Chapter 8, Mesenteric Arterial Disease: Diagnosis and Treatment

CONSTANTINOS CONSTANTINOU, MD; VIKRAM S. KASHYAP, MD

CASE STUDY:

A 60-year-old female presents complaining of abdominal pain over the past 2 years that has been progressively worsening. On further questioning, she associates the pain with food intake. She states that it starts approximately half an hour following food ingestion and lasts approximately one hour. She also admits to weight loss of 7 kg over the past 6 months. She underwent an upper and a lower gastrointestinal endoscopy and a gallbladder ultrasound, all of which were unremarkable. She has a history of hypertension, hyperlipidemia, and a 40-pack-year smoking history.

On exam, her blood pressure is 125/86, her heart rate is 88, and she weighs 43 kg. She appears emaciated, with a prominent rib cage and a scaphoid abdomen. The abdomen is soft and nontender. On auscultation, a bruit is appreciated in the epigastric region. Laboratory workup, including a renal function panel, is normal.

Case Study: Chapter 8

* 1.) What is the next best diagnostic test in this patient?

Plain abdominal x-ray
Duplex ultrasonography
Magnetic resonance angiography (MRA)
Conventional angiography

The correct answer is 2, Duplex ultrasonography. This clinical scenario presents a typical case of a patient with chronic mesenteric ischemia (CMI). These patients are often symptomatic for a long period of time, are misdiagnosed as having one of the more common abdominal conditions, and undergo a multitude of tests before arriving at the correct diagnosis.

Duplex ultrasonography is often the first test used in making the diagnosis of CMI. Real-time images and flow characteristics of both the celiac trunk and the superior mesenteric artery are obtained. It is inexpensive, noninvasive, and associated with sensitivity, specificity, and accuracy in excess of 90% in evaluation of patients with suspected CMI. Normal celiac and superior mesenteric artery velocities in an adequately performed study essentially exclude the presence of mesenteric ischemia. Its main limitations are that it is both operator dependent and patient-dependent.

Abdominal x-ray may be of value in patients presenting with acute peritoneal symptoms. It can identify the presence of free air or small bowel obstruction, thereby determining whether an expedited trip to the operating room or further diagnostic studies and conservative management, respectively, are in order.

MR angiography is less commonly used in the diagnostic algorithm of patients with CMI than CT angiography. MRA is of particular value when CTA is contraindicated. Both MRA and CTA can help confirm or exclude the diagnosis of CMI, and can also determine whether an alternative or associated abdominal pathology is present. MR is associated with claustrophobia, takes longer to perform than CT, may overestimate the degree of stenosis, and causes signal dropout in patients with prior stent placement.

Conventional angiography is of value in both diagnosis and treatment of CMI. Anteroposterior and lateral views, as well as pressure transductions with or without administration of vasodilators, are utilized in making the diagnosis. When amenable to angiographic intervention, angioplasty and stenting have emerged as the first-line therapy for patients with CMI in many institutions across the country. Nevertheless, prior to embarking with this invasive study with its associated complications, diagnostic testing with duplex is indicated.

* 2.) A mesenteric duplex was obtained. The celiac artery peak systolic velocity (PSV) was 225 cm/ sec and SMA PSV was 400 cm/sec. What is the next step in management?

Antegrade bypass to the SMA
CT angiogram
Retrograde bypass to the SMA
Angiogram

* 3.) The lesion was not amenable to angioplasty and stenting. Surgery is contemplated. Which of the following statements is true regarding open surgical intervention?

The disadvantage of antegrade bypass is that the aorta at that location is more involved with atherosclerotic degeneration.
The advantage of antegrade bypass is that the supraceliac aorta is more familiar to most vascular surgeons than the aortic bifurcation.
Surgery compared to percutaneous intervention is associated with greater perioperative mortality and longer hospital stay
Percutaneous intervention is associated with a high technical and clinical success rate, and is more durable than open surgery.

Comprehensive Review in Vascular and Endovascular Medicine

Case Studies and Study Questions

Case Study: Chapter 08

Case Study: Chapter 8