が発現する前に、まず激しい腹痛を訴える。腹部膨満、筋性防御などは発症後数時間で認められるようになり腸管穿孔などに起因するショック状態などは日単位の後に陥る。

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文献 

S Acosta, M Ogren, N-H Sternby, D Bergqvist, M Björck
Incidence of acute thrombo-embolic occlusion of the superior mesenteric artery--a population-based study.
Eur J Vasc Endovasc Surg. 2004 Feb;27(2):145-50. doi: 10.1016/j.ejvs.2003.11.003.
Abstract/Text OBJECTIVE: To determine the incidence of acute thrombo-embolic occlusion of the superior mesenteric artery (AOSMA) in a population-based study.
MATERIAL: All clinical (n=23,446) and forensic (n=7569) autopsies performed in the city of Malmö between 1970 and 1982 (population 264,000-230,000 inhabitants). The autopsy rate was 87%.
METHODS: Calculation of the incidence of AOSMA with intestinal gangrene in those autopsies coded for bowel ischaemia (997/23,446 clinical and 9/7569 forensic autopsies). The operative procedures performed in 1970, 1976 and 1982 were also analysed.
RESULTS: Two forensic and 211 clinical autopsies demonstrated AOSMA with intestinal gangrene. Previous suspicion of intestinal ischaemia was noted in only 33%. Sixteen patients were operated. The cause-specific mortality was 6.0/1000 deaths. The incidence was 8.6/100,000 person years, increasing exponentially with age (p<0.001). Mortality was 93%.
CONCLUSIONS: The incidence and mortality of AOSMA is higher than previously reported from clinical series. There is seldom any suspicion of the diagnosis prior to death.

PMID 14718895
Ivo G Schoots, Marcel M Levi, Jim A Reekers, Johan S Lameris, Thomas M van Gulik
Thrombolytic therapy for acute superior mesenteric artery occlusion.
J Vasc Interv Radiol. 2005 Mar;16(3):317-29. doi: 10.1097/01.RVI.0000141719.24321.0B.
Abstract/Text The aim of this review is to evaluate thrombolytic therapy for acute superior mesenteric artery occlusion as an alternative or adjunctive treatment modality to surgical therapy and to provide current knowledge for timely and informed decisions regarding treatment of acute mesenteric ischemia. A systematic analysis of the available literature from 1966 to 2003 regarding thrombolytic therapy for superior mesenteric artery thromboembolism was performed. A total of 20 case reports and seven small series covered 48 patients with acute superior mesenteric artery thromboembolism. In the herein reviewed series, thrombolytic therapy of acute superior mesenteric artery thromboembolism resulted in angiographic resolution of the thromboembolism in 43 patients, in clinical success without requiring additional surgical intervention in 30 patients, and in survival in 43 patients, with similar complication rates as in thrombolytic treatment of peripheral vascular occlusions. Remission of abdominal pain during the first few hours of treatment formed the most important indicator of therapeutic success. Insufficient evidence from reviewed literature is available to determine the relative effectiveness and safety of thrombolytic treatment for acute superior mesenteric artery thromboembolism; however, initial results appear to be promising. Thrombolytic therapy can be effective relatively quickly, may obviate surgery, and has the potential to resolve the clot completely. In some cases it can be used as an alternative or neo-adjunctive treatment modality to surgery. A treatment guideline for thrombolysis of acute superior mesenteric artery thromboembolism should be developed.

PMID 15758127
Ashish Wasnik, Ravi K Kaza, Mahmoud M Al-Hawary, Peter S Liu, Joel F Platt
Multidetector CT imaging in mesenteric ischemia--pearls and pitfalls.
Emerg Radiol. 2011 Apr;18(2):145-56. doi: 10.1007/s10140-010-0921-8. Epub 2010 Dec 4.
Abstract/Text Mesenteric ischemia is a complex and devastating disease which still remains a diagnostic challenge to the clinicians due to non-specific clinical and laboratory findings. Several imaging features have been described with multidetector computed tomography which allows the diagnosis of mesenteric ischemia with high sensitivity and specificity. However, there are imaging features which overlap with other pathologies including benign inflammation and infection. Knowledge of imaging findings in mesenteric ischemia and its potential mimics is important in early and definitive diagnosis.

