History

• The classic description of intestinal angina is abdominal pain that is out of proportion with physical examination.
  
• The hallmark of this condition is disabling midepigastric or central abdominal pain that develops 10-15 minutes after eating.
  
  
  
  • The pain gradually increases in intensity, reaches a plateau, and then slowly decreases in intensity several hours after eating.
    
  • Initially, this pain pattern develops only after large meals, but
    as the disease progresses, even small meals may be poorly tolerated.
    
  </li>
  
• Some patients have associated motility disturbances such as diarrhea or constipation, bloating, or vomiting.
  
• The pain is poorly localized and described as cramplike or a dull
  ache. Occasionally, a patient may have constant or intermittent pain
  that occurs without a clear temporal relationship to eating.
  
• Soon, patients associate eating with pain and develop a
  characteristic fear of food (ie, sitophobia) or food-avoidance
  behavior. In several clinical series, reported weight loss averages
  15-25 lb.
  
• The constellation of abdominal pain, weight loss, and an average
  age of 60 years commonly leads to a presumed diagnosis of malignancy
  and a protracted workup. Because none of the usual contrast studies or
  endoscopies performed in the course of a workup for malignancy are
  diagnostic, considerable delay in diagnosis typically results. In
  several series, the reported delay averages 16-18 months.
  
• If patients have multiple risk factors for atherosclerotic
  occlusive disease, a heightened clinical suspicion for this diagnosis
  shortens the typical delay in diagnosis.
  
• A history of peripheral vascular disease is common. As with other
  vasculopathies, individuals who smoke predominate in all series.
  
• Although diabetes occurs in all series, it is uncommon in patients
  with this syndrome (in contrast to most other vascular problems).
  
• Occasionally, a patient presents with a duodenal or gastric ulcer (which may be Helicobacter pylori negative) or with ischemic colitis.
  
• Ischemic pancreatitis also may occur and is associated with
  epigastric pain. Laboratory studies reveal mildly elevated amylase and
  lipase. Steatorrhea may be observed.
  

Physical

• Physical examination reveals stigmata of weight loss. The
  abdomen typically is scaphoid and soft, even during an episode of pain.
  
• In one series, approximately 10% of patients had positive test results for guaiac.
  
• Abdominal bruit is present in 60-90% of patients, but this is
  common in many elderly persons who are not affected by this syndrome.
  
• Signs of peripheral vascular disease, particularly aortoiliac occlusive disease, may be present.
  

Causes

• Smoking is an associated risk factor. In most series, approximately 75-80% of patients smoke
  
• Differential Diagnoses
  
  Other Problems to Be Considered
  
  Many patients initially are assumed to have cancer. The constellation
  of weight loss, abdominal pain, and an age of older than 60 years
  leads to a workup with GI contrast studies, CT scans, and other
  diagnostic tests related to malignancy, none of which are diagnostic
  for chronic mesentric vascular disease.
  Workup
  Laboratory Studies
  
• No laboratory tests are diagnostic.
  
• Patients with ischemic pancreatitis may have elevated amylase or lipase levels.
  

Imaging Studies

• Biplane aortography still is the criterion standard test.
  Because the vessels emerge from the anterior wall of the aorta, the
  ostia are visualized only on a lateral view, as depicted below.
  
  
• </li>
  
• A
  lateral aortogram shows abrupt cutoffs at the origin of the
  visceral vessels and a tapered occlusion of the distal aorta.
  Because these vessels originate from the anterior surface of the
  aorta, stenoses and occlusions are not observed clearly on standard
  anteroposterior views.
  
  
  
• </li>
  
• A
  lateral aortogram shows abrupt cutoffs at the origin of the
  visceral vessels and a tapered occlusion of the distal aorta.
  Because these vessels originate from the anterior surface of the
  aorta, stenoses and occlusions are not observed clearly on standard
  anteroposterior views.
  
• A meandering mesenteric artery, shown below, is another clue. In
  addition to demonstrating the level of stenosis or occlusion of the
  mesenteric vessels, angiography findings also help plan the operative
  approach by delineating the anatomy of the supraceliac and infrarenal
  abdominal aorta.
  
  
• This
  arteriogram illustrates a meandering mesenteric artery. The
  appearance of a meandering mesenteric artery such as this one
  supports the diagnosis of chronic mesenteric ischemia.
  
