refrences : ratherford vascular surgery current cameron

1. Acute Mesenteric
Ischemia
By Dr. Salsabeel Alkhudairi

2. Outline
.
1. Background, Epidemiology
2. Classification & Risk factors
3. Clinical manifestations
4. Diagnosis
5. Management approach
MM.DD.20XX ADD A FOOTER 2

3. Definition:
Sudden onset of small intestinal hypoperfusion, which can be due to occlusive
or nonocclusive obstruction of the arterial blood supply or obstruction of
venous outflow
 Chronic mesenteric ischemia?
accounts for less than 1 in 1000 hospital admissions
High mortality 25%-80%

6. Etiologies of Mesenteric Ischemia

7. Risk
factors

8. Pathophysiology

9. Clinical manifestation
1 2 3 4
Pain , NV, Fever,
Abdominal
distension,
bloody diarrhea
Hx of MI or AF
Embolic AMI
Abdominal angina
Food fear
Wt. loss , Diarrhea
Ex: malnourished,
bruit, diminished
pulses
Thrombotic AMI
NOAMI
HX of Hyper
coagulable state
Hx of DVT
Settle course
MVT
• Hx & Ex to exclude other causes !
• Abdominal pain out of proportion to
examination findings
• Sick patients

10. Diagnosis: imaging
• X-ray : not sensitive or specific
• Suspicious finding In CT scan:
- Bowel wall thickening
- Free intraperitoneal fluid
- Peri-intestinal soft tissues stranding
- Abnormal bowel wall enhancement
- Portal vein SMA gas
• Computed tomographic angiography (CTA) best.
• Other? US, duplex US, Echo..
• Lab:
- Leukocytosis
- Electrolyte derangements
- Elevated amylase,
- Lactic acidosis.
- Elevated hematocrit
- D- dimer!!
• Additional : ECG, cardiac enzyme

12. Thrombotic MI

13. Embolic AMI

14. MVT

15. NOAMI

16. NOAMI

18. Management
Aggressive resuscitation IVF, pressor “avoided”, .Electrolyte abnormalities.
Anticoagulant ???
Antibiotics , pain management
Arrhythmias Management
Perioperative Management
Occlusive vs non occlusive vs venous thrombosis
Peritonitis or no peritonitis
Laparotomy vs initial revascularization & post intervention look
Operative vs Non operative Management
Embolectomy
Endovascular Approaches; Bypass
Management of Ischemic Bowel
Hybrid Open and Endovascular Revascularization
Operative Approach

19. Occlusive vs non occlusive vs venous thrombosis
Peritonitis or no peritonitis
Operative vs Non operative Management
 Venous thrombosis:
• Anticoagulant (95%
successful)
• Thrombus removal lysis
“ Rare”
• Intestinal stricture ?
 Non occlusive :
• Supportive
• Use of intraarterial infusion of
vasodilator medication
“papaverine”!
• Surgery??!
• No evidence for anticoagulation
use

20. Management of Ischemic Bowel
Operative Approach: Thrombotic & embolic
 Laparotomy, Prepping?
 Revascularization should precede resection
of any bowel.
 Allow reperfusion of any threatened areas of
bowel & come back for second look
 Don’t anastomose if questionable bowel
viability
Bowel
resection
• Assess bowel viability:
- Visible& palpable pulsation
- color and appearance
- Peristalsis
- Duplex US
- Florescence IV contrast

21.  Exposure of SMA
- Anterior
- Lateral

22. Embolectomy
Operative Approach : Embolic Or thrombotic
 Transverse incision
 Embolus removal
 Heparinization
 Closure
 Reassessment of the
bowel

23. Graft bypass
Operative Approach : Embolic Or thrombotic
 Antegrade vs retrograde
revascularization
 Aortic vs iliac inflow
 Autogenous vein vs
prosthetic conduit
 Reassessment of the bowel

24. Hybrid Open and Endovascular Revascularization
Operative Approach
 Open laparotomy with
retrograde stenting of the SMA
with access via a branch of the
SMA.
 Success rate of patency 76%-
92%
 Mortality 20%-45%

25. Endovascular Approaches
Operative Approach
 In case of very low suspicion
for necrotic bowel
 In chronic mesenteric
ischemia
 Outcome compared to Open
 Use of covered vs bare metal
stent
 Assessment of bowel ??
 Complication: access site thrombosis,
hematomas, and infection

26.  Lifelong anticoagulation
 Aspirin& Antiplatelet therapy
 Duplex ultrasound: detect graft stenosis.
Post operative management

27. Summary
• high index of suspicion is necessary
• Use CTA to RO the diagnosis
• Management depend on the etiology
• Endovascular revascularization
procedures may have a role with partial
arterial occlusion
• Post operative workup & management
to prevent a sconed episode

28. Thank you
References
1.Schwartz, Seymour I.,Brunicardi, F. Charles. (Eds.) (2011) Schwartz's
principles of surgery :ABSITE and board review New York : McGraw-
Hill Medical,
2.CAMERON., 2019. CURRENT SURGICAL THERAPY 13
3.Acute mesenteric ischemia: guidelines of the World Society of
Emergency Surgery Bala et al. World Journal of Emergency Surgery
(2017) 12:38
4.Up to date