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Goto D, Yanishi K, Ozawa T, Yoshimura J, Kawamata H, Fujioka A, Seki T, Zen K, Matoba S. Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database. J Am Heart Assoc 2024; 13:e035017. [PMID: 38879458 PMCID: PMC11255773 DOI: 10.1161/jaha.124.035017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/23/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection. METHODS AND RESULTS Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization. CONCLUSIONS EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained. REGISTRATION URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.
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Affiliation(s)
- Daiki Goto
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Takaaki Ozawa
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Jun Yoshimura
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Ayumu Fujioka
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
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Parekh R, Athavale V, Kelshikar S. Superior Mesenteric Artery Thrombosis in COVID-19-Positive Patients: A Rare Coincidence. Cureus 2024; 16:e62136. [PMID: 38993447 PMCID: PMC11238150 DOI: 10.7759/cureus.62136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Since the start of the SARS-CoV-2 pandemic, which is otherwise known as the worldwide coronavirus disease, 2019, has had a well-established pro-thrombotic character. Patients often first exhibit respiratory symptoms, and those whose severity increases eventually develop acute hypoxic respiratory failure. The systemic hypercoagulable condition and arterial/venous thrombosis related to COVID-19 have a poor prognosis. Even though superior mesenteric artery (SMA) thrombosis and acute mesenteric ischemia (AMI) are uncommon, they frequently coexist with fatal gastrointestinal (GI) pathologies that necessitate prompt diagnosis and treatment by the doctor. This calls for more research into the effects of anticoagulation therapy in COVID-19-positive patients. The main treatment aims for this condition are early detection, surgical or intravascular re-establishment of blood supply to the ischemic bowel, and surgical resection. The study aimed to see the outcome after surgical intervention in patients with SMA thrombosis post-COVID-19 infection. This study was from March 2021 to January 2022, with a sample size of 5 patients with SMA thrombosis, which was confirmed on contrast-enhanced computed tomography (CECT) abdomen and pelvis with angiography. The patients underwent exploratory laparotomy. Bowel resection and anastomosis were performed in three individuals; bowel resection and stoma placement were performed in two patients. Doctors have significant clinical challenges as a result of the thromboembolic manifestations of the unexpected and deadly nature of the virus, such as AMI. The high morbidity and mortality associated with AMI calls for further study on prophylactic anticoagulation therapy in COVID-19-positive individuals.
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Affiliation(s)
- Rushabh Parekh
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Virendra Athavale
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Saili Kelshikar
- General Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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Li W, Liu M, Jin L, Feng H, Chen X, Zhang Z. Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery. J Cardiothorac Surg 2024; 19:235. [PMID: 38627835 PMCID: PMC11020894 DOI: 10.1186/s13019-024-02745-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment. METHODS The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group. RESULTS Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency. CONCLUSIONS Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.
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Affiliation(s)
- Wenrui Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Mingyuan Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Lei Jin
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhiwen Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Intra-Arterial Urokinase for Acute Superior Mesenteric Artery Occlusion: A Retrospective 12-Year Report of 13 Cases. Biomedicines 2023; 11:biomedicines11020267. [PMID: 36830803 PMCID: PMC9952883 DOI: 10.3390/biomedicines11020267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/04/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted.
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Tamme K, Reintam Blaser A, Laisaar KT, Mändul M, Kals J, Forbes A, Kiss O, Acosta S, Bjørck M, Starkopf J. Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis. BMJ Open 2022; 12:e062846. [PMID: 36283747 PMCID: PMC9608543 DOI: 10.1136/bmjopen-2022-062846] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022. ELIGIBILITY CRITERIA Studies reporting data on the incidence and outcomes of AMI in adult populations. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms. RESULTS From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4). CONCLUSIONS In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised. PROSPERO REGISTRATION NUMBER CRD42021247148.
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Affiliation(s)
- Kadri Tamme
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Luzern, Luzern, Switzerland
| | - Kaja-Triin Laisaar
- Department of Epidemiology and Biostatistics, Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Merli Mändul
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Statistics, Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia
| | - Jaak Kals
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Surgery Clinic, Tartu University Hospital, Tartu, Estonia
| | - Alastair Forbes
- Department of Internal Medicine, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Internal Medicine Clinic, Tartu University Hospital, Tartu, Estonia
| | - Olga Kiss
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Martin Bjørck
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
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Hou L, Wang T, Wang J, Zhao J, Yuan D. Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review. Vascular 2021; 30:669-680. [PMID: 34154466 DOI: 10.1177/17085381211024503] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years. METHODS Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs). RESULTS In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I2 = 84%), 26% (95% CI, 0.19-0.33; I2 = 33%), and 32% (95% CI, 0.21-0.44; I2 = 26%), respectively. CONCLUSIONS The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.
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Affiliation(s)
- Li Hou
- West China School of Medicine, West China Hospital, 12530Sichuan University, Chengdu, China.,Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, 12530Sichuan University, Chengdu, China
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Figlewicz MR, Bridwell RE, Lowe J, Cibrario A, Oliver J. Acute Mesenteric Ischemia With Secondary Thromboembolism: A Rare Complication. Cureus 2020; 12:e9458. [PMID: 32874790 PMCID: PMC7455393 DOI: 10.7759/cureus.9458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute mesenteric ischemia presents a clinical challenge due to its subtle presentation and high mortality rate, which can mimic a variety of other conditions. Acute mesenteric ischemia requires a high index of suspicion, especially in those with comorbidities and risk factors such as hypertension, diabetes, atrial fibrillation, and peripheral arterial disease. The inciting thrombus commonly originates in the left atrial appendage or left atrium, embolizing to occlude mesenteric vessels, with resulting gut ischemia. Patients commonly present with post-prandial abdominal pain as mesenteric vascular demands increase, though diarrhea and gastrointestinal bleeding may be the presenting symptom. CT angiography of the abdomen and pelvis provides rapid confirmation of the diagnosis and visualization of the thrombus, aiding vascular surgical management. The authors present a novel case of a 69-year-old female with an acute mesenteric ischemia of her superior mesenteric artery and a second acute arterial thromboembolism to the right axillary artery visualized from her left atrial appendage.