  This
  arteriogram illustrates a meandering mesenteric artery. The
  appearance of a meandering mesenteric artery such as this one
  supports the diagnosis of chronic mesenteric ischemia.
  
• Hydrating the patient well before angiography is extremely
  important, not only to avoid renal toxicity but also because visceral
  infarction may be precipitated by the injection of contrast.
  
• Duplex ultrasonographic examination is emerging as a useful
  screening modality. It currently is most useful in patients in whom
  the diagnosis is suspected. If the duplex examination is positive,
  angiography is performed.^2,3
  
• Indices that are studied include the following:
  
  
  
  • Peak systolic flow is increased if a stenosis is present.
    
  • When an increase is expected, a change in flow velocities occurs
    in response to feeding, unless a flow-limiting stenosis is present.
    
  • Perform a spectral analysis of Doppler frequencies.
    
  </li>
  
• Magnetic resonance angiography has been used as an alternative to
  aortography in patients who have contrast sensitivity or who are at
  risk for contrast-related renal dysfunction. It is emerging as an
  excellent diagnostic modality due to its ability to delineate the
  anatomy. It also is a useful experimental tool for studying metabolic
  parameters.
  

Other Tests

• Because most of these patients have generalized vascular
  disease, performing a cardiovascular evaluation prior to surgery is
  prudent.
  

Related Subject

New Coma Scale Detects More Wakefulness in Some Patients
Epilepsy: A Comprehensive Textbook (3-volume set)
Vascular Surgery. Springer Specialist Surgery Series 2010
Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment (Contempor
Haimovici's Vascular Surgery, 5th Edition
Vascular Complications in Human Disease: Mechanisms and Consequences
Intracranial Pressure and Brain Monitoring XIII: Mechanisms and Treatment 2010

Treatment
Medical Care
No effective medical therapy exists. Percutaneous transluminal
angioplasty (PTA) may be an alternative therapy for selected patients.
Currently, the most common indication for treatment of stenoses or
occlusions of mesenteric vessels is the presence of symptoms related to
intestinal ischemia. In the absence of sufficient data on the natural
history of mesenteric arterial stenosis, the presence of asymptomatic
disease does not constitute an indication for treatment. In the only
study reporting the clinical course of patients with asymptomatic
stenosis of mesenteric vessels, Thomas and colleagues reviewed 980
aortograms and identified 15 patients with stenosis of all 3 mesenteric
vessels, only 4 of whom developed symptoms. ^4,5
Surgical Care
Mesenteric revascularization relieves the symptoms of abdominal angina
and may prevent intestinal infarction. Classically, the operation for
relieving the symptoms of abdominal angina includes thrombectomy
(removal of the obstructing lesion) and/or bypass of the obstructed
portion of the blood vessel with an endogenous or prosthetic vascular
conduit. Because atherosclerosis involves systemic circulation,
generally all 3 blood vessels (celiac artery, superior mesenteric
artery, inferior mesenteric artery) are involved. Typically, patients
become symptomatic only when all 3 blood vessels are severely narrowed
by atherosclerosis. Relieving the symptoms of abdominal angina requires
revascularization of at least 2 of the 3 blood vessels. With the
advent of modern endovascular surgery, many new techniques have emerged
as possible alternatives to bypass surgery. Its less invasive nature
makes endovascular surgery ideal for patients with multiple
comorbidities, who may be at high risk for complications from open
surgery.
When endovascular surgery for mesenteric revascularization is
performed, the patient is placed on a fluoroscopy table and sedated by
the anesthesiologist. Generally, most of these procedures do not
require general anesthesia. Bilateral groins are prepped and draped in
standard surgical fashion, the femoral pulse is palpated, and a needle
is inserted into the artery. Using the Seldinger technique, a guide
wire is inserted through the needle, and its position is checked with
fluoroscopy. The artery is dilated, and sheaths are left in place. An
appropriate catheter is introduced through the sheath, and an angiogram
is performed.⁶ Below is a more detailed description of endovascular surgery.

Endovascular surgery
First, an aortogram is performed, and the origins of the celiac,
superior mesenteric, and inferior mesenteric arteries are visualized.
The left anterior oblique view is best for visualizing the origins of
the celiac and superior mesenteric arteries. Once a narrowed artery is
identified, a guide wire is passed through the catheters, and an
attempt is made to pass the wire across the narrowed portion of the
artery under direct fluoroscopy. Once the wire is passed across the
stenotic area, the artery's narrowed portion can be dilated with a
dilator, and a balloon angioplasty is performed.