PMID 21132342
Stefan Acosta, Mats Ogren, Nils-Herman Sternby, David Bergqvist, Martin Björck
Mesenteric venous thrombosis with transmural intestinal infarction: a population-based study.
J Vasc Surg. 2005 Jan;41(1):59-63. doi: 10.1016/j.jvs.2004.10.011.
Abstract/Text OBJECTIVE: To determine the cause-specific mortality from and incidence of transmural intestinal infarction caused by mesenteric venous thrombosis (MVT) in a population-based study and to evaluate the findings at autopsy by evaluating autopsies and surgical procedures.
METHODS: All clinical (n = 23,446) and forensic (n = 7569) autopsies performed in the city of Malmö between 1970 and 1982 (population 264,000 to 230,000) were evaluated. The autopsy rate was 87%. The surgical procedures were performed in 1970, 1976, and 1982. Autopsy protocols coded for intestinal ischemia or mesenteric vessel occlusion, or both, were identified in a database. In all, 997 of 23,446 clinical and 9 of 7,569 forensic autopsy protocols were analyzed. A 3-year sample of the surgical procedures, comprising 21.3% (11,985 of 56,251) of all operations performed during the entire study period, was chosen to capture trends of diagnostic and surgical activity. In a nested case-control study within the clinical autopsy cohort, four MVT-free controls, matched for gender, age at death, and year of death were identified for each fatal MVT case to evaluate the clinical autopsy findings.
RESULTS: Four forensic and 23 clinical autopsies demonstrated MVT with intestinal infarction. Seven patients were operated on, of whom six survived. The cause-specific mortality ratio was 0.9:1000 autopsies. The incidence was 1.8/100,000 person years. At autopsy, portal vein thrombosis and systemic venous thromboembolism occurred in 2 of 3 and 1 of 2 of the cases, respectively. Obesity was an independent risk factor for fatal MVT (P =.021).
CONCLUSIONS: The estimated incidence of MVT with transmural intestinal infarction was 1.8/100,000 person years. Portal vein thrombosis, systemic venous thromboembolism and obesity were associated with fatal MVT.

PMID 15696045
S Kumar, M G Sarr, P S Kamath
Mesenteric venous thrombosis.
N Engl J Med. 2001 Dec 6;345(23):1683-8. doi: 10.1056/NEJMra010076.
Abstract/Text
PMID 11759648
P Gertsch, J Matthews, J Lerut, P Luder, L H Blumgart
Acute thrombosis of the splanchnic veins.
Arch Surg. 1993 Mar;128(3):341-5.
Abstract/Text The consequence of an acute thrombosis in the splanchnic veins on the viability of the intestine has not been well defined in the literature. Spontaneous recovery or total necrosis of the bowel have both been described. We treated seven patients with thrombosis of the splanchnic veins and adopted a surgical approach in three patients with extended and complete thrombosis of the superior mesenteric vein, portal vein, and splenic vein, while four patients with partial thrombosis of the superior mesenteric vein or protal vein recovered with conservative treatment. A 22-year literature review has identified 64 cases of acute thrombosis in the splanchnic veins, with complete information regarding the location and extent of the thrombosis, the treatment, and the outcome. Different anatomical patterns of thrombosis with mortality rates varying between 0% and 76% seem to be related to the extent and completeness of venous obstruction.

