From the Guidelines
The treatment approach for chronic mesenteric ischemia primarily involves endovascular revascularization as the first-line intervention for most patients, due to its lower perioperative risks and complications compared to open surgical intervention. This approach is supported by recent guidelines and studies, including the 2022 update of the ACR Appropriateness Criteria for radiologic management of mesenteric ischemia 1. Endovascular procedures, such as angioplasty with stenting of the affected mesenteric arteries, offer a minimally invasive option with faster recovery times.
The key benefits of endovascular therapy include:
- Lower procedural risks and complications compared to open surgery 1
- Shorter hospital admissions 1
- Faster recovery times
- Effective in restoring blood flow to the intestines
Open surgical revascularization, such as mesenteric artery bypass or endarterectomy, is typically reserved for patients with:
- Extensive disease
- Failed endovascular treatment
- Anatomy unsuitable for stenting
Before revascularization, patients should receive:
- Antiplatelet therapy (aspirin 81-325 mg daily)
- Statins to reduce cardiovascular risk Nutritional support is also crucial, with small, frequent meals recommended to minimize postprandial pain. Following revascularization, patients require long-term antiplatelet therapy and regular follow-up with duplex ultrasound to monitor for restenosis. Risk factor modification is essential, including smoking cessation, blood pressure control, diabetes management, and lipid management. These interventions are necessary because chronic mesenteric ischemia results from progressive atherosclerotic narrowing of the mesenteric vessels, leading to inadequate blood flow during increased intestinal demand, particularly after meals.
From the Research
Treatment Approaches for Chronic Mesenteric Ischemia
- Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization or with angioplasty and stenting 2.
- Surgical revascularization has better success and patency rates but also a higher short- and midterm mortality and morbidity, especially in patients at high surgical risk 2.
- Endovascular treatment appears safe and effective in selected patients, with lower perioperative complication rates compared to surgery in patients at high surgical risk 2, 3.
Comparison of Open and Endovascular Revascularization
- Open surgical revascularization (OR) is still predominantly used, but endovascular revascularization (ER) has recently gained popularity as an alternative modality of treatment 4.
- Patients who underwent ER had lower postoperative mortality and morbidity, and shorter intensive care unit and hospital stay, but higher restenosis rate compared to OR 4.
- ER is preferable for unfit patients or those with short life expectancy, while OR is recommended for patients who are fit or whose fitness could be improved before surgery 4, 5.
Endovascular Treatment Outcomes
- Endovascular intervention is considered the first-line treatment for CMI when feasible, especially in patients with occlusive superior mesenteric artery lesions 6.
- SMA revascularization appears to be the key determinant for symptomatic outcomes and repeat intervention in patients with CMI and occlusive SMA lesions 6.
- Patient counseling should include potential future need for surgical revascularization if endovascular SMA treatment cannot be accomplished 6.
Key Considerations
- The choice of treatment approach depends on the patient's overall health, comorbidities, and the severity of the disease 2, 3, 4, 5, 6.
- A multidisciplinary approach, involving vascular surgeons, interventional radiologists, and other specialists, is essential for optimal management of CMI 2, 3, 4, 5, 6.