Effects of a Multimodal Management Strategy for Acute Mesenteric Ischemia on Survival and Intestinal Failure  Olivier Corcos, Yves Castier, Annie Sibert, Sebastien Gaujoux, Maxime Ronot, Francisca Joly, Catherine Paugam, Frederic Bretagnol, Mohamed Abdel–Rehim, Fadi Francis, Vanessa Bondjemah, Marianne Ferron, Magaly Zappa, Aurelien Amiot, Carmen Stefanescu, Guy Leseche, Jean–Pierre Marmuse, Jacques Belghiti, Philippe Ruszniewski, Valerie Vilgrain, Yves Panis, Jean Mantz, Yoram Bouhnik  Clinical Gastroenterology and Hepatology  Volume 11, Issue 2, Pages 158-165.e2 (February 2013) DOI: 10.1016/j.cgh.2012.10.027 Copyright © 2013 AGA Institute Terms and Conditions

Figure 1 Multimodal treatment according to the pathophysiology of AMI. O2, oxygene therapy; PPI, proton pump inhibitor. Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions

Figure 2 Indication for laparotomy was decided if persistent abdominal tenderness with sepsis, organ failure, peritonitis, or radiologic revascularization failure occurred. Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions

Figure 3 (A) Superior mesenteric artery occlusion appears as a filling defect on arterial phase imaging (axial slice, white arrow). Portal phase imaging depicting (B) aeroportia, (C) pneumatosis intestinalis in the unenhanced, dilated segment of the small intestine (white arrow). Six days after endovascular hepatic artery revascularization by stent placement, without intestinal resection: (E) Regression of aeroportia, (D) hepatic artery stent (white arrow). (F) Persistence of colon and small intestine wall thickening with regression of intestinal pneumatosis (arrow). Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions

Figure 4 (A) Intestinal resection length (cm). White bar: intestinal resection length (all patients, n = 18; surgical patients, n = 7; mean; cm). Gray bar: intestinal resection length, with revascularization (all patients, n = 12; surgical patients, n = 4; mean; cm). Black bar: length of intestinal resection, without revascularization (all patients, n = 6, surgical patients, n = 3; mean; cm). (B) Rate (%), intestinal resection length (cm), and time in ICU (d) in early vs late AMI patients. White bar: all patients. Gray bar: early AMI patients. Black bar: late AMI patients. (C) Survival probability (Kaplan–Meier curve) in all 18 patients. (D) Survival probability (Kaplan–Meier curve) in 11 early (solid line) and 7 late (hashed line) AMI patients. Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions

Supplementary Figure 1 Intestinal stroke center organization. For each patient admitted with AMI, an emergency interdisciplinary discussion was performed between a gastroenterologist, radiologist, digestive/vascular surgeon, and intensive care specialists concerning diagnosis, severity evaluation, and therapeutic management. Early AMI patients were managed most often by gastroenterologists and vascular radiologists, whereas late AMI patients were managed most often by intensive care specialists and vascular/digestive surgeons. Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions

Supplementary Figure 2 Enhanced thoracic and abdominal CT scan features an acute embolic mesenteric ischemia in a 79-year-old man (patient 15, Table 2). (A) Intracardiac thrombus caused by arrhythmia (white arrow) was responsible for multiple embolic events: (B) splenic infarctions (white arrow), and (C) superior mesenteric artery partial occlusion depicted as intravascular material partially occluding the vessel lumen (white arrow). (C) On the same slice, visible thickened and ill-enhanced intestine loops with fat standing corresponding to ischemic segments (dashed circle) in comparison with normally enhanced small intestine (full line circle) can be seen. This patient responded to the medical protocol and did not require intestinal resection. Clinical Gastroenterology and Hepatology 2013 11, 158-165.e2DOI: (10.1016/j.cgh.2012.10.027) Copyright © 2013 AGA Institute Terms and Conditions