What is the management of the superior mesenteric artery (SMA)?

From the Guidelines

The management of superior mesenteric artery (SMA) occlusion should prioritize endovascular interventions, such as aspiration embolectomy, as the initial treatment approach to rapidly restore inline arterial flow and minimize morbidity and mortality. This recommendation is based on the most recent and highest quality study available, which suggests that endovascular interventions are associated with lower rates of mortality and bowel resection compared to traditional open surgery 1.

Key Considerations

• The primary goal of treatment is to restore blood flow to the affected bowel as quickly as possible to prevent ischemic damage and necrosis.
• Endovascular interventions, including aspiration embolectomy and transcatheter thrombolysis, have been shown to be effective in achieving this goal with high technical success rates 1.
• While surgical intervention may still be necessary in some cases, particularly for bowel resection or diversion, a multidisciplinary approach that prioritizes endovascular interventions can help minimize the need for surgery and improve patient outcomes 1.
• The use of a focused care bundle and a multidisciplinary team in a dedicated center can also improve outcomes by reducing delays and increasing the number of revascularizations 1.

Treatment Approach

• Initial treatment should focus on volume resuscitation, empiric antibiotic therapy, and anticoagulation to prevent further thromboembolic events.
• Endovascular interventions, such as aspiration embolectomy, should be performed as soon as possible to restore blood flow to the affected bowel.
• Surgical intervention should be reserved for cases where endovascular interventions are not possible or have failed, or where bowel resection or diversion is necessary.
• Patients undergoing revascularization should have surveillance imaging and long-term anticoagulation to prevent relapse and stent or graft restenosis 1.

From the Research

Superior Mesenteric Artery Management

• The management of superior mesenteric artery (SMA) occlusion or stenosis involves various treatment options, including endovascular recanalization and stenting, aspiration embolectomy, thrombolysis, and open surgical embolectomy 2.
• Endovascular therapy has become an important alternative, especially in patients with both acute and chronic thrombotic SMA occlusion, and may be preferred in elderly and fragile patients 2.
• Percutaneous transluminal angioplasty with stent implantation has been successfully used to treat acute embolism of the SMA and significant stenosis of the celiac trunk 3.
• A multimodal and multidisciplinary approach, combining the use of a systematic medical protocol, early revascularization of viable bowel, and resection of non-viable bowel when needed, has dramatically improved the prognosis of acute mesenteric ischemia (AMI), with current survival rates of 80% and bowel resection being avoided in nearly two-thirds of patients 4.
• Covered stenting of the SMA has been recommended by expert centers and provides satisfactory midterm results in patients with mesenteric occlusive disease, with an excellent primary assisted patency rate at 2 years 5.

Diagnostic Modalities

• Computed tomography (CT) is a standard tool for diagnosing SMA syndrome and can be used to evaluate the extent of mesenteric ischemia 2, 3, 6.
• Ultrasonography has advantages in safety and capability of real-time assessments of SMA mobility and duodenum passage, and can be used as a diagnostic modality for SMA syndrome 6.
• CT angiogram can be urgently performed in cases of clinically suspected AMI to confirm the diagnosis 4.

Treatment Options

• Conservative treatment, including postural change, gastroduodenal decompression, and nutrient management, is usually the initial treatment for SMA syndrome, with success rates of 70%-80% 6.
• Surgical treatment, such as laparoscopic duodenojejunostomy, is recommended if conservative therapy fails, with success rates of 80%-100% 6.
• Endovascular therapy, including percutaneous transluminal angioplasty and stent implantation, can be used to treat acute embolism of the SMA and significant stenosis of the celiac trunk 3.