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Affiliation(s)
| | - Rachel E Bridwell
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Josh Lowe
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Amber Cibrario
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Joshua Oliver
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
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Hayashi K, Hayashi K, Narita M, Tsunoda A, Kusanagi H. Still time to perform intestinal revascularization in patients with acute mesenteric ischemia with peritonitis: An analysis of bowel viability in resections. SAGE Open Med 2020; 8:2050312120923227. [PMID: 32547750 PMCID: PMC7249549 DOI: 10.1177/2050312120923227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 04/08/2020] [Indexed: 11/17/2022] Open
Abstract
Objective: Acute mesenteric ischemia is often fatal, and many survivors develop short
bowel syndrome. To avoid massive bowel resection, revascularization is
recommended for acute mesenteric ischemia patients. However, whether acute
mesenteric ischemia patients with clinical peritonitis can be revascularized
remains uncertain. Therefore, this study aimed to evaluate the
histopathological potential reversibility of resected bowel in acute
mesenteric ischemia patients with peritonitis. Methods: We retrospectively reviewed the medical records of acute mesenteric ischemia
patients treated at the Kameda Medical Center between January 2001 and March
2015. Pathological evaluation regarding bowel resection was performed.
Patients with and without peritonitis were compared. The primary outcome was
the proportion of patients with reversible or irreversible ischemia.
Patients with reversible and irreversible ischemia were characterized. Results: Of 41 patients, 17 underwent laparotomy, 6 endovascular surgery, and 18
palliative care. Among 23 patients receiving curative treatment, 7 had
peritonitis and 13 did not. Seven patients of each group received bowel
resection, but 85.7% of those with peritonitis had reversible ischemia. We
categorized patients with ischemia into reversible and irreversible groups.
The median time between symptom onset and diagnosis in the reversible group
was >27 h. Systemic inflammatory response syndrome was found in 72.2% and
66.7% of the reversible and irreversible groups, respectively. Conclusion: Acute mesenteric ischemia patients with clinical peritoneal signs may have
potentially reversible ischemia. As a result, revascularization should be
considered, even in the case of peritonitis.
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Affiliation(s)
- Kentaro Hayashi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Ken Hayashi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Makoto Narita
- Department of Pathology, Kameda Medical Center, Kamogawa, Japan
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, Kamogawa, Japan
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Aboyans V, Ricco JB, Bartelink MLEL, Björck M, Brodmann M, Cohnert T, Collet JP, Czerny M, De Carlo M, Debus S, Espinola-Klein C, Kahan T, Kownator S, Mazzolai L, Naylor AR, Roffi M, Röther J, Sprynger M, Tendera M, Tepe G, Venermo M, Vlachopoulos C, Desormais I. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2019; 39:763-816. [PMID: 28886620 DOI: 10.1093/eurheartj/ehx095] [Citation(s) in RCA: 2230] [Impact Index Per Article: 371.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Liu YR, Tong Z, Hou CB, Cui SJ, Guo LR, Qi YX, Qi LX, Guo JM, Gu YQ. Aspiration therapy for acute embolic occlusion of the superior mesenteric artery. World J Gastroenterol 2019; 25:848-858. [PMID: 30809084 PMCID: PMC6385017 DOI: 10.3748/wjg.v25.i7.848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/20/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Embolic superior mesenteric artery (SMA) occlusion is associated with high mortality rates. Delayed treatment often leads to serious consequences, including intestinal necrosis, resection, and even patient death. Endovascular repair is being introduced, which can improve clinical symptoms and prognosis and decrease the incidence of exploratory laparotomy. Many reports have described successful endovascular revascularization of embolic SMA occlusion. However, most of those reports are case reports, and there are few reports on Chinese patients. In this paper, we describe the technical and clinical outcomes of aspiration therapy using a guiding catheter and long sheath technique which facilitates the endovascular repair procedure.
AIM To evaluate the complications, feasibility, effectiveness, and safety of endovascular treatment for the acute embolic occlusion of the SMA.
METHODS This retrospective study reviewed eight patients (six males and two females) from August 2013 to October 2018 at Xuanwu Hospital, Capital Medical University. The patients presented with acute embolic occlusion of the SMA on admission and were initially diagnosed by computed tomography angiography (CTA). The patients who underwent endovascular treatment with a guiding catheter had no obvious evidence of bowel infarct. No intestinal necrosis was identified by gastrointestinal surgeons through peritoneal puncture or CTA. The complications, feasibility, effectiveness, safety, and mortality were assessed.
RESULTS Six (75%) patients were male, and the mean patient age was 70.00 ± 8.43 years (range, 60-84 years). The acute embolic occlusion of the SMA was initially diagnosed by CTA. All patients had undertaken anticoagulation primarily, and percutaneous aspiration using a guiding catheter was then undertaken because the emboli had large amounts of thrombus residue. No death occurred among the patients. Complete patency of the suffering artery trunk was achieved in six patients, and defect filling was accomplished in two patients. The in-hospital mortality was 0%. The overall 12-mo survival rate was 100%. All patients survived, and two of the eight patients had complications (the clot broke off during aspiration).
CONCLUSION Aspiration therapy is feasible, safe, and beneficial for acute embolic SMA occlusion. Aspiration therapy has many benefits for reducing patients’ death, resolving thrombi, and improving symptoms.
