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Mesenteric Ischemia: A Minimally Invasive Approach

Mesenteric Ischemia: A Minimally Invasive Approach. Danielle Pineda, MD April 7, 2017. Chronic Mesenteric Ischemia. Rare Disease Accounts for less than 2% of all hospital admissions for GI conditions -But atherosclerosis of mesenteric vessels much more prevalent (usually asymptomatic).

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Mesenteric Ischemia: A Minimally Invasive Approach

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

  2. Chronic Mesenteric Ischemia

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

  4. Rutherford 8th Edition

  5. FOOD FEAR • Pain after meals (30 mins on average) • Weight loss • Avoiding meals Pre-operative Necessities • Endoscopy • Colonoscopy • CT scan

  6. Endovascular Approach Options

  7. Technique • Femoral or brachial approach • Lateral position for C-arm • Cross atherosclerotic lesion • May need to pre-dilate with angioplasty and place sheath through stenosis • Balloon-expandable Stent versus stent graft • SMA preferential vessel although can also treat celiac/IMA in higher risk patients

  8. Complications • Cardiac events (patients high risk secondary to atherosclerosis) • GI bleeding • Embolus/dissection leading to bowel ischemia • Access related problems (especially brachial) • Renal failure

  9. Hybrid Approach • Midline laparotomy • Micropuncture access of the SMA • Cross stenosis/occlusion in retrograde fashion • Balloon expandable stent or stent graft • Transverse closure or patch closure

  10. Acute Mesenteric Ischemia

  11. Multiple Causes • Arterial emboli • 40-50% of cases • Intracardiac mural thrombus, endocarditis, proximal thoracic aortic aneurysms • Arterial thrombosis • 20-35% of cases • Preexisting atherosclerosis – acute on chronic picture • Nonocclusive Mesenteric Ischemia • Mesenteric Venous Thrombosis

  12. Signs and Symptoms • Pain out of proportion to exam • Pneumatosis on CT scan • Elevated WBC, lactate

  13. Endovascular Approach Options

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

  15. Case 1 • 80 yo F with history of supraceliac aorta to celiac and SMA bypass • Represents with weight loss and post-prandial pain

  16. Occluded bypass Celiac artery stenosis

  17. Questions???

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