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Chronic mesenteric ischemia

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic mesenteric ischemia are prepared by our editorial team based on guidelines from the Society for Vascular Surgery (SVS 2021), the European Association for Gastroenterology, Endoscopy and Nutrition (EAGEN/CIRSE/NVMDL/HSGO/UEG/DMIS/ESGAR 2020), the American College of Radiology (ACR 2018), the European Society of Cardiology (ESC/ESVS 2018), the European Society for Vascular Surgery ...
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Screening and diagnosis

Diagnosis: as per SVS 2021 guidelines, make a diagnosis of chronic mesenteric ischemia in patients with the appropriate clinical scenario and the presence of significant stenoses (> 70%) within the celiac axis and superior mesenteric artery. Consider making the diagnosis in patients involving only one of these arteries.
B
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  • Differential diagnosis

Diagnostic investigations

Diagnostic imaging: as per SVS 2021 guidelines, obtain mesenteric duplex ultrasound as the preferred screening test for mesenteric artery occlusive disease.
B
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  • Laboratory testing

Diagnostic procedures

Gastrointestinal endoscopy: as per SVS 2021 guidelines, perform upper and/or lower gastrointestinal endoscopy to exclude gastrointestinal malignancies and other potential causes in patients with abdominal pain, weight loss, and fear of food.
B

Medical management

Setting of care: as per CIRSE/DMIS/EAGEN/ESGAR/HSGO/NVMDL/UEG 2020 guidelines, refer patients with symptoms and radiological features of vasculitis to an expert in the treatment of vasculitis before proceeding to endovascular revascularization.
B

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  • Antihypertensive therapy

  • Lipid-lowering therapy

  • Glycemic control

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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  • Nutritional support

Therapeutic procedures

Indications for revascularization: as per SVS 2021 guidelines, perform revascularization in patients with chronic mesenteric ischemia to reverse the presenting symptoms (weight loss, fear of food, diarrhea, postprandial pain) and improve the overall QoL.
B
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  • Endovascular revascularization

Perioperative care

Evaluation before revascularization
As per SVS 2021 guidelines:
Ensure optimization from a medical standpoint in patients undergoing revascularization for chronic mesenteric ischemia before performing an intervention but expedite their preoperative evaluation.
Obtain CTA to delineate the vascular anatomy before any revascularization. Consider obtaining catheter-based arteriogram as an alternative if the anatomy is not clear on CTA.
B

Surgical interventions

Surgical revascularization
As per SVS 2021 guidelines:
Rreserve open surgical revascularization for patients with chronic mesenteric ischemia with lesions not amenable to endovascular therapy, endovascular failures, and a selected group of younger, healthier patients in which the long-term benefits may offset the increased perioperative risks.
B
Determine the choice of open surgical revascularization for patients with chronic mesenteric ischemia based on anatomy, comorbidities, prior interventions and provider preference.

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  • Celiac artery release

Specific circumstances

Asymptomatic patients, management
As per CIRSE/DMIS/EAGEN/ESGAR/HSGO/NVMDL/UEG 2020 guidelines:
Perform revascularization for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of all 3 mesenteric vessels only after carefully weighing the risks and benefits of treatment, given the low level of evidence.
B
Consider performing endovascular intervention for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of ≥ 2 mesenteric vessels requiring to undergo major abdominal surgery with potential ligation of collateral circulation.
C

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  • Asymptomatic patients (follow-up)

Patient education

General counseling: as per SVS 2021 guidelines, educate and counsel patients undergoing revascularization for chronic mesenteric ischemia about the recurrent symptoms due to the high rate of recurrence.

Preventative measures

Secondary prevention
As per CIRSE/DMIS/EAGEN/ESGAR/HSGO/NVMDL/UEG 2020 guidelines:
Consider assessing the cardiovascular risk profile in patients with an asymptomatic atherosclerotic stenosis of the mesenteric arteries.
C
Consider initiating cardiovascular secondary prevention in patients with symptomatic atherosclerotic chronic mesenteric ischemia as soon as the diagnosis is made.
C

Follow-up and surveillance

Post-revascularization antiplatelet therapy
As per CIRSE/DMIS/EAGEN/ESGAR/HSGO/NVMDL/UEG 2020 guidelines:
Consider administering dual antiplatelet therapy for at least 1 month after endovascular mesenteric artery stenting, followed by lifelong antiplatelet monotherapy.
C
Consider adding one antiplatelet agent for 4 weeks after endovascular mesenteric artery stenting in patients treated with DOACs, VKAs or LMWH.
C

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  • Follow-up after revascularization

  • Patients with recurrent disease (evaluation)

  • Patients with recurrent disease (management)

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