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Affiliation(s)
- Yi-Ren Liu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Zhu Tong
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Cheng-Bei Hou
- Center of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Shi-Jun Cui
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Lian-Rui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Yi-Xia Qi
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Li-Xing Qi
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Jian-Ming Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Yong-Quan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
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Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Sanddal Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Geelkerken B, Gloviczki P, Huber T, Naylor R. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 53:460-510. [PMID: 28359440 DOI: 10.1016/j.ejvs.2017.01.010] [Citation(s) in RCA: 414] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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12
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Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 55:305-368. [PMID: 28851596 DOI: 10.1016/j.ejvs.2017.07.018] [Citation(s) in RCA: 720] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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13
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What is the Best Revascularization Strategy for Acute Occlusive Arterial Mesenteric Ischemia: Systematic Review and Meta-analysis. Cardiovasc Intervent Radiol 2017; 41:27-36. [DOI: 10.1007/s00270-017-1749-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/13/2017] [Indexed: 01/02/2023]
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Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (Part II) - Vascular and endovascular surgical approaches. Best Pract Res Clin Gastroenterol 2017; 31:27-38. [PMID: 28395785 DOI: 10.1016/j.bpg.2016.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/08/2016] [Accepted: 11/29/2016] [Indexed: 01/31/2023]
Abstract
The modern treatment of acute mesenteric ischemia (AMI) requires seamless collaboration of gastrointestinal surgeons, vascular surgeons, and interventional radiologists. The treatment strategy is straightforward aiming at rapid restoration of blood flow to the intestine. Bowel resection is performed on demand. The first thing to consider is the patient's clinical condition at presentation, whether there are signs of peritonitis or not, and whether the patient is hemodynamically stable or not. Second, there are four etiologies of AMI that need to be distinguished as they differ in treatment: superior mesenteric artery embolism, mesenteric arterial occlusive disease, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. In this review, we describe the basic vascular and endovascular treatment modalities accompanied by a simple algorithm for the various situations in AMI. Furthermore, the indications for damage control and primary definitive surgery are discussed.
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Affiliation(s)
- Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, P.O. Box 100, 70029 Kuopio, Finland.
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Sweden.
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Zhao Y, Yin H, Yao C, Deng J, Wang M, Li Z, Chang G. Management of Acute Mesenteric Ischemia. Vasc Endovascular Surg 2016; 50:183-92. [PMID: 27036673 DOI: 10.1177/1538574416639151] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence. Methods: A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate. Results: Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review. Conclusion: Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.
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Affiliation(s)
- Yang Zhao
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Henghui Yin
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiong Deng
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mian Wang
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zilun Li
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guangqi Chang
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Abstract
Acute mesenteric ischemia (AMI) is a rare disease that most commonly affects the elderly. The vague symptoms often lead to delayed diagnosis and consequent high mortality. Physical exam and laboratory findings lack the sensitivity and specificity to exclude AMI, but computed tomography angiography can rapidly and accurately confirm the diagnosis. Survival improves with prompt restoration of perfusion and resection of nonviable bowel. Advances in imaging, operative techniques, and critical care have led to a steady decline in overall mortality; however, long-term survival is limited because of the comorbidities in this patient group.
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Affiliation(s)
- Thomas W Carver
- Division of Trauma and Critical Care, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
| | - Ravi S Vora
- Division of Digestive Diseases, Emory University, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Amit Taneja
- Division of Pulmonary and Critical Care Medicine, The Medical College of Wisconsin, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Björck M, Orr N, Endean ED. Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemia. J Vasc Surg 2015; 62:767-72. [PMID: 26304485 DOI: 10.1016/j.jvs.2015.04.431] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Our discussants will attempt to clarify these issues.
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Affiliation(s)
- Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
| | - Nathan Orr
- Department of Surgery, University of Kentucky, Lexington, Ky
| | - Eric D Endean
- Department of Surgery, University of Kentucky, Lexington, Ky.
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Part One: For the Motion. An Endovascular First Strategy is the Optimal Approach for Treating Acute Mesenteric Ischemia. Eur J Vasc Endovasc Surg 2015; 50:273-5. [PMID: 26315052 DOI: 10.1016/j.ejvs.2015.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Choi KS, Kim JD, Kim HC, Min SI, Min SK, Jae HJ, Chung JW. Percutaneous Aspiration Embolectomy Using Guiding Catheter for the Superior Mesenteric Artery Embolism. Korean J Radiol 2015; 16:736-43. [PMID: 26175572 PMCID: PMC4499537 DOI: 10.3348/kjr.2015.16.4.736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 03/04/2015] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To evaluate the technical feasibility and clinical outcome of percutaneous aspiration embolectomy for embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS Between January 2010 and December 2013, 9 patients with embolic occlusion of the SMA were treated by percutaneous aspiration embolectomy in 2 academic teaching hospitals. The aspiration embolectomy procedure was performed with the 6-Fr and 7-Fr guiding catheter. Thrombolysis was performed with urokinase using a multiple-sidehole infusion catheter. The clinical outcome was investigated retrospectively. RESULTS Superior mesenteric artery occlusion was initially diagnosed by computed tomography (CT) in all patients, and all patients had no obvious evidence of bowel infarction on CT scan. Percutaneous aspiration embolectomy was primarily performed in 6 patients, and thrombolysis was initially performed in 3 patients. In 3 patients who received primary thrombolysis, percutaneous aspiration was undertaken because the emboli were resistant to urokinase. Complete angiographic success was achieved in 6 patients and partial angiographic success was accomplished in 3 patients. One patient underwent bowel resection. One patient died of whole bowel necrosis and sepsis, and 8 patients survived without complications. CONCLUSION Percutaneous aspiration embolectomy is a useful tool in recanalization of embolic occlusion of the SMA in select patients.
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Affiliation(s)
- Kyu Sung Choi
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Ji Dae Kim
- Department of Radiology, Eulji University Hospital, Daejeon 302-799, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Sang-Il Min
- Department of Surgery, Seoul National University Hospital, Seoul 110-744, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University Hospital, Seoul 110-744, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
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Adaba F, Askari A, Dastur J, Patel A, Gabe SM, Vaizey CJ, Faiz O, Nightingale JMD, Warusavitarne J. Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies. Colorectal Dis 2015; 17:566-77. [PMID: 25739990 DOI: 10.1111/codi.12938] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 01/19/2015] [Indexed: 12/12/2022]
Abstract
AIM The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.
