Therapeutic efficacy between endovascular and open surgery groups [10].
Abstract
The current standard care for acute mesenteric ischemia involves urgent revascularization and resection of the necrotic bowel. A dedicated protocol for early treatment and urgent revascularization is pivotal to improving diagnostic rate and patient survival. In this chapter, the critical components of diagnosis and treatment protocol are reviewed. Different treatment choices with endovascular approaches are discussed. After endovascular revascularization, a dedicated team consisting of surgeons and critical care specialists are needed to provide post-intervention care and second-look laparoscopy when necessary. In geographic regions where healthcare resources are lacking, a time-efficient strategy adopted by interventional radiologists or cardiologists should be considered to improve patient survival.
Keywords
- acute
- mesenteric ischemia
- endovascular
1. Introduction
1.1 How we begin our treatment protocol
On August 24, 2012, we started our first endovascular treatment for acute mesenteric ischemia. The patient received diagnosis of acute abdomen in the emergent department, and our general surgeon per- formed laparotomy, which found diffuse mesenteric necrosis. After emergent operation, the interven- tional cardiology team was consulted. Endovascular revascularization was performed by Dr. Mu-Yang Hsieh and Dr. Kuei-Chien Tsai. A coronary bare-metal stent was placed to revascularize SMA (superior mesenteric artery) (Integrity, bare-metal stent, 4.0 x 28 mm, Medtronics) (Figure 1).
On August 17, 2012, Dr. Mu-Yang Hsieh initiated a draft for Acute Mesenteric Ischemia Protocol. Be- tween 2013 and 2014, interventional radiologist Dr. Chih-Hon Wu provided valuable revision sugges- tions. In the following years, another seven patients received emergent endocvascular revascularization for acute mesenteric ischemia.
1.1.1 The goal of the protocol
Initial goals: a definitive invasive angiography become a reasonable options for dignosis improvement. To have an in-hospital monitor program.
Intermediate goals: become a center for emergent treatment for acute mesenteric ischemia.
Longterm goals: to achieve better survival as reported from previous literatures. Make our one-year survival rate approximate 88%.
1.2 Statistics in our hospital
“Patients only have hours before irreversible gut ischemia ensues, followed by profound distributive shock, and death. (quoted from Moore and Ahn, Chapter 35).”
Bowel ischemia was diagnosed in around 0.1% of hospitalized patients [1]. But the mortality of acute mesenteric ischemia is quite high. In our hospital, about 95%mesenteric ischemia presented with acute abdomen.
Because the diagnosis of acute ischemic bowel is often difficult, we initiated a dedicated diagnosis pro- tocol to improve the patient outcomes. (Figure 2):
Emergent primary surgery with f/u angio: 4 patients, all received angio, with 2 SMA lesions fixed, survival 75% (3/4).
Emergent primary endovascular approach (with second look laparoscopy when indicated): 18 pa- tients, 5 failure, survival 0% (0/5), 13 success, survival 92.3% (12/13), 4 required laparoscopy/laparotomy.
Totally conservative management: 6 patients, survival 0% (0/6).
A filling defect (clot) was found in the SMA (Figure 3):
Early invasive endovascular approach: 8 patients, survival 75% (6/8).
Conservative medical management: 5 patients, survival 0% (0/5).
2. Literature review
2.1 Review articles and guideline update
Since 2016, there are numerous literature reported that endovascular is better than open surgery [2, 3].
In 2017, a guideline suggested for patients with acute mesenteric ischemia, emergent surgical or endovascular intervention is reasonable.6.
In the absence of RCTs, evidence is based on prospective registries. In the case of embolic occlusion, open and endovascular revascularizations seem to do equally well, whereas, with thrombotic occlusion, endovascular therapy is associated with lower mortality and bowel resection rates. The principles of damage control surgery are important to follow when treating these frail patients. This concept focuses on saving life by restoring normal physiology as quickly as possible, thus avoiding unnecessary time-consuming procedures. Although laparotomy is not mandatory after endovascular therapy in these patients with acute bowel ischaemia, it is often necessary to inspect the bowel. In this setting, second-look laparotomy is also indicated after open revascularization. Intra-arterial catheter thrombolysis of the superior mesenteric artery has been reported with good results. Severe bleeding complications were uncommon, except when intestinal mucosal gangrene was present [4].
2.2 Incidence
Acute mesenteric ischemia is one etiology among many causes of acute abdominal pain (< 1/1000) [5].
2.3 Mortality
In reported literatures, the mortality is around 60–80% among patients with acute mesenteric ischemia [5, 6, 7, 8].
