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Minimally Invasive Management of Mesenteric Ischemia: Techniques and Complications

Explore the minimally invasive approaches for chronic and acute mesenteric ischemia, including endovascular and hybrid techniques. Learn about signs, symptoms, and complications of the condition. Case studies provide practical insights.

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Minimally Invasive Management of Mesenteric Ischemia: Techniques and Complications

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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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