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Affiliation(s)
- F Adaba
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Askari
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
| | - J Dastur
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - A Patel
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - S M Gabe
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - C J Vaizey
- Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
| | - O Faiz
- Surgical Epidemiology Trials and Outcome Centre, St Mark's Hospital, Harrow, UK
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Trichard S, Zamour C, Nicol A, Durel CA. Une ischémie mésentérique révélatrice d’un syndrome des antiphospholipides. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0479-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cudnik MT, Darbha S, Jones J, Macedo J, Stockton SW, Hiestand BC. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med 2013; 20:1087-100. [PMID: 24238311 DOI: 10.1111/acem.12254] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 02/13/2013] [Accepted: 07/20/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED. METHODS In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project. RESULTS The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated. CONCLUSIONS The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.
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Affiliation(s)
- Michael T. Cudnik
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Subrahmanyam Darbha
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Janice Jones
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
| | - Julian Macedo
- The Departments of Emergency Medicine; The Ohio State University; Columbus OH
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Yanar F, Agcaoglu O, Sarici IS, Sivrikoz E, Ucar A, Yanar H, Aksoy M, Kurtoglu M. Local thrombolytic therapy in acute mesenteric ischemia. World J Emerg Surg 2013; 8:8. [PMID: 23394456 PMCID: PMC3626770 DOI: 10.1186/1749-7922-8-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 01/29/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI). METHODS From January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator. RESULTS LTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45-87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining. CONCLUSION Early intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.
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Affiliation(s)
- Fatih Yanar
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Orhan Agcaoglu
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Inanc Samil Sarici
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Emre Sivrikoz
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Adem Ucar
- Istanbul Medical Faculty, Department of Radiology, Istanbul University, Istanbul, Turkey
| | - Hakan Yanar
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Murat Aksoy
- Department of General Surgery, Bahcesehir University, Istanbul, Turkey
| | - Mehmet Kurtoglu
- Istanbul Medical Faculty, Department of General Surgery, Istanbul University, Istanbul, Turkey
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Acosta S, Block T, Björnsson S, Resch T, Björck M, Nilsson T. Diagnostic pitfalls at admission in patients with acute superior mesenteric artery occlusion. J Emerg Med 2011; 42:635-41. [PMID: 22137151 DOI: 10.1016/j.jemermed.2011.03.036] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 08/29/2010] [Accepted: 03/18/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute superior mesenteric artery (SMA) occlusion leads to acute intestinal ischemia and is associated with high mortality. Early diagnosis is often missed, and confounding factors leading to diagnostic delays need to be highlighted. OBJECTIVES To identify potential diagnostic laboratory pitfalls at admission in patients with acute SMA occlusion. METHODS Fifty-five patients with acute SMA occlusion were identified from the in-hospital register during a 4-year period, 2005-2009. RESULTS The median age was 76 years; 78% were women. The occlusion was embolic in 53% and thrombotic in 47% of patients. At admission, troponin I was above the clinical decision level (> 0.06 μg/L) for acute ischemic myocardial injury in 9/19 (47%) patients with embolic occlusion. Elevated pancreas amylase and normal plasma lactate were found in 12/45 and 13/27, respectively. A troponin I (TnI) above the clinical decision level was associated with a high frequency of referrals from the general surgeon to a specialist in internal medicine (p = 0.011) or a cardiologist (p = 0.024). The diagnosis was established after computed tomography angiography in 98% of the patients. The overall in-hospital mortality rate was 33%. Attempting intestinal revascularization (n = 43; p < 0.001), with a 95% frequency rate of completion control of the vascular procedure, was associated with a higher survival rate, whereas referral to the cardiologist was associated with a higher mortality rate (p = 0.018). CONCLUSION Elevated TnI was common in acute SMA occlusion, and referral to the cardiologist was found to be associated with adverse outcome. Elevated pancreas amylase and normal plasma lactate values are also potential pitfalls at admission in patients with acute SMA occlusion.
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Affiliation(s)
- Stefan Acosta
- Vascular Center, Malmö University Hospital, Malmö, Sweden
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Björnsson S, Björck M, Block T, Resch T, Acosta S. Thrombolysis for acute occlusion of the superior mesenteric artery. J Vasc Surg 2011; 54:1734-42. [PMID: 21889287 DOI: 10.1016/j.jvs.2011.07.054] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 07/13/2011] [Accepted: 07/13/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND This study evaluated the incidence, complications, and outcome of local intra-arterial thrombolytic therapy for acute superior mesenteric artery (SMA) occlusion in Sweden. METHODS Patients undergoing local intra-arterial thrombolytic therapy for acute SMA occlusion were identified in the Swedish Vascular Registry (SWEDVASC) between 1987 and 2009. Patient data were retrieved in a structured protocol by local vascular surgeons at each participating hospital. RESULTS Included were 34 patients (20 women) from 12 hospitals. Median age was 78 years. The first patient was treated in 1997, and the annual number of patients undergoing thrombolysis increased continuously from 2004 to 2009. Twenty-eight patients (82%) had embolic occlusion. No patients (0%) had acute peritonitis, and one (3%) had bloody stools at admission. Thirty-two patients (94%) were diagnosed by computed tomography with intravenous contrast enhancement. The median dose of alteplase was 20 mg (interquartile range, 11.6-34.0). Successful thrombolysis was achieved in 30 patients (88%). Initial adjunctive aspiration thromboembolectomy was performed in 10 patients. There were six self-limiting bleeding complications; one from the gastrointestinal tract. Thirteen explorative laparotomies, 10 repeat laparotomies, and eight bowel resections were performed. The in-hospital mortality rate was 26% (9 of 34). Age was not associated with in-hospital death (P = .42). Successful thrombolysis was associated with decreased mortality (P = .048). CONCLUSION Local thrombolysis for acute SMA occlusion is a minimally invasive and effective treatment alternative in a select group of patients without peritonitis. The few technique-related complications were mild.