If residual stenosis after the angioplasty is more than 50% of the expected artery luminal, it is advisable to place a stent⁷ across
the narrowed portion of the blood vessel. After stent placement, an
angiogram is performed to determine whether there has been a complete
resolution of stenosis. If resolution has occurred, the catheters and
sheaths can be removed. The arteriotomy site in the femoral arteries can
be closed by various commercially available endovascular devices or by
open surgical techniques. After the completion of the procedure,
patients are started on a clear liquid diet, with the diet advanced as
tolerated.
Potential complications of endovascular mesenteric revascularization
procedures are dissection of mesenteric arteries (which necessitates
conversion to open surgery), rupture of mesenteric arteries (small
areas of perforation can be covered by stent grafts, but larger areas
of perforation require open surgery), embolization of atherosclerotic
plaques (which can lead to gangrene of the small/large bowel), groin
hematoma (which necessitates performing duplex ultrasonography to rule
out pseudoaneurysm of the common femoral artery), and acute limb
ischemia (from embolization of atherosclerotic plaques to the
extremity).

Open surgery
Lesions that are not amenable to endovascular management are dealt with
through open surgical technique. The surgery is performed under
general anesthesia, the patient’s abdomen is prepped and draped, and a
midline incision is made from xiphoid to pubic tubercle. Skin,
subcutaneous tissue, and anterior rectus fascia are divided, and the
peritoneal cavity is then entered. The transverse colon is reflected
upwards, and the middle colic artery is identified and traced back to
the origin of the superior mesenteric artery. Proximal and distal
control of the superior mesenteric artery is obtained and an
arteriotomy is performed to open the artery, followed by embolectomy
and removal of atherosclerotic plaques.
There are 2 types of arteriotomy that can be performed: transverse and
longitudinal. Transverse arteriotomy can be closed primarily, but for
longitudinal arteriotomies, a vein patch closure is preferred to avoid
residual stenosis of the artery. Other surgical options include the
following:

• Antegrade bypass: A vascular conduit is used to bypass the
  stenosed area of the mesenteric vessel. Inflow is from the supraceliac
  aorta. Unlike other vascular bypasses, where native vein is the
  preferred conduit, prosthetic grafts are more suitable for mesenteric
  revascularization. (See first 3 images below.)
  
• Retrograde bypass: In this bypass, inflow for the conduit comes
  from the distal, nondiseased portion of the aorta or common iliac
  arteries.
  

The celiac artery is exposed at its origin in preparation for antegrade bypass.

[ CLOSE WINDOW ]<blockquote></blockquote>The celiac artery is exposed at its origin in preparation for antegrade bypass.
The superior mesenteric artery and several branches are exposed for antegrade bypass.
[ CLOSE WINDOW ]<blockquote></blockquote>The superior mesenteric artery and several branches are exposed for antegrade bypass.
This
photo shows an antegrade bypass from the aorta to the superior
mesenteric artery and the celiac artery (superior mesenteric artery
anastomosis is shown) using a Dacron graft.

[ CLOSE WINDOW ]<blockquote></blockquote>This
photo shows an antegrade bypass from the aorta to the superior
mesenteric artery and the celiac artery (superior mesenteric artery
anastomosis is shown) using a Dacron graft.
This
operative photograph shows a completed retrograde bypass to the
superior mesenteric artery using ePTFE graft material. Photograph
courtesy of Jamal Hoballah, MD, University of Iowa College of
Medicine.

[ CLOSE WINDOW ]<blockquote></blockquote>This
operative photograph shows a completed retrograde bypass to the
superior mesenteric artery using ePTFE graft material. Photograph
courtesy of Jamal Hoballah, MD, University of Iowa College of
Medicine.

Classic surgical operations have excellent outcomes. Possible
complications include embolization of atherosclerotic plaques, leading
to gangrenous bowel, wound infection, and damage to native
aorta/iliac arteries.

• Intraoperative duplex ultrasonographic examination is performed
  to confirm the technical adequacy of the revascularization, as shown
  below.
  This completion duplex ultrasonographic study shows excellent flow at the distal anastomosis.
  
