Tips for Managing Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a rare diagnosis that can lead to significant weight loss or present as acute ischemia. Although many patients with this condition are treatable by endovascular means, patient selection and diagnosis can be challenging. In this Q&A, John Angle, MD, Division Director of Vascular and Interventional Radiology at the University of Virginia, shares tips and tricks for managing chronic mesenteric ischemia. He spoke on this topic at the 2019 International Symposium on Endovascular Therapy (ISET) in Hollywood, Florida.

What are some symptoms that can assist in making the diagnosis? 

The classic symptoms are weight loss, fear of eating, and postprandial abdominal pain. In my experience, that combination is uncommon, though some patients will have one or two of these symptoms. Clinical judgment is important in these scenarios, as there may be other explanations for the patient’s pain, and chronic mesenteric ischemia is a rare diagnosis. Not every primary caregiver is comfortable identifying this condition, so getting patients to diagnostic imaging remains a challenge. The presentation of chronic mesenteric ischemia is variable, and there are many potential causes for abdominal pain and weight loss. Fortunately, we have tools such as duplex ultrasound and computed tomography angiography (CTA) to assist in diagnosis and treatment decisions.

What are the challenges of treating treating chronic mesenteric ischemia? 

The biggest challenge for a vascular specialist is figuring out who should be treated. Chronic mesenteric ischemia is a rare diagnosis, which has led to difficulties in standardizing diagnostic testing as well as management.  There are many questionable cases. Many patients are screened with a duplex, which leads to CTA, but neither test is perfect in terms of quantifying whether a lesion is significant. Performing an angiogram and measuring pressures makes it clear which vessels need to be treated. I think we need to be aggressive in performing angiography in these questionable cases, measuring pressure gradients, and treating appropriately.

What are treatment options?

Some patients with mesenteric ischemia are not treatable using endovascular means. Surgery should always be considered in the management of symptomatic occlusions, but in our practice, most short occlusions undergo an initial attempt at endovascular treatment. Our success rates are overall very high, though flush atherosclerotic occlusions of the vessels can be very challenging to cross. Rarely, we can cross a superior mesenteric artery (SMA) occlusion in a retrograde fashion via the celiac and gastroduodenal arteries. There is increasing interest in managing flush SMA-origin occlusions with a hybrid procedure where the SMA is accessed distal to the occlusion, and the lesion is crossed retrograde, so we will continue to increase the percentage of patients that can be managed either either with an endovascular or a hybrid procedure.

With careful case selection, the technical success rate should be 90%. However, some opportunities for success might be missed if all the challenging cases are avoided. Some of the borderline cases are worth taking on because treatment may be successful, and there are few downsides to attempting the procedure. Some flush occlusions, longer occlusions, and very calcified lesions appear intimidating on CT scan but are worth attempting.

What are some indications that a borderline case might be worth attempting an endovascular procedure? 

Cases in which there is a small portion of the proximal SMA to engage and the reconstituted SMA is visible are generally worth trying. Even though the occlusion may appear relatively long, it is often shorter than it seems on CT scan or on angiography. Overall, as long as there is a small portion of the SMA available to engage a catheter, then it is worth attempting the procedure.

Do you have any tips for treating multivessel disease? 

Symptomatic chronic mesenteric ischemia typically involves two vessels, but I find that the SMA is the most important artery to try to revascularize, if at all possible. Even if other vessels are occluded, the patient will often become asymptomatic if just the SMA is opened. The SMA is the key to clinical success. 

Are there any important points to remember when performing the procedure? 

While crossing these lesions is a technical challenge, thrombus and friable plaques present a risk for distal emboli. The role of distal protection is not yet clearly defined. At times, we need to be aggressive with endovascular treatment, but not in cases where the risk of embolus appears high and there is no surgical backup. 

It is also important to use the correct tools. In my practice, we start with a .035-inch system rather than an .018-inch or .014-inch system. I find that an angled tip, hydrophilic, nitinol .035-inch wire crosses aggressively, but remains intraluminal. One of the biggest challenges is ending up in the subintimal space, which is difficult because you need to get back into the true lumen before entering any branches. In the superficial femoral artery, that is often a long distance. The SMA lacks the length necessary to do a re-entry. Also, it is important to avoid creating a dissection out into any branches.

What are some teaching points that you hope people take away from this interview?

As we learned with renal angioplasty many years ago, there is not a role for angioplasty only. The rates of recoil and restenosis are unacceptable. Aortic disease encroaches on the SMA, and that stent extends into the aorta a short distance to have an adequate result.

Another teaching point is that the literature strongly supports using a covered balloon-expandable stent. I think that that is really the go-to device, and there are now three choices on the market. 

Lastly, many celiac lesions represent median arcuate ligament compression. Placing a stent into a compressed celiac will almost always lead to stent fracture, making subsequent recanalization of the celiac artery very difficult.  

Can you describe the post procedure care and follow-up of these patients?

Patients can have reperfusion syndrome, so slowly advancing their diet over at least 24 hours is important. Patients will sometimes have abdominal pain and small amounts of ascites, and these are probably related to reperfusion. 

Long-term follow-up is very important. These patients need to be monitored for life for recurrent stenoses. Depending on the region and practice preferences, that monitoring can be carried out with duplex ultrasound or CTA. With most of these patients, if you have success, it is a dramatic result, and it is a very gratifying procedure. Patients are more than glad to come back and see you for follow-up. n

Disclosure: Dr Angle consults for Proteon Daiichi Sankyo and receives grant/research support from Siemens Medical.