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Mesenteric ischemia. JAAPA 2011; 24:44-8. [DOI: 10.1097/01720610-201107000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Romano N, Prosperi V, Basili G, Lorenzetti L, Gentile V, Luceretti R, Biondi G, Goletti O. Acute thrombosis of the superior mesenteric artery in a 39-year-old woman with protein-S deficiency: a case report. J Med Case Rep 2011; 5:17. [PMID: 21244677 PMCID: PMC3036636 DOI: 10.1186/1752-1947-5-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Accepted: 01/18/2011] [Indexed: 12/24/2022] Open
Abstract
Introduction Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery. Case presentation A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis. Conclusion Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.
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Affiliation(s)
- Nicola Romano
- General Surgery Department, Health Unit Five, "F, Lotti" hospital Pontedera, Pisa, Italy.
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Block TA, Acosta S, Björck M. Endovascular and open surgery for acute occlusion of the superior mesenteric artery. J Vasc Surg 2010; 52:959-66. [PMID: 20620006 DOI: 10.1016/j.jvs.2010.05.084] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 05/09/2010] [Accepted: 05/15/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute thromboembolic occlusion of the superior mesenteric artery (SMA) is associated with high mortality. Recent advances in diagnostics and surgical techniques may affect outcome. METHODS Through the Swedish Vascular Registry (Swedvasc), 121 open and 42 endovascular revascularizations of the SMA at 28 hospitals during 1999 to 2006 were identified. Patient medical records were retrieved, and survival was analyzed with multivariate Cox-regression analysis. RESULTS The number of revascularizations of the SMA increased over time with 41 operations in 2006, compared to 10 in 1999. Endovascular approach increased sixfold by 2006 as compared to 1999. The endovascular group had thrombotic occlusion (P < .001) and history of abdominal angina (P = .042) more often, the open group had atrial fibrillation more frequently (P = .031). All the patients in the endovascular group, but only 34% after open surgery, underwent completion control of the vascular reconstruction (P < .001). Bowel resection (P < .001) and short bowel syndrome (SBS; P = .009) occurred more frequently in the open group. SBS (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.3-5.0) and age (HR, 1.03/year; 95% CI, 1.00-1.06) were independently associated with increased long-term mortality. Thirty-day and 1-year mortality rates were 42% vs 28% (P = .03) and 58% vs 39% (P = .02), for open and endovascular surgery, respectively. Long-term survival after endovascular treatment was better than after open surgery (log-rank, P = .02). CONCLUSION The results after endovascular and open surgical revascularization of acute SMA occlusion were favorable, in particular among the endovascularly treated patients. Group differences need to be confirmed in a randomized trial.
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Affiliation(s)
- Tomas A Block
- Department of Anesthesia and Intensive Care, St Göran Hospital, Stockholm, Sweden.
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Affiliation(s)
- M J Sise
- Department of Surgery, Scripps Health, San Diego, CA, USA.
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Yang HJ, Cho YK, Jo YJ, Jung YY, Choi SA, Lee SH. Successful recanalization of acute superior mesenteric artery thrombotic occlusion with primary aspiration thrombectomy. World J Gastroenterol 2010; 16:4112-4. [PMID: 20731029 PMCID: PMC2928469 DOI: 10.3748/wjg.v16.i32.4112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Prompt revascularization of the superior mesenteric artery (SMA) thrombotic occlusion can prevent intestinal infarction and decrease necrosis of the bowel segment. Herein, we describe two cases who underwent successful endovascular recanalization for acute SMA thrombosis using a primary aspiration thrombectomy because of possible consequent laparotomy for survey of bowel viability. The two patients had dramatic pain relief immediately after the procedure and remained symptom-free during the follow-up period.
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32
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Indications and procedures for second-look surgery in acute mesenteric ischemia. Surg Today 2010; 40:700-5. [DOI: 10.1007/s00595-009-4140-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Accepted: 07/08/2009] [Indexed: 12/11/2022]
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Abstract
Mortality related to acute mesenteric arterial occlusion remains very high. Patient survival is dependent on prompt recognition and revascularization before ischemia progresses to intestinal gangrene. Biphasic computed tomography angiography has surpassed angiography as the diagnostic test of choice due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia. Unlike chronic mesenteric ischemia, the treatment of acute arterial mesenteric ischemia, either embolic or thrombotic, remains largely surgical. This is due to the emergent need for revascularization combined with a careful evaluation of the intestines. Endovascular techniques remain useful, however, and can save precious time in the treatment of these challenging patients if integrated into a treatment pathway combined with definitive surgical treatment. A new hybrid endovascular-surgical treatment for the treatment of acute mesenteric thrombosis is described.
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Affiliation(s)
- Mark C Wyers
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Boston, MA 02215, USA.
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34
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Acute intestinal ischemia—a rare and underestimated complication in thermally injured patients. EUROPEAN JOURNAL OF PLASTIC SURGERY 2010. [DOI: 10.1007/s00238-009-0385-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Mani K, Björck M, Lundkvist J, Wanhainen A. Improved Long-Term Survival After Abdominal Aortic Aneurysm Repair. Circulation 2009; 120:201-11. [DOI: 10.1161/circulationaha.108.832774] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Treatment of abdominal aortic aneurysm (AAA) has changed significantly over the past 2 decades. In this perspective, time trends in long-term survival were studied.