  [ CLOSE WINDOW ]<blockquote></blockquote>This completion duplex ultrasonographic study shows excellent flow at the distal anastomosis.
  
• Controversies in surgical treatment include the following:
  
  
  
  • Antegrade bypass versus transaortic endarterectomy versus retrograde bypass
    
  • The role of duplex ultrasonography in follow-up
    
  • The role of magnetic resonance imaging (MRI) in follow-up
    
  • The management of asymptomatic occlusion detected at follow-up
    
  • The best material for bypass, ie, vein or prosthetic graft
    
  </li>
  
• The specific approach to surgical reconstruction, ie, bypass
  versus endarterectomy (shown below), depends on the location and number
  of stenoses, previous surgeries, patient comorbidities, and local
  operative conditions. Because patency and the rates of morbidity and
  mortality are similar for both types of surgery, the authors prefer to
  individualize each patient, applying the technique best suited to the
  circumstances. Follow-up of patients with duplex ultrasonography is
  performed yearly for the first several years. Asymptomatic occlusions
  are followed expectantly. Most patients succumb to other atherosclerotic
  comorbidities before developing symptomatic restenoses or occlusions.
  However, if a restenosis is identified, it is treated based on the
  same criteria as the original lesion.
  This
  diagram shows the possible incision for a trapdoor aortotomy.
  Plaque at the orifices of the visceral vessels is removed after the
  trapdoor incision is lifted. When a satisfactory endarterectomy has
  been achieved, the trapdoor is sutured shut.
  <blockquote></blockquote>This
  diagram shows the possible incision for a trapdoor aortotomy.
  Plaque at the orifices of the visceral vessels is removed after the
  trapdoor incision is lifted. When a satisfactory endarterectomy has
  been achieved, the trapdoor is sutured shut.
  

Diet

• Although most of these patients are cachectic, preoperative
  central venous nutrition has not been shown to decrease complications
  and is employed only selectively.
  
• No particular dietary restrictions are associated with the surgery.
  After adequate surgical correction, patients may resume the usual
  diet for their particular underlying medical condition (if any).
  

Further Inpatient Care

• Intraoperative considerations
  
  
  
  • Cardiac monitoring with transesophageal echo or invasive monitoring may be needed.
    
  • Intraoperative duplex ultrasonographic examination of the reconstruction is important.
    
  </li>
  
• Postoperative care and complications
  
  
  
  • Most patients require monitoring in an intensive care unit. Postoperative ileus is common.
    
  • In addition to the usual cardiac problems traditionally associated
    with major vascular repairs, major postoperative complications include
    bleeding and coagulopathy, pulmonary insufficiency, and hepatic and
    renal failure.
    
  • In multiple studies, a picture similar to multiorgan dysfunction
    occurs in a small but significant minority of patients. Reperfusion
    injury has been hypothesized to trigger this cascade of events.
    Immediate pronounced hepatocellular dysfunction has been noted as an
    early event in some of these cases.
    
  • In one series, coronary artery disease and chronic renal
    insufficiency prior to surgery were associated with postoperative
    complications.
    
  
  </li>
  

Further Outpatient Care

• Duplex ultrasonography and MRI have been used for follow-up,
  but because the proper management of an asymptomatic occlusion of a
  reconstruction is unknown, this generally is not recommended.
  

Complications

• .
  

Prognosis

• The literature describes good early clinical results after
  surgical revascularization, and this treatment remains the criterion
  standard.⁸
  
• Reocclusion is more prevalent in males than in females (in contrast to the female predominance noted at initial presentation).
  
• Several series have demonstrated that 86-96% of patients remain
  asymptomatic at 5 and 10 years, with similar graft patency rates.
  
• Research suggests that subsequent to endovascular treatment,
  symptom relief is immediate in 85% of patients, with 75% of patients
  remaining symptom-free beyond 1 year. An overall morbidity rate of
  30.8% has been reported, as has an inhospital/30-day mortality rate of
  7.7%. The most common complication has been reported to be access site
  hematoma/pseudoaneurysm/thrombosis (15.4%), followed by bowel
  infarction (4.6%). In a study of 65 patients, all deaths occurred ≤60
  days after treatment. ⁹
  

Patient Education

• Patients should be counseled to stop smoking.
  