PMID 8442693
C Schäfer, J Zundler, J C Bode
Thrombolytic therapy in patients with portal vein thrombosis: case report and review of the literature.
Eur J Gastroenterol Hepatol. 2000 Oct;12(10):1141-5.
Abstract/Text A 29-year-old male patient with Crohn's disease of the terminal ileum and previous abdominal surgery was admitted because of severe abdominal pain and signs of bacterial sepsis. The diagnosis of portal vein thrombosis and multiple liver abscesses due to Streptococcus intermedius septicaemia was made and antibiotic therapy was instituted immediately. As high-dose heparin therapy was ineffective, urokinase was administered intravenously over a total of 7 days. Within 2 days, the patient's symptoms completely subsided. Colour duplex ultrasonography revealed complete recanalization of the main stem of the portal vein; the right branch of the portal vein, however, remained occluded. Other case reports on thrombolytic therapy in patients with portal vein thrombosis are reviewed.

PMID 11057461
D M Warshauer, J K Lee, M A Mauro, G C White
Superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases.
AJR Am J Roentgenol. 2001 Oct;177(4):837-41. doi: 10.2214/ajr.177.4.1770837.
Abstract/Text OBJECTIVE: Our purpose was to examine the clinical presentation, imaging appearance, etiology, and clinical outcome in patients who had acute thrombosis of the superior mesenteric vein with radiologically occult cause.
CONCLUSION: The most common predisposing factors in superior mesenteric vein thrombosis with radiologically occult cause are recent abdominal surgery, infection, and hypercoagulable states. Although no correlation was noted between risk factor and outcome, the presence of bowel wall thickening and mesenteric congestion on CT or MR imaging was associated with the development of bowel ischemia. Prognosis is good in this group of patients, with a mortality of only 7%, although bowel ischemia was noted in 21%.

PMID 11566684
R A Abdu, B J Zakhour, D J Dallis
Mesenteric venous thrombosis--1911 to 1984.
Surgery. 1987 Apr;101(4):383-8.
Abstract/Text The objective of this study was to identify those patients in whom mesenteric venous thrombosis (MVT) is likely to develop and to review the pathophysiology, clinical presentation, diagnostic modalities, and patient outcome. We present a review of the literature from 1911 to 1984 with respect to 372 patients with MVT, including five of our own patients. Data on 99 of these patients were obtained from autopsy reports and were not included in the study. This disease is common in the sixth and seventh decades of life, with 81% of these older patients having associated illnesses. MVT involves segments of the small bowel, but rarely of the colon, with hemorrhagic infarcts rather than gangrene. This disease does not conform to a pattern, although a prodromal period of days or weeks of abdominal pain (which is usually out of proportion to physical findings), marked leukocytosis, and dehydration are all highly suggestive of MVT. Serosanguineous fluid obtained by means of peritoneal tap is a useful diagnostic tool. A high index of suspicion, early diagnosis, and prompt surgical intervention with the addition of anticoagulants seems to improve survival and reduce recurrence.

PMID 3563882
Tiina T Lehtimäki, Jussi M Kärkkäinen, Petri Saari, Hannu Manninen, Hannu Paajanen, Ritva Vanninen
Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: Review of 95 consecutive patients.
Eur J Radiol. 2015 Dec;84(12):2444-53. doi: 10.1016/j.ejrad.2015.09.006. Epub 2015 Sep 11.
Abstract/Text OBJECTIVES: (1) To evaluate the ability of emergency room radiologists to detect acute mesenteric ischemia (AMI) from computed tomography (CT) images in patients with acute abdominal pain. (2) To identify factors affecting radiologists' performance in the CT interpretation and patient outcome.
MATERIALS AND METHODS: A retrospective study of 95 consecutive patients treated for 97 AMI events between 2009 and 2013 was carried out. The etiology of AMI was embolism in 24 (25%), atherosclerotic vascular disease (ASVD) in 39 (40%), non-obstructive mesenteric ischemia (NOMI) in 25 (26%), and mesenteric venous thrombosis (MVT) in nine (9%) cases. The protocols, referrals and initial radiology reports of the abdominal CTs were analyzed. The CT studies were further scrutinized for vascular and intestinal findings.
RESULTS: The referring clinician had suspected AMI in 30 (31%) cases prior to imaging. The crucial findings of AMI had been stated in 97% of the radiology reports if the clinician had mentioned AMI suspicion in the referral; if not, the corresponding rate was 81% (p=0.04). Patients without suspicion of AMI prior to CT were more prone to undergo bowel resection. CT protocol was optimal for AMI (with contrast enhancement in arterial and venous phases) in only 34 (35%) cases. Intestinal findings were more difficult to detect than vascular findings. Vascular findings were retrospectively detectable in 92% of cases with embolism and 100% in ASVD and MVT. Some evidence of intestinal abnormality was retrospectively found in the CT findings in 92%, 100%, 100% and 67% of cases with embolism, ASVD, NOMI and MVT, respectively.
CONCLUSIONS: AMI is underdiagnosed in the CT of the acute abdomen if there is no clinical suspicion.

Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
PMID 26413771
Michael T Cudnik, Subrahmanyam Darbha, Janice Jones, Julian Macedo, Sherrill W Stockton, Brian C Hiestand
The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis.
Acad Emerg Med. 2013 Nov;20(11):1087-100. doi: 10.1111/acem.12254.
Abstract/Text OBJECTIVES: Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED.
METHODS: In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project.
RESULTS: The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated.
CONCLUSIONS: The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.

© 2013 by the Society for Academic Emergency Medicine.
PMID 24238311
I G Schoots, G I Koffeman, D A Legemate, M Levi, T M van Gulik
Systematic review of survival after acute mesenteric ischaemia according to disease aetiology.
Br J Surg. 2004 Jan;91(1):17-27. doi: 10.1002/bjs.4459.
Abstract/Text BACKGROUND: Differentiation of acute mesenteric ischaemia on the basis of aetiology is of great importance because of variation in disease progression, response to treatment and outcome. The aim of this study was to analyse the published data on survival following acute mesenteric ischaemia over the past four decades in relation to disease aetiology and mode of treatment.
METHOD: A systematic review of the available literature from 1966 to 2002 was performed.
RESULTS: Quantitative analysis of data derived from 45 observational studies containing 3692 patients with acute mesenteric ischaemia showed that the prognosis after acute mesenteric venous thrombosis is better than that following acute arterial mesenteric ischaemia; the prognosis after mesenteric arterial embolism is better than that after arterial thrombosis or non-occlusive ischaemia; the mortality rate following surgical treatment of arterial embolism and venous thrombosis (54.1 and 32.1 per cent respectively) is less than that after surgery for arterial thrombosis and non-occlusive ischaemia (77.4 and 72.7 per cent respectively); and the overall survival after acute mesenteric ischaemia has improved over the past four decades.
CONCLUSION: There are large differences in prognosis after acute mesenteric ischaemia depending on aetiology. Surgical treatment of arterial embolism has improved outcome whereas the mortality rate following surgery for arterial thrombosis and non-occlusive ischaemia remains poor.

Copyright 2004 British Journal of Surgery Society Ltd.
PMID 14716789
Michelle S Bradbury, Peter V Kavanagh, Robert E Bechtold, Michael Y Chen, David J Ott, John D Regan, Therese M Weber
Mesenteric venous thrombosis: diagnosis and noninvasive imaging.
Radiographics. 2002 May-Jun;22(3):527-41. doi: 10.1148/radiographics.22.3.g02ma10527.
Abstract/Text Mesenteric venous thrombosis is an uncommon but potentially lethal cause of bowel ischemia. Several imaging methods are available for diagnosis, each of which has advantages and disadvantages. Doppler ultrasonography allows direct evaluation of the mesenteric and portal veins, provides semiquantitative flow information, and allows Doppler waveform analysis of the visceral vessels; however, it is operator dependent and is often limited by overlying bowel gas. Conventional contrast material-enhanced computed tomography (CT) allows sensitive detection of venous thrombosis within the central large vessels of the portomesenteric circulation and any associated secondary findings; however, it is limited by respiratory misregistration, motion artifact, and substantially decreased longitudinal spatial resolution. Helical CT and CT angiography, especially when performed with multi-detector row scanners, and magnetic resonance (MR) imaging, particularly gadolinium-enhanced MR angiography, enable volumetric acquisitions in a single breath hold, eliminating motion artifact and suppressing respiratory misregistration. Helical CT angiography and three-dimensional gadolinium-enhanced MR angiography should be considered the primary diagnostic modalities for patients with a high clinical suspicion of mesenteric ischemia. Conventional angiography is reserved for equivocal cases at noninvasive imaging and is also used in conjunction with transcatheter therapeutic techniques in management of symptomatic portal and mesenteric venous thrombosis.