Methods and Results—
We identified 8663 primary intact and 4171 ruptured AAA repairs in the Swedish Vascular Registry from 1987 to 2005. Mortality was obtained from the national population registry. Crude survival was analyzed, including all mortality. To analyze the long-term outcome among those surviving the AAA repair, relative survival, which denotes the survival rate of patients compared with that of the general population adjusted for age, sex, and calendar year, was calculated, excluding 90-day mortality. In a comparison of AAA repairs from 1987 to 1999 and 2000 to 2005, age (71.4 versus 72.5 years;
P
<0.001), patients with comorbidities (65.0% versus 68.5%;
P
<0.001), and endovascular repair (1.6% versus 17.0%;
P
<0.001) increased. After intact AAA repair, crude 5-year survival was 69.0% (99% confidence interval [CI], 67.7 to 70.4), and relative 5-year survival excluding 90-day mortality was 90.3% (99% CI, 88.6 to 92.0). Relative 5-year survival was better for those operated on from 2000 to 2005 compared with 1987 to 1999 (difference, 4.7%; 99% CI, 1.3 to 8.1), for men versus women (4.6%; 99% CI, 0.4 to 8.8), and for octogenarians versus patients <80 years of age (10.2%; 99% CI, 1.5 to 18.8); no difference was observed between open and endovascular repair (6.0%; 99% CI, −1.5 to 13.4). After ruptured AAA repair, crude 5-year survival was 41.7% (99% CI, 39.6 to 43.7) and relative 5-year survival was 87.1% (99% CI, 83.9 to 90.3). No significant differences in relative 5-year survival were observed between time periods, sex, or age groups.
Conclusions—
Long-term survival improved over time after intact AAA repair despite a change in case mix toward older patients with more comorbidities. Long-term survival was stable after ruptured AAA repair.
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Affiliation(s)
- Kevin Mani
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Martin Björck
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Jonas Lundkvist
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
| | - Anders Wanhainen
- From the Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala (K.M., M.B., A.W.), and Medical Management Centre, Karolinska Institutet, Stockholm (J.L.), Sweden
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Gregory O, Ghambir S, Koelmeyer TD. Death by midgut infarction: clinical lessons from 88 post-mortems in Auckland, New Zealand. ANZ J Surg 2009; 79:38-41. [DOI: 10.1111/j.1445-2197.2008.04796.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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External validation of the Swedvasc registry: a first-time individual cross-matching with the unique personal identity number. Eur J Vasc Endovasc Surg 2008; 36:705-12. [PMID: 18851920 DOI: 10.1016/j.ejvs.2008.08.017] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 08/23/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To study external validity of the Swedvasc registry concerning numbers of procedures and mortality. MATERIALS AND METHODS Vascular registry data for carotid, infrainguinal bypass and aortic aneurysm (AAA) procedures were compared to the Swedish Hospital Discharge Register (SHDR) data, and the National Population Registry (for mortality) by matching every individual patient using the unique personal identity numbers (PINs). The time-period studied was 2000-2004 (5 years) for carotid and infrainguinal procedures. A separate analysis was performed for AAA-surgery in 2006. RESULTS The external validity for carotid, infrainguinal bypass and AAA repair was 93.4%, 93.0% and 93.1%, respectively. The 30-day mortality was 0.86% after carotid and 2.9% after infrainguinal bypass procedures. Mortality was 2.6% after planned and 25.9% after unplanned AAA repair. Although there was a general trend towards inferior outcomes after procedures not registered in the Swedvasc, those procedures were so few that in none of the analyses did the inclusion of non-registered procedures affect general outcomes significantly. Combining data from both registries, the incidence for carotid, infrainguinal bypass and AAA procedures was 7.8, 15.2 and 13.6 per 100,000 person-years, respectively. In the hospital-specific analysis for 2006 it was shown that the non-registered procedures for AAA were localized to one non-compliant county hospital, and small district hospitals not performing elective AAA-surgery but only rare emergency operations. CONCLUSION The external and internal validity of the Swedvasc registry allows to confidently assess volumes of, and mortality after, vascular surgery in Sweden.
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Wanhainen A, Mani K, Björck M. The Value of a Nationwide Vascular Registry in Understanding Contemporary Time Trends of Abdominal Aortic Aneurysm Repair. Scand J Surg 2008; 97:142-5. [DOI: 10.1177/145749690809700214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nationwide vascular registries offer rapid feed-back in an environment of fast new technical development, as is the case with the treatment of abdominal aortic aneurysm (AAA). Furthermore, they offer an opportunity to study non-selected, population-based data. The aim of this review was to analyze time-trends in published papers from nationwide registries on AAA-repair. In contrast to several US reports, an increased rate of intact AAA repair, associated with the introduction of endovascular repair, was reported in a recent publication based on the Swedish Vascular Registry (Swedvasc). The rate of ruptured abdominal aortic aneurysm (rAAA) repair is stable in most reports, while some report a decreasing incidence. Most nationwide studies report a reducing mortality over time after intact AAA repair, while time trends on the mortality after ruptured AAA repair are more heterogenic.
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Affiliation(s)
- A. Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - K. Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - M. Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
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Gunduz A, Turedi S, Mentese A, Karahan SC, Hos G, Tatli O, Turan I, Ucar U, Russell RM, Topbas M. Ischemia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study. Am J Emerg Med 2008; 26:202-5. [PMID: 18272103 DOI: 10.1016/j.ajem.2007.04.030] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2007] [Revised: 04/09/2007] [Accepted: 04/11/2007] [Indexed: 01/30/2023] Open
Abstract
Ischemia-modified albumin (IMA) is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, and stroke. However, there are no studies showing whether IMA increases in mesenteric ischemia. The aim of this study was to determine whether IMA was elevated in acute mesenteric ischemia. This case-controlled study was performed in an emergency department of a university hospital. The measurement of IMA levels in patient plasma yielded means of 0.264 +/- 0.057 absorbance units (ABSU) in the thromboembolic occlusion of the superior mesenteric artery (SMA) group and 0.163 +/- 0.025 ABSU in the control group. When plasma IMA levels in the thromboembolic occlusion SMA group were compared with those in the control group, statistically significant increases in IMA were observed in the occlusion group (P = .003). Findings indicating that IMA may have a place in the diagnosis of acute mesenteric embolism were obtained in this preliminary study. Further prospective studies are needed to see if IMA is clinically useful in the early detection of thromboembolic occlusion of the SMA.