2.4 Types of acute mesenteric ischemia
embolism
thrombosis
non-occlusive mesenteric ischemia
venous thrombosis
Current report addresses that non-occlusive mesenteric ischemia will lead to a worse prognosis.
2.5 Endovascular treatment- cost-effective study
2.5.1 Endovascular interventions decrease the length of hospitalization and are cost-effective in acute mesenteric ischemia
Dr. Erben reported in 2018 that endovascular revascularization for acute mesenteric ischemia is cost-saving, with a lower rate of in-hospital mortality [9].
2.5.2 Endovascular treatment for acute thromboembolic occlusion of the superior Mesen-teric artery and the outcome comparison between endovascular and open Surgi-cal treatments: A retrospective study
Similar good endovascular treatment results were also obtained in a cohort of Chinese population. A table comparing endovascular versus open surgery groups offer a good perspective on this topic (Table 1) [10].
Variable | Endovascular group ( | Open surgery group ( | ||
---|---|---|---|---|
Symptom onset to treatment (h) | 20.8 ± 15.2 | 25.8 ± 11.3 | 0.35 | −0.96 |
Laparotomy required (%/ | 33.33 (6) | 58.33 (7) | 0.26 | |
Time to laparotomy (h) | 26.3 ± 16.8 | 18.0 ± 7.7 | 0.26 | 1.18 |
Bowel resection (cm) | 88 ± 44 | 253 ± 103 | 0.01 | 3.85 |
Thirty-day mortality (%/ | 16.7 (3) | 33.3 (4) | 0.68 |
2.6 Contemporary management of acute mesenteric ischemia in the Endovascular era
Dr. Lim et al. reported in 2019 that for acute mesenteric ischemia, both open surgery and endovascular revascularization are viable options in the modern era [11].
Findings | Acute MI, n = 26 | Control, n = 36 | Sensitivity (%) | Specificity (%) |
---|---|---|---|---|
Pneumatosis intestinalis | 11 | 0 | 42 | 100 |
SMA or combined CA and IMA occlusion | 5 | 0 | 19 | 100 |
Arterial embolism | 3 | 0 | 12 | 100 |
SMA or portal venous gas | 3 | 0 | 12 | 100 |
Focal lack of bowel wall enhancement | 11 | 1 | 42 | 97 |
Free intraperitoneal air | 5 | 2 | 19 | 94 |
SMA or portal venous thrombosis | 4 | 2 | 15 | 94 |
Solid organ infarction | 4 | 2 | 15 | 94 |
Bowel obstruction | 3 | 2 | 12 | 94 |
Bowel dilatation | 17 | 6 | 65 | 93 |
Mucosal enhancement | 12 | 7 | 46 | 81 |
Bowel wall thickening | 22 | 10 | 85 | 72 |
Mesenteric stranding | 23 | 14 | 88 | 61 |
Ascites | 19 | 24 | 73 | 33 |
Author (Year) | Data Source | Morbidity | Mortality |
---|---|---|---|
Schermerhorn et al. (2009) | Nationwide Inpatient Sample | Length of stay: 9 days vs. 14 days | In-hospital: 16% vs. 39% |
Bowel resection: 28% vs. 37% | |||
Acute kidney injury: 11.4% vs. 18.4% | |||
Cardiac complication: 2.1% vs. 7.2% | |||
Respiratory complication: 1.1% vs. 5.7% | |||
Block et al. (2010) | Swedish Vascular Registry | Laparotomy: 55% vs. 100% | 30-day: 28% vs. 42% |
Bowel resection: 19% vs. 63% | |||
Second-look operation: 31% vs. 67% | 1 year: 39% vs. 58% | ||
Short bowel syndrome: 27% vs. 55% | |||
Arthur et al. (2011) | Single-Center Chart Review | Laparotomy: 69% vs. 100% | 36% vs. 50% |
Bowel resection: 52 cm vs. 160 cm | |||
Beaulieu et al. (2014) | Nationwide Inpatient Sample | Length of stay: 12.9 vs. 17.1 days | In-hospital: 24.9% vs. 39.3% |
Bowel resection: 14.4% vs. 33.4% | |||
TPN support: 13.7% vs. 24.4% | |||
Branco et al. (2015) | Nasional Surgical Quality Improvement Program | Transfusion: 3.7% vs. 19.3% | Odds ratio 0.4 (CI 0.2–0.9) |
Pneumonia: 22.2% vs. 27.8% | |||
Sepsis: 25.9% vs. 35.5% | |||
Arya et al. (2016) | Single-Center Chart Review | Bowel resection: 36.4% vs. 43.5% | 30-day: 45.4% vs. 34.8% |
Sepsis: 45.4% vs. 22.7% | |||
Re-exploration: 63.6% vs. 56.5% | |||
Major morbidity: 63.6% vs. 69.6% |
2.7 Clinical problems
For the suspected case of acute mesenteric ischemia, is following serum lactate level useful to confirm acute mesenteric ischemia?
