1. Mesenteric Ischemia: A Minimally Invasive Approach
Danielle Pineda, MD
April 7, 2017

2. Chronic Mesenteric Ischemia
11/22/2017

3. Rare Disease Accounts for less than 2% of all hospital admissions for GI conditions -But atherosclerosis of mesenteric vessels much more prevalent (usually asymptomatic)

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Rutherford 8th Edition

5. FOOD FEAR Pain after meals (30 mins on average) Weight loss
Avoiding meals
Pre-operative Necessities
Endoscopy
Colonoscopy
CT scan
Claudication: ischemic neuropathy involving small unmyelinated A delta and C sensory fibers and a local intramuscular acidosis from anaerobic metabolism enhanced by substance P
11/22/2017

6. Endovascular Approach Options

7. Technique Femoral or brachial approach Lateral position for C-arm
Cross atherosclerotic lesion
May need to pre-dilate with angioplasty and place sheath through stenosis
Balloon-expandable Stent versus stent graft
SMA preferential vessel although can also treat celiac/IMA in higher risk patients
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8. Complications
Cardiac events (patients high risk secondary to atherosclerosis)
GI bleeding
Embolus/dissection leading to bowel ischemia
Access related problems (especially brachial)
Renal failure
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9. Hybrid Approach Midline laparotomy Micropuncture access of the SMA
Cross stenosis/occlusion in retrograde fashion
Balloon expandable stent or stent graft
Transverse closure or patch closure
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11. Acute Mesenteric Ischemia
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12. Multiple Causes Arterial emboli Arterial thrombosis
40-50% of cases
Intracardiac mural thrombus, endocarditis, proximal thoracic aortic aneurysms
Arterial thrombosis
20-35% of cases
Preexisting atherosclerosis – acute on chronic picture
Nonocclusive Mesenteric Ischemia
Mesenteric Venous Thrombosis

13. Signs and Symptoms Pain out of proportion to exam
Pneumatosis on CT scan
Elevated WBC, lactate
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14. Endovascular Approach Options

15. Mechanical Thrombolysis
Usually reserved for high risk surgical patients if no bowel ischemia suspected
Risk of embolus to distal SMA branches could precipitate bowel ischemia
Angioplasty and Stent
Used in situations when patient has acute on chronic disease in conjunction with mechanical thrombolysis or in retrograde approach as discussed

16. Case 1
80 yo F with history of supraceliac aorta to celiac and SMA bypass
Represents with weight loss and post-prandial pain
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17. Celiac artery stenosis
Occluded bypass
Celiac artery stenosis
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19. Questions???