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Affiliation(s)
- Abdulkadir Gunduz
- Department of Emergency Medicine, Karadeniz Technical University Faculty of Medicine, 61080 Trabzon, Turkey
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40
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Ravn H, Wanhainen A, Björck M. Risk of new aneurysms after surgery for popliteal artery aneurysm. Br J Surg 2008; 95:571-5. [DOI: 10.1002/bjs.6074] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
The risk of developing a new aneurysm after surgery for popliteal artery aneruysm (PAA) is not well known. The aim was to study this risk in a cohort of patients.
Methods
A total of 571 patients who had primary operation for PAA (717 legs) between 1987 and 2002 were identified from the Swedish Vascular Registry (Swedvasc). Of these, 190 patients were re-examined by ultrasonography after a median of 7 (range 2·9–18·7) years.
Results
The number of patients with at least one aneurysm in addition to the PAA was 108 (56·8 per cent) at the index operation and 131 (68·0 per cent) at re-examination. The overall number of aneurysms increased by 41·8 per cent, from 244 to 346. Among the 82 patients who had an isolated PAA at the index operation, 23 developed a new aneurysm; these patients tended to be older (P = 0·004). Bilateral PAA at the index operation was associated with a later development of abdominal aortic aneurysm (P = 0·004). Age (P = 0·004) and hypertension (P = 0·012) at the time of the index operation were associated with multianeurysm disease at any time. Six (4·3 per cent) of 138 legs treated by venous bypass grafts had developed a graft aneurysm by the time of re-examination. No normal arterial segment developed an aneurysm that required surgery within 3 years.
Conclusion
The development of new aneurysms was common in patients with a PAA; lifelong surveillance may be warranted.
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Affiliation(s)
- H Ravn
- Department of Vascular Surgery, Institution of Surgical Sciences, University Hospital, Uppsala, Sweden
- Department of Surgery, District Hospital, Eksjö, Sweden
| | - A Wanhainen
- Department of Vascular Surgery, Institution of Surgical Sciences, University Hospital, Uppsala, Sweden
| | - M Björck
- Department of Vascular Surgery, Institution of Surgical Sciences, University Hospital, Uppsala, Sweden
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41
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Wanhainen A, Bylund N, Björck M. Outcome after abdominal aortic aneurysm repair in Sweden 1994–2005. Br J Surg 2008; 95:564-70. [DOI: 10.1002/bjs.6109] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim was to study the epidemiology of abdominal aortic aneurysm (AAA) repair in Sweden.
Methods
Primary AAA repairs registered in the Swedish Vascular Registry between 1994 and 2005 were studied. Mortality data were obtained from the national population registry, and age- and sex-specific populations for each calendar year from Statistics Sweden.
Results
Some 10 691 primary AAA repairs were identified. In the population aged 60 years or over the incidence of intact AAA repair increased from 27·0 per 100 000 in 1994–1999 to 28·8 per 100 000 in 2000–2005 (P = 0·006), while the incidence of surgery for ruptured AAA (rAAA) remained stable (13·8 versus 14·1 per 100 000; P = 0·595). Open repair with a bifurcated graft decreased, whereas endovascular repair (EVAR) increased to 35·0 per cent of intact AAA and 10·3 per cent of rAAA procedures in 2005. Patients who had EVAR were older than those undergoing open repair (74·1 versus 71·9 years; P < 0·001). The 30-day mortality rate decreased over time for intact and ruptured aneurysm operations (P = 0·001). Age, female sex and open repair (compared with EVAR) were independently associated with a higher 30-day mortality rate in a logistic regression model.
Conclusion
The introduction of EVAR was associated with an increasing incidence of intact AAA repair, whereas the rate of rAAA was stable. Perioperative mortality rates decreased over time.
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Affiliation(s)
- A Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - N Bylund
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgery, Gävle County Hospital, Gävle, Sweden
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
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42
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Twenty Years with the Swedvasc Registry. Eur J Vasc Endovasc Surg 2008; 35:129-30. [DOI: 10.1016/j.ejvs.2007.11.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Accepted: 11/25/2007] [Indexed: 11/15/2022]
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43
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Galeotti R, Torabi Parizi S, Vasquez G, Zamboni P, Manfredini R, Boari B. Diffuse acute abdominal pain and palpation of the lower limb pulses: what kind of link? Intern Emerg Med 2006; 1:216-7. [PMID: 17120468 DOI: 10.1007/bf02934740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Schneider CG, Zehler O, Kastl S, Izbicki JR. Chirurgisches Konzept bei akuter mesenterialer Ischämie. Visc Med 2006. [DOI: 10.1159/000091944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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45
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Sauerland S, Agresta F, Bergamaschi R, Borzellino G, Budzynski A, Champault G, Fingerhut A, Isla A, Johansson M, Lundorff P, Navez B, Saad S, Neugebauer EAM. Laparoscopy for abdominal emergencies. Surg Endosc 2005; 20:14-29. [PMID: 16247571 DOI: 10.1007/s00464-005-0564-0] [Citation(s) in RCA: 232] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 07/12/2005] [Indexed: 01/10/2023]
Abstract
BACKGROUND Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.
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Affiliation(s)
- S Sauerland
- Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimer Strasse 200, D 51109, Cologne, Germany
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Abstract
BACKGROUND Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. METHODS A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. RESULTS Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. CONCLUSIONS Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.
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Affiliation(s)
- Anthony J Freeman
- Department of Surgery, Lismore Base Hospital, New South Wales, Australia.