Copyright RSNA, 2002
PMID 12006685
Robert J Beaulieu, K Dean Arnaoutakis, Christopher J Abularrage, David T Efron, Eric Schneider, James H Black
Comparison of open and endovascular treatment of acute mesenteric ischemia.
J Vasc Surg. 2014 Jan;59(1):159-64. doi: 10.1016/j.jvs.2013.06.084. Epub 2013 Nov 5.
Abstract/Text INTRODUCTION: Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding the rates of bowel resection following endovascular vs open repair of AMI.
METHODS: Using the National Inpatient Sample database, admissions from 2005 through 2009 were identified according to International Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities were also examined. Outcome measures included mortality, length of stay, the need for bowel resection (45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization. Statistical analysis was conducted by χ(2) tests and Wilcoxon rank-sum comparisons.
RESULTS: Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025).
CONCLUSIONS: Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.

Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
PMID 24199769
Tomas A Block, Stefan Acosta, Martin Björck
Endovascular and open surgery for acute occlusion of the superior mesenteric artery.
J Vasc Surg. 2010 Oct;52(4):959-66. doi: 10.1016/j.jvs.2010.05.084.
Abstract/Text BACKGROUND: Acute thromboembolic occlusion of the superior mesenteric artery (SMA) is associated with high mortality. Recent advances in diagnostics and surgical techniques may affect outcome.
METHODS: Through the Swedish Vascular Registry (Swedvasc), 121 open and 42 endovascular revascularizations of the SMA at 28 hospitals during 1999 to 2006 were identified. Patient medical records were retrieved, and survival was analyzed with multivariate Cox-regression analysis.
RESULTS: The number of revascularizations of the SMA increased over time with 41 operations in 2006, compared to 10 in 1999. Endovascular approach increased sixfold by 2006 as compared to 1999. The endovascular group had thrombotic occlusion (P < .001) and history of abdominal angina (P = .042) more often, the open group had atrial fibrillation more frequently (P = .031). All the patients in the endovascular group, but only 34% after open surgery, underwent completion control of the vascular reconstruction (P < .001). Bowel resection (P < .001) and short bowel syndrome (SBS; P = .009) occurred more frequently in the open group. SBS (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.3-5.0) and age (HR, 1.03/year; 95% CI, 1.00-1.06) were independently associated with increased long-term mortality. Thirty-day and 1-year mortality rates were 42% vs 28% (P = .03) and 58% vs 39% (P = .02), for open and endovascular surgery, respectively. Long-term survival after endovascular treatment was better than after open surgery (log-rank, P = .02).
CONCLUSION: The results after endovascular and open surgical revascularization of acute SMA occlusion were favorable, in particular among the endovascularly treated patients. Group differences need to be confirmed in a randomized trial.

Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
PMID 20620006
Zachary M Arthurs, Jessica Titus, Mohsen Bannazadeh, Matthew J Eagleton, Sunita Srivastava, Timur P Sarac, Daniel G Clair
A comparison of endovascular revascularization with traditional therapy for the treatment of acute mesenteric ischemia.
J Vasc Surg. 2011 Mar;53(3):698-704; discussion 704-5. doi: 10.1016/j.jvs.2010.09.049. Epub 2011 Jan 14.
Abstract/Text OBJECTIVES: Few centers have adopted endovascular therapy for the treatment of acute mesenteric ischemia (AMI). We sought to evaluate the effect of endovascular therapy on outcomes for the treatment of AMI.
METHODS: A single-center, retrospective cohort review was performed on all consecutive patients with thrombotic or embolic AMI presenting between 1999 and 2008. Patients with mesenteric venous thrombosis, nonocclusive mesenteric ischemia, and ischemia associated with aortic dissection were excluded. Demographic factors, preoperative metabolic status, and etiology were compared. Primary clinical outcomes included endovascular technical success, operative complications, and in-hospital mortality.
RESULTS: Seventy consecutive patients were identified with AMI (mean age, 64 ± 13 years). Etiology of mesenteric ischemia was 65% thrombotic and 35% embolic occlusions. Endovascular revascularization was the preferred treatment (81%) vs operative therapy (19%). Successful endovascular treatment was achieved in 87%. Endovascular therapy required laparotomy in 69% vs traditional therapy in 100% (P < .05), with a median 52-cm necrotic bowel resected (interquartile range [IQR], 11-140 cm) vs 160 cm (IQR, 90-250 cm; P < .05), respectively. Acute renal failure and pulmonary failure occurred less frequently with endovascular therapy (27% vs 50%; P < .05 and 27% vs 64%; P < .05). Successful endovascular treatment resulted in a mortality rate of 36% compared with 50% (P < .05) with traditional therapy, whereas the mortality rate for endovascular failures was 50%. Endovascular therapy was associated with improved mortality in thrombotic AMI (odds ratio, 0.10; 95% confidence interval, 0.10-0.76; P < .05).
CONCLUSIONS: Endovascular therapy has altered the management of AMI, and there are measurable advantages to this approach. Using endovascular therapy as the primary modality for AMI reduces complications and improves outcomes.

Published by Mosby, Inc.
PMID 21236616
Marc L Schermerhorn, Kristina A Giles, Allen D Hamdan, Mark C Wyers, Frank B Pomposelli
Mesenteric revascularization: management and outcomes in the United States, 1988-2006.
J Vasc Surg. 2009 Aug;50(2):341-348.e1. doi: 10.1016/j.jvs.2009.03.004. Epub 2009 Apr 16.
Abstract/Text BACKGROUND: Recent reports have suggested that angioplasty, with and without stenting (PTA/S), may have a lower perioperative mortality rate than open surgery for revascularization of acute (AMI) and chronic mesenteric ischemia (CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is actually a mortality benefit.
METHODS: We identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S mesenteric revascularization from the Nationwide Inpatient Sample from 1988 to 2006. A diagnosis by International Classification of Diseases, 9th Revisioncoding of AMI or CMI was required for inclusion. We evaluated trends in management during this period and compared in-hospital death and complications between surgical bypass and PTA/S for the years 2000 to 2006.
RESULTS: From 1988 to 2006, there were 6342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily, surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. The mortality rate was lower after PTA/S than after bypass for CMI (3.7% vs 13%, P < .01) and AMI (16% vs 28%, P < .01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P < .01). This subgroup showed an increased in-hospital mortality rate for both repair types (54% and 25%, respectively).
CONCLUSION: PTA/S is being used with increasing frequency for revascularization of CMI and AMI. The lower in-hospital mortality rate for patients, as they are currently being selected, shows that PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group, making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

