What is the treatment for inferior mesenteric artery occlusion?

Treatment for Inferior Mesenteric Artery Occlusion

For inferior mesenteric artery occlusion, endovascular therapy should be considered as first-line treatment for revascularization, with open surgery reserved for cases where endovascular approaches fail or when signs of bowel infarction are present. 1

Diagnostic Approach

Before treatment, proper diagnosis is crucial:

1. Urgent CTA (Computed Tomography Angiography)

   • Recommended as the first-line diagnostic tool 1
   • Should be performed with arterial and venous phases using 1mm slices
   • Has excellent diagnostic accuracy with 94% sensitivity and 95% specificity 1
   • Specifically ask radiologists to evaluate mesenteric arteries

2. D-dimer measurement

   • Should be considered to help rule out the diagnosis 1
   • High sensitivity (96%) but low specificity (40%) 1

3. Warning signs of bowel infarction on imaging

   • Wall thickening, dilatation, intestinal pneumatosis
   • Portal venous air, peritoneal fluid
   • These findings indicate urgent surgical intervention rather than endovascular approaches 1

Treatment Algorithm

Acute Occlusion

1. Endovascular Therapy (First-Line)

   • Recommended for thrombotic occlusion of mesenteric arteries 1
   • Options include:
     • Aspiration embolectomy for embolic occlusions 1
     • Thrombolysis for appropriate cases 1
     • Percutaneous transluminal angioplasty with stenting (PTA/S) 1
     • Catheter-directed vasodilator infusion for associated vasospasm 1

2. Open Surgery

   • Reserved for when endovascular therapy fails or is not feasible 1
   • First choice when signs of bowel infarction are present (peritonitis, pneumoperitoneum, intramural air) 1
   • May include embolectomy, bypass, or endarterectomy

3. Benefits of Endovascular Approach

   • Decreased amount of bowel resection 1
   • Lower incidence of concomitant renal or respiratory failure 1
   • Lower subsequent incidence of short bowel syndrome 1
   • Lower mortality compared to open surgery 1

Chronic Mesenteric Ischemia with IMA Occlusion

1. Endovascular Therapy

   • Angioplasty and stenting have become the first option 1
   • Can be successful even for isolated IMA revascularization in selected cases 2
   • Consider revascularizing multiple vessels when feasible 3

2. Open Surgical Bypass

   • Reserved for failed endovascular therapy 1
   • Offers improved patency and lower re-intervention rates 1
   • Better freedom from recurrent symptoms long-term 1

Special Considerations

• Nonocclusive Mesenteric Ischemia (NOMI)

  • If vasospasm is present, intra-arterial vasodilator therapy is recommended 1
  • Options include nitroglycerin, papaverine, or glucagon 1
  • High-dose intravenous prostaglandin E1 may be equally effective 1

• Collateral Circulation

  • When superior mesenteric artery (SMA) and celiac artery are occluded, the IMA may become a critical vessel for visceral circulation 2, 4, 5
  • In such cases, IMA revascularization becomes particularly important

• Timing of Intervention

  • Early diagnosis and treatment (within 4-6 hours of symptom onset) are critical to improve outcomes 6
  • Delayed revascularization is associated with clinical deterioration, bowel infarction, and sepsis 1

Pitfalls and Caveats

• Elevated creatinine levels should not contraindicate CTA when mesenteric ischemia is suspected 1
• The inability to confidently exclude bowel infarction has limited widespread use of thrombolysis 1
• When both SMA and celiac artery are occluded, the IMA becomes critically important and its revascularization should be prioritized 2, 4
• Endovascular treatment has higher recurrence rates and may require more frequent reinterventions compared to open surgery 1
• Complications of endovascular treatment include distal embolization, branch perforation, dissection, stent dislodgement, and stent thrombosis 1