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47
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Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M. Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients. Ann Surg 2005; 241:516-22. [PMID: 15729076 PMCID: PMC1356992 DOI: 10.1097/01.sla.0000154269.52294.57] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study findings at autopsy in patients with fatal acute thromboembolic occlusion of the superior mesenteric artery (SMA). SUMMARY BACKGROUND DATA Acute occlusion of the SMA is difficult to diagnose and mortality remains high. In Malmo, Sweden, the autopsy rate between 1970 and 1982 was 87%, creating possibilities for a population-based study. METHODS Among 23,496 clinical autopsies and 7569 forensic autopsies, 213 cases with acute thromboembolic occlusion of the SMA and intestinal infarction were identified. RESULTS A clinical suspicion of intestinal infarction was documented in 32% of the patients, only 35% being in the care of surgeons. The embolus/thrombus ratio was 1.4 to 1. Thrombotic occlusions were located more proximally than embolic occlusions (P < 0.001), intestinal infarction was more extensive (P = 0.025) and thrombotic occlusions were associated with old brain infarction (P = 0.048), aortic wall thrombosis (P = 0.080), and disseminated cancer (P = 0.079). Patients with embolic occlusions (n = 122) had a higher frequency of acute myocardial infarction (AMI) than patients with thrombotic occlusions (P = 0.049). The embolic source was identified in 80%. In 115 (94%), synchronous embolism and/or source of embolus were present. There were findings of remaining cardiac thrombi in 58 (48%) and synchronous emboli affected 273 other arterial segments in 83 (68%). CONCLUSIONS Early recognition and revascularization would have been a prerequisite for survival in at least half of the patients, since the jejunum, ileum, and colon were affected by infarction. A minority of all patients were under surgical care. AMI, cardiac thrombi, and synchronous emboli were common findings among patients with embolic occlusions.
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Affiliation(s)
- Stefan Acosta
- Department of Vascular Surgery, Uppsala University Hospital, Sweden.
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48
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Acosta S, Nilsson TK, Björck M. D-dimer testing in patients with suspected acute thromboembolic occlusion of the superior mesenteric artery. Br J Surg 2004; 91:991-4. [PMID: 15286959 DOI: 10.1002/bjs.4645] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
Background
There is no accurate non-invasive method available for the diagnosis of acute thromboembolic occlusion of the superior mesenteric artery (SMA). The aim of this study was to assess the diagnostic properties of the fibrinolytic marker D-dimer.
Methods
From September 2000 to April 2003 consecutive patients aged over 50 years admitted to hospital with acute abdominal pain were studied. Patients with possible acute SMA occlusion at presentation had blood samples taken within 24 h of the onset of the pain for analysis of D-dimer, plasma fibrinogen, activated partial thromboplastin time, prothrombin time and antithrombin. The value of D-dimer testing to diagnose SMA occlusion was assessed by means of likelihood ratios.
Results
Nine of 101 patients included had acute SMA occlusion. The median D-dimer concentration was 1·6 (range 0·4–5·6) mg/l, which was higher than that in 25 patients with inflammatory disease (P = 0·007) or in 14 patients with intestinal obstruction (P = 0·005). The combination of a D-dimer level greater than 1·5 mg/l, atrial fibrillation and female sex resulted in a likelihood ratio for acute SMA occlusion of 17·5, whereas no patient with a D-dimer concentration of 0·3 mg/l or less had acute SMA occlusion.
Conclusion
D-dimer testing may be useful for the exclusion of patients with suspected acute SMA occlusion.
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Affiliation(s)
- S Acosta
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden.
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49
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Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg 2004; 91:17-27. [PMID: 14716789 DOI: 10.1002/bjs.4459] [Citation(s) in RCA: 289] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Differentiation of acute mesenteric ischaemia on the basis of aetiology is of great importance because of variation in disease progression, response to treatment and outcome. The aim of this study was to analyse the published data on survival following acute mesenteric ischaemia over the past four decades in relation to disease aetiology and mode of treatment. METHOD A systematic review of the available literature from 1966 to 2002 was performed. RESULTS Quantitative analysis of data derived from 45 observational studies containing 3692 patients with acute mesenteric ischaemia showed that the prognosis after acute mesenteric venous thrombosis is better than that following acute arterial mesenteric ischaemia; the prognosis after mesenteric arterial embolism is better than that after arterial thrombosis or non-occlusive ischaemia; the mortality rate following surgical treatment of arterial embolism and venous thrombosis (54.1 and 32.1 per cent respectively) is less than that after surgery for arterial thrombosis and non-occlusive ischaemia (77.4 and 72.7 per cent respectively); and the overall survival after acute mesenteric ischaemia has improved over the past four decades. CONCLUSION There are large differences in prognosis after acute mesenteric ischaemia depending on aetiology. Surgical treatment of arterial embolism has improved outcome whereas the mortality rate following surgery for arterial thrombosis and non-occlusive ischaemia remains poor.
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Affiliation(s)
- I G Schoots
- Department of Surgery and Internal Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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50
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Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M. Incidence of acute thrombo-embolic occlusion of the superior mesenteric artery--a population-based study. Eur J Vasc Endovasc Surg 2004; 27:145-50. [PMID: 14718895 DOI: 10.1016/j.ejvs.2003.11.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the incidence of acute thrombo-embolic occlusion of the superior mesenteric artery (AOSMA) in a population-based study. MATERIAL All clinical (n=23,446) and forensic (n=7569) autopsies performed in the city of Malmö between 1970 and 1982 (population 264,000-230,000 inhabitants). The autopsy rate was 87%. METHODS Calculation of the incidence of AOSMA with intestinal gangrene in those autopsies coded for bowel ischaemia (997/23,446 clinical and 9/7569 forensic autopsies). The operative procedures performed in 1970, 1976 and 1982 were also analysed. RESULTS Two forensic and 211 clinical autopsies demonstrated AOSMA with intestinal gangrene. Previous suspicion of intestinal ischaemia was noted in only 33%. Sixteen patients were operated. The cause-specific mortality was 6.0/1000 deaths. The incidence was 8.6/100,000 person years, increasing exponentially with age (p<0.001). Mortality was 93%. CONCLUSIONS The incidence and mortality of AOSMA is higher than previously reported from clinical series. There is seldom any suspicion of the diagnosis prior to death.
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Affiliation(s)
- S Acosta
- Department of Surgery, Blekinge County Hospital, Karlskrona, Sweden
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