PMID 19372025
M Björck, S Acosta, F Lindberg, T Troëng, D Bergqvist
Revascularization of the superior mesenteric artery after acute thromboembolic occlusion.
Br J Surg. 2002 Jul;89(7):923-7. doi: 10.1046/j.1365-2168.2002.02150.x.
Abstract/Text BACKGROUND: The outcome and prognostic factors after revascularization of acute thromboembolic occlusion of the superior mesenteric artery (SMA) are poorly documented.
METHODS: Sixty patients with acute thromboembolic occlusion of the SMA had revascularization procedures at 21 hospitals from 1987 to 1998. They were registered prospectively in the Swedish Vascular Registry. Patient files were analysed retrospectively.
RESULTS: The median age of the patients was 76 years; 73 per cent suffered from cardiac disease and 23 per cent had previous vascular surgery. Onset of symptoms was classified as sudden (30 per cent), acute (33 per cent) or insidious (37 per cent). The occlusions were thought to be either embolic (67 per cent) or thrombotic (33 per cent). The diagnosis was suspected on first examination in 32 per cent of patients, a group whose median time to operation was shorter (P = 0.01). Fifty-eight patients had an exploratory laparotomy and subsequent revascularization, and two were treated with thrombolysis alone. Second-look laparotomy was performed in 41, and third look in eight patients; 19 required an additional bowel resection. The overall mortality rates were 43, 52, 60 and 67 per cent at 30 days, discharge, 1 and 5 years, respectively. No patient was dependent on intravenous nutrition after 1 year. Previous vascular surgery resulted in a higher institutional mortality rate (79 per cent; P = 0.02). Patients who had a sudden onset of symptoms outside hospital had a better outcome (mortality rate 27 per cent; P = 0.02).
CONCLUSION: Many non-diagnostic radiological examinations were performed and a routine second-look is warranted. The results suggest that attempts at revascularization procedures for acute mesenteric ischaemia may improve the outcome.

PMID 12081744
S Hirota, S Matsumoto, T Yoshikawa, S Ichikawa, M Sako, M Kono
Simultaneous thrombolysis of superior mesenteric artery and bilateral renal artery thromboembolisms with three transfemoral catheters.
Cardiovasc Intervent Radiol. 1997 Sep-Oct;20(5):397-400.
Abstract/Text Successful treatment was achieved for a patient with superior mesenteric artery thromboembolism concomitant with bilateral renal artery thromboembolism. Thrombi of the three vessels were lysed simultaneously with a three-catheter technique using short-term, high-dose urokinase followed by overnight infusion with low-dose urokinase.

PMID 9271655
Hyun S Kim, Ajanta Patra, Jawad Khan, Aravind Arepally, Michael B Streiff
Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis.
J Vasc Interv Radiol. 2005 Dec;16(12):1685-91. doi: 10.1097/01.RVI.0000182156.71059.B7.
Abstract/Text PURPOSE: To evaluate clinical outcomes after percutaneous treatment of superior mesenteric vein (SMV) thrombosis.
MATERIALS AND METHODS: A retrospective chart review was conducted of all patients with SMV thrombosis treated with percutaneous catheter-directed thrombectomy/thrombolysis. The demographics of the study population, potential causative factors contributing to SMV thrombosis, and morbidity and mortality associated with therapy were assessed.
RESULTS: Eleven patients (mean age, 44.3 years +/- 12.8) with SMV thrombosis were treated with percutaneous transhepatic catheter-directed thrombectomy/thrombolysis. Potential causative factors included recent major abdominal surgery, thrombophilic conditions, pancreatitis, and repetitive abdominal trauma. The mean duration between the onset of symptoms and percutaneous treatment was 8.6 days +/- 6.5. Computed tomography confirmed the clinical diagnosis in nine patients (81.8%). One patient (9.1%) had a bleeding complication, which was treated by chest tube drainage without long-term sequelae. One patient (9.1%) with refractory SMV thrombosis died of sepsis and multiple organ failure. No recurrent episode of SMV thrombosis or mortality was documented during a mean follow-up of 42 months +/- 22.5.
CONCLUSIONS: Percutaneous transhepatic catheter-directed thrombectomy/thrombolysis for SMV thrombosis is associated with a rapid improvement in symptoms and low incidences of long-term morbidity and mortality. Percutaneous thrombectomy and thrombolysis should be considered in all patients with acute SMV thrombosis without evidence of bowel necrosis.

