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Acute mesenteric ischemia

What's new

The European Society for Vascular Surgery (ESVS) has published updated guidelines on the management of acute mesenteric ischemia (AMI). Urgent computed tomography angiography (CTA) with contrast enhancement in arterial and venous phases using ≤1 mm slices (with optional non-contrast CT) is recommended in cases of suspected AMI, regardless of renal function. A single measurement of a biomarker such as lactate or D-dimer is not recommended to confirm or exclude the diagnosis of AMI. Revascularization before bowel resection is suggested in the management of AMI. Endovascular revascularization is recommended as the first-line treatment for thrombotic or embolic superior mesenteric artery occlusion. Retrograde open mesenteric artery stenting may be considered when percutaneous stenting is not feasible. In patients undergoing acute mesenteric revascularization who require bowel resection, resection without primary reconstruction and a planned second-look laparotomy should be considered for definitive management. .

Background

Overview

Definition
AMI is a sudden interruption of blood flow to the small intestine, leading to ischemia and potential tissue death.
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Pathophysiology
The pathophysiology of AMI can be categorized into four types based on the clinical scenario and risk factors: mesenteric arterial embolism, mesenteric arterial thrombosis, non-occlusive mesenteric ischemia, and mesenteric venous thrombosis.
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Epidemiology
The incidence of AMI in Finland is estimated at 2 per 100,000 person-years. It is reported to account for 0.01% of hospital admissions in the US and 1% of acute abdomens in Germany.
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Disease course
Clinically, it often presents with severe abdominal pain, nausea, vomiting, and bloody diarrhea. Patients may also exhibit signs of a systemic inflammatory response, including fever and tachycardia.
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Prognosis and risk of recurrence
The prognosis is often poor, with a mortality rate reaching up to 80%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute mesenteric ischemia are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2025,2017), the European Society of Cardiology (ESC 2024), the World Society of Emergency Surgery (WSES 2022), the American Association for the Study of Liver Diseases (AASLD 2021), the American College ...
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Screening and diagnosis

Diagnosis
As per WSES 2022 guidelines:
Suspect AMI in patients with severe abdominal pain out of proportion to physical examination until disproven.
B
Suspect non-occlusive mesenteric ischemia in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multiorgan dysfunction.
B
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Classification and risk stratification

Classification: as per WSES 2022 guidelines, differentiate AMI into the following types based on the clinical scenario and risk factors:
mesenteric arterial embolism
mesenteric arterial thrombosis
non-occlusive mesenteric ischemia
mesenteric venous thrombosis.
B
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Diagnostic investigations

General principles: as per ESC 2024 guidelines, obtain assessment by a vascular team in patients with AMI.
B
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  • Diagnostic imaging

  • Laboratory tests

Diagnostic procedures

Laparoscopy: as per ESTES 2016 guidelines, insufficient evidence to support routine use of laparoscopy in patients with AMI.
I
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Respiratory support

Oxygen therapy: as per ESTES 2016 guidelines, administer immediate supplementary oxygen in patients with AMI.
B
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Medical management

General principles: as per ESVS 2025 guidelines, manage patients with AMI in centers with 24/7 multidisciplinary services and experience in both open and endovascular mesenteric artery revascularization.
B
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  • Supportive therapy

  • Antibiotic therapy

  • Antithrombotic therapy

  • Antihypertensive therapy

  • Lipid-lowering therapy

  • Palliative care

Inpatient care

Intra-abdominal pressure monitoring
As per ESVS 2017 guidelines:
Obtain intra-abdominal pressure monitoring to prevent non-occlusive mesenteric ischemia in patients with known risk factors for intraabdominal hypertension/abdominal compartment syndrome.
B
Initiate medical treatment in patients with intraabdominal pressure > 12 mmHg to prevent abdominal compartment syndrome and non-occlusive mesenteric ischemia.
B
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Nonpharmacologic interventions

Lifestyle modifications: as per ESC/ESVS 2018 guidelines, advise smoking cessation,
B
healthy diet and physical activity in all patients with PADs.
B
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Therapeutic procedures

Nasogastric decompression: as per WSES 2022 guidelines, perform nasogastric decompression in patients with AMI.
B
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  • Revascularization

Surgical interventions

Prompt surgery: as per WSES 2022 guidelines, perform prompt laparoscopy/laparotomy in patients with overt peritonitis.
B
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  • Bowel resection

  • Damage control surgery

Specific circumstances

Patients with non-occlusive mesenteric ischemia: as per ESVS 2025 guidelines, do not use a single measurement of a biomarker such as lactate or D-dimer to confirm or rule out the diagnosis in patients with a clinical suspicion of non-occlusive mesenteric ischemia.
D
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  • Patients with isolated mesenteric artery dissection

  • Patients with mesenteric vein thrombosis (diagnostic imaging)

  • Patients with mesenteric vein thrombosis (evaluation for etiology)

  • Patients with mesenteric vein thrombosis (anticoagulation therapy, indications)

  • Patients with mesenteric vein thrombosis (anticoagulation therapy, duration)

  • Patients with mesenteric vein thrombosis (prevention of variceal bleeding)

Preventative measures

Secondary prevention: as per ESVS 2017 guidelines, offer secondary medical prevention including smoking cessation, statin therapy, and antiplatelet or anticoagulation therapy in patients surviving AMI.
B
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Follow-up and surveillance

Second-look procedures: as per ESVS 2017 guidelines, consider performing second-look laparotomy and damage control surgery in patients undergoing acute intestinal revascularization.
C
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  • Follow-up imaging

Quality improvement

Hospital requirements: as per ESC/ESVS 2018 guidelines, healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.
B
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