published on oct 5 presentation on management on mesenteric vascular occlusion.

1. TREATMENT OF MESENTERIC
VASCULAR OCCLUSION
Dr. Rachitha Radhakrishnan
Post Graduate
Dept of General Surgery
VMKVMCH

2. Initial Treatment
• Fluid resuscitation.
• Systemic anticoagulation with heparin.
• Metabolic acidosis – corrected with sodium
bicarbonate
• Secure CVP, Peripheral arterial catheter,
urinary bladder catherization
• Antibiotics

3. Options available
• Surgical repair
• Endovascular treatment

4. Surgical repair
• Operative intervention- mainstay
• Assess bowel viability
• Determine etiology
• Perform revascularization where possible
• Resect nonviable bowel.

5. Indications
• Failed thrombolytic therapy
• Presentation after 8 hours of pain
• Features of peritonitis

6. Done for
• Acute embolic mesenteric ischemia
• Acute thrombotic mesenteric ischemia
• Chronic mesenteric ischemia
• Coeliac artery compression syndrome

7. Acute embolic mesenteric ischemia
• Primary goal – removal of embolus – restore
blood flow
• Approach to SMA
– TC lifted and small intestine reflected to right
upper quadrant
– SMA approached at the root of Mesentery.
– Alternatively approached from lateral side of D4
and D4 rotated medially to expose SMA.

8. • Vascular clamps applies -Transverse arteriotomy
done- embolus extracted using standard balloon
embolectomy catheter.
• Following restoration of flow
– Viability assessed
– Nonviable bowel resected
• Assessment of viability
– Intra op flouresceine injection and inspection with
Wood’s lamp
– Doppler assessment of antemesenteric intestinal
artery pulsations.

10. • Second look procedure in 24-48 hours.
• Goal
– Reassessment of extent of bowel viability
• If non viable bowel present – additional bowel
resection indicated.

11. Acute thrombotic mesenteric ischemia
• Involves severely atherosclerotic vessels –
Coeliac artery and SMA
• Reconstructive procedure to bypass proximal
occlusive disease.
• Bypass graft
– Saphenous vein – graft of choice
– Prosthetic – avoided

12. • Graft can originate from
– Supracoeliac infradiaphragmatic Aorta
– Iliac artery
• Advantage
– Inflow graft includes smoother graft configuration
with less kinking
– Absence of atherosclerotic disease
• Disadvantage
– Exposure difficult

15. Chronic mesenteric ischemia
• Therapeutic goal – revascularization.
• Methods
– Transaortic endarterectomy
– Mesenteric artery bypass.

16. • Transaortic endarterectomy
– Lateral aortotomy done encompassing both CA
and SMA orifices.

17. • Mesenteric artery bypass
– for occlusive lesions 1-2 cms distal to origin
– Approaches
• Antegrade : supraceliac aorta
• Retrograde : infrarenal aorta or iliac artery
– Grafts : saphenous vein / prosthetic graft.

18. Celiac artery compression syndrome
• Treatment goal :
– release compression by arcuate ligament
– Correct stricture by bypass graft
• Angioplasty and stenting not advocated.
• Open or laparoscopic median arcuate
ligament release done.

20. Endovascular treatment
• Chronic mesenteric ischemia
• Acute mesenteric ischemia
• Nonocclusive mesenteric ischemia
• Methods
– Balloon dilation
– Stent placement

21. Indications
• Calcified ostial stenosis
• High grade eccentric stenosis
• Chronic occlusions
• Dissection after angioplasty
• Residual stenosis >30%

22. Acute mesenteric ischemia
• Catheter directed thrombolytic therapy
• Intraarterial delivery during angiography
• Thrombolytics used
– Urokinase
– Recombinant tissue plasminogen activator
• Successful when performed within 12 hours of
onset of symptoms.

23. • Later, elective operative mesenteric vascular
revascularization or balloon angioplasty and
stenting done.
• Drawbacks
– Cannot inspect ischemic bowel.
– Serial angiography to document resolution
– Unsusccessful procedure delays operative
revascularization.

24. Non occlusive mesenteric ischemia
• Treatment primarily pharmacological.
• Catheterization of selective mesenteric artery
– infusion of vasodilatory agents.
• Agents used
– Talazoline
– Papaverine 30-60 mg/h
• Concomitant heparin IV infusion

25. • During papaverine infusion
– Hemodynamic status monitored
– Can cause hypotension
• Symptoms resolve – angiography for
documentation
• Does not resolve – surgical exploration.

26. Technique
• Intraluminal access
– Femoral artery
– Brachial artery
• Anteroposterior and lateral aortogram
obtained.
• Mesenteric artery cannulated.

27. • Selective angled catheters used
– RDC
– Cobra-2
– Simmons I
– SOS Omni Catheter

28. • Once artery cannulated Heparin (5000IU)
given IV.
• Selective mesenteric angiogram.
• Guide wire passed across stenotic segment.
• Catheter advanced over guide wire.
• Balloon angioplasty with mounted stent
advanced over guide wire.

29. • Stent deployed by expanding balloon.
• Post angioplasty angiogram obtained.
• Maintain guidewire access until satisfactory
angiogram obtained.
• Intra arterial papaverine/nitroglycerine during
procedure.
• Antiplatelet agent administration for 6 months
post procedure.

31. Complications
• Dissection
• Access site thrombosis
• Hematoma
• Infection
• Distal embolization

32. Summary

33. TAKE HOME MESSAGE
• Rare disease with a fatal outcome.
• Early recognition is key.
• Prompt imaging with CT angio
• Interdisciplinary approach in diagnosis and
treatment.

34. Thank you