PMID 16371536
S M Rivitz, S C Geller, C Hahn, A C Waltman
Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion.
J Vasc Interv Radiol. 1995 Mar-Apr;6(2):219-23; discussion 224-8.
Abstract/Text
PMID 7787355
P J Levy, M M Krausz, J Manny
Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients.
Surgery. 1990 Apr;107(4):372-80.
Abstract/Text Acute mesenteric ischemia (AMI) is a curable disease if diagnosis and therapy are instituted before irreversible changes have occurred. AMI has been diagnosed with increasing frequency, during the last two decades, yet the mortality rate remains as high as 80% to 95%. Ninety-two patients with AMI were treated at Hadassah University Hospital between 1952 and 1987. Seventy-seven patients were treated surgically: 15 underwent only explorative laparotomy, and 62 underwent bowel resection or revascularization or both. The latter patients were divided into two groups: 17 patients treated surgically between 1952 and 1976, in whom bowel resection and primary anastomosis was the only surgical procedure carried out (group 1), and 45 patients treated in the last decade (group 2), in whom one or more of the following procedures were performed: bowel resection with primary anastomosis (n = 16), revascularization (n = 16), "second-look" (n = 18), and delayed anastomosis (n = 10). The overall mortality rate in 62 surgically treated patients was 40% (82% in group 1 and 24% in group 2) and 21% in 29 patients treated in a combined surgical approach. The reasons for improved results in group 2 patients are discussed, and an algorithm for surgical treatment of patients with AMI of different causes is proposed.

PMID 2321134
D W Wilmore, J M Lacey, R P Soultanakis, R L Bosch, T A Byrne
Factors predicting a successful outcome after pharmacologic bowel compensation.
Ann Surg. 1997 Sep;226(3):288-92; discussion 292-3.
Abstract/Text OBJECTIVES: The authors determined those factors that predict a successful outcome in patients who receive pharmacologic agents to promote bowel absorption after massive intestinal resection.
SUMMARY BACKGROUND DATA: Patients with the short bowel syndrome are maintained on long-term total parenteral nutrition (TPN) or more frequently considered for intestinal transplantation as part of their treatment program. The authors have administered a combination of trophic agents and a specialized diet to further enhance intestinal compensation and optimize nutrient absorption in patients with intestinal failure.
METHODS: Forty-five TPN-dependent adults with a jejunal-ileal remnant < or = 50 cm and a portion of colon in continuity were treated with growth hormone, glutamine, and a modified diet for 4 weeks and observed for an average of 1.8 years.
RESULTS: The average age of the patients was 43 years, the average jejunal-ileal length was 23 cm, and the average length of time the patient received TPN was 4.3 years. After 4 weeks of therapy, 26 (58%) were free of TPN support. Predictors of a favorable response included greater bowel length, lower body weight, and greater bowel length-body weight ratio. At follow-up, the percentage of patients who were not receiving TPN had fallen to 40%.
CONCLUSIONS: Approximately half of a group of patients, thought to have absorptive surface area inadequate to be independent of TPN support, can maintain themselves on enteral feedings after this intestinal rehabilitation program. Because of the risk, costs, and alterations in lifestyle associated with long-term TPN or intestinal transplantation or both, it seems prudent to consider a program of bowel rehabilitation with an individual patient before embarking on another therapeutic plan.

PMID 9339935
R S SHAW, R H RUTLEDGE
Superior-mesenteric-artery embolectomy in the treatment of massive mesenteric infarction.
N Engl J Med. 1957 Sep 26;257(13):595-8. doi: 10.1056/NEJM195709262571303.
Abstract/Text
PMID 13477354
B Condat, F Pessione, M Helene Denninger, S Hillaire, D Valla
Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy.
Hepatology. 2000 Sep;32(3):466-70. doi: 10.1053/jhep.2000.16597.
Abstract/Text Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.

PMID 10960436

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