Related Subject

New Coma Scale Detects More Wakefulness in Some Patients
Epilepsy: A Comprehensive Textbook (3-volume set)
Vascular Surgery. Springer Specialist Surgery Series 2010
Asymptomatic Atherosclerosis: Pathophysiology, Detection and Treatment (Contempor
Haimovici's Vascular Surgery, 5th Edition
Vascular Complications in Human Disease: Mechanisms and Consequences
Intracranial Pressure and Brain Monitoring XIII: Mechanisms and Treatment 2010

(Enlarge Image)

Media file 1: The superior mesenteric artery and inferior mesenteric artery share collateral circulation near the splenic flexure of the colon. When dilated, this vessel is termed the meandering mesenteric artery. As seen on an angiogram, this is a sign of chronic mesenteric ischemia.

[ CLOSE WINDOW ]

The
superior mesenteric artery and inferior mesenteric artery share
collateral circulation near the splenic flexure of the colon. When
dilated, this vessel is termed the meandering mesenteric artery. As
seen on an angiogram, this is a sign of chronic mesenteric ischemia.

(Enlarge Image)

Media file 2: The pancreaticoduodenal arcades are collateral pathways between the celiac artery and the superior mesenteric artery.

[ CLOSE WINDOW ]

The pancreaticoduodenal arcades are collateral pathways between the celiac artery and the superior mesenteric artery.

(Enlarge Image)

Media file 3: A lateral aortogram shows abrupt cutoffs at the origin of the visceral vessels and a tapered occlusion of the distal aorta. Because these vessels originate from the anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.

[ CLOSE WINDOW ]

A
lateral aortogram shows abrupt cutoffs at the origin of the
visceral vessels and a tapered occlusion of the distal aorta.
Because these vessels originate from the anterior surface of the
aorta, stenoses and occlusions are not observed clearly on standard
anteroposterior views.

(Enlarge Image)

Media file 4: This arteriogram illustrates a meandering mesenteric artery. The appearance of a meandering mesenteric artery such as this one supports the diagnosis of chronic mesenteric ischemia.

[ CLOSE WINDOW ]

This
arteriogram illustrates a meandering mesenteric artery. The
appearance of a meandering mesenteric artery such as this one
supports the diagnosis of chronic mesenteric ischemia.

(Enlarge Image)

Media file 5: The celiac artery is exposed at its origin in preparation for antegrade bypass.

[ CLOSE WINDOW ]

The celiac artery is exposed at its origin in preparation for antegrade bypass.

()	Media file 6: The superior mesenteric artery and several branches are exposed for antegrade bypass.

[ CLOSE WINDOW ]

The superior mesenteric artery and several branches are exposed for antegrade bypass.

(Enlarge Image)

Media file 7: This photo shows an antegrade bypass from the aorta to the superior mesenteric artery and the celiac artery (superior mesenteric artery anastomosis is shown) using a Dacron graft.

[ CLOSE WINDOW ]

This
photo shows an antegrade bypass from the aorta to the superior
mesenteric artery and the celiac artery (superior mesenteric artery
anastomosis is shown) using a Dacron graft.

(Enlarge Image)

Media file 8: This operative photograph shows a completed retrograde bypass to the superior mesenteric artery using ePTFE graft material. Photograph courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.

[ CLOSE WINDOW ]

This
operative photograph shows a completed retrograde bypass to the
superior mesenteric artery using ePTFE graft material. Photograph
courtesy of Jamal Hoballah, MD, University of Iowa College of
Medicine.

(Enlarge Image)

Media file 9: This diagram shows the possible incision for a trapdoor aortotomy. Plaque at the orifices of the visceral vessels is removed after the trapdoor incision is lifted. When a satisfactory endarterectomy has been achieved, the trapdoor is sutured shut.

[ CLOSE WINDOW ]

This
diagram shows the possible incision for a trapdoor aortotomy.
Plaque at the orifices of the visceral vessels is removed after the
trapdoor incision is lifted. When a satisfactory endarterectomy has
been achieved, the trapdoor is sutured shut.

(Enlarge Image)

Media file 10: This completion duplex ultrasonographic study shows excellent flow at the distal anastomosis.

[ CLOSE WINDOW ]

This completion duplex ultrasonographic study shows excellent flow at the distal anastomosis.

(Enlarge Image)

Media file 11: Upper gastrointestinal series (barium swallow) shows an ulcer.