It is not helpful to wait for evidence of increasing serum lactate levels to proceed with further testing; ideally, in fact, intervention would occur in patients with acute mesenteric ischemia before lactic acidosis develops, with the goal of saving additional intestine from full-thickness injury [5].
When the clinical suspicion of acute mesenteric ischemia is high, we should proceed with CT angiography. And in cases with equivocal CT findings, invasive angiography should be considered.
In the early phase of abdominal pain, is serum amylase or lipase diagnostic? In the first eight patients of our case series, amylase and lipase is not useful.
In the first CT study, for patients with no bowel necrosis but still have equivocal CT findings of acute mesenteric ischemia, the best diagnostic method is invasive angiography.
2.8 Primary stenting for acute mesenteric ischemia
Only a few report focused on primary stenting for acute mesenteric ischemia. Dr. Forbrig reported in 2017 with a case series of 19 consecutive patients and demonstrated that endovascular revascularization has high clinical success rates [12].
2.9 Methodology: using Stentriever
Besides balloon angioplasty and stenting, for large thrombus burden, Dr. Miura reported in 2017 that using a stent retriever achieved rapid and good revascularization in a patient with SMA embolism [13].
2.10 Filter protection
Dr. Mendes reported in 2018 that using a distal protection device can redude the event of distal em- bolization [14].
2.11 Special scenario: bypass and its post-OP course
Dr. Morbi reported a patient with acute mesenteric ischemia and the patient received emergent by-pass surgery utilizing an aorto-SMA bypass, with good-quality long saphenous vein and segmental small bowel resection [15].
2.12 Special scenario: dissection
SMA (superior mesenteric artery) dissection has been reported extensively, and the most common problem is when performing open surgery, it is difficult to perform re-entry into the true lumen. The resolution is retrograde open mesenteric stenting (ROMS). The ROMS is performed by opening distal SMA true lumen with placement of a sheath, then proceeding with retrograde wiring and stenting [16].
2.12.1 Classification- SMA dissection
The proposed classification of SMA dissection (Figure 6).
For SMA dissection, Dr. Loeffler reported in 2017, that if there was no evidence of bowel necrosis, even in symptomatic SMA dissection, regular medical treatment with follow-up may avoid the necessity of open surgery or endovascular stenting [17].
2.12.2 Endovascular treatment of spontaneous dissections of the superior mesenteric artery
Gobble et al. reported in 2009, included 9 patients (all isolated spontaneous SMA dissection). The treatment modality was variable, including expectant management (4 patients), anticoagulation (2 patients), and endovascular stent placement (3 patients). Among patients who received stenting, acute luminal gain is better [16].
Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery has been reported to be successful.
Systematic review and meta-analysis for patients with spontaneous isolated superior mesenteric artery dissection also suggested conservative treatment [17, 18, 19].
2.13 Special scenario: combined celiac trunk and SMA disease
In our patient treated in December 2016, the patient had diffuse aorta atherosclerosis, with celiac trunk- hepatic artery and SMA ostial occlusion.
2.13.1 Chronic mesenteric ischemia involving both celiac trunk and SMA
For patients with chronic mesenteric ischemia due to occlusion of both celiac trunk and SMA, SMA revascularization alone may be adequate to improve symptoms [20].
2.14 Special scenario: ischemia: reperfusion syndrome
2.14.1 Reperfusion syndrome
Severe reperfusion syndrome after acute mesenteric ischemia revascularization has been reported. But optimal medical treatment has not been established
2.15 Recurrent superior mesenteric artery stent fracture
After successful stenting and salvage for acute mesenteric ischemia, stent fracture has been reported. This issue needs further study to establish the best treatment algorithm. Currently, we suggest following patients with abdominal contrast-enhanced CT to evaluate the patency of the stent
3. Diagnosis of acute mesenteric ischemia
3.1 Initial phase- clinical challenges
The symptoms of acute mesenteric ischemia are described in most general text of most medical textbooks. We do not repeat the symptoms but wish to address the most common clinical challenges in the initial phase of diagnosis: after performing KUB plain film of CT angiography, it is still frequent to fail to proceed to invasive angiography due to multiple reasons: physicians do not familiar with invasive angiography, lack of staffs to perform emergent angiography, no bowel necrosis and surgeon wish to treat the patient conservatively. Following serum lactate level only detects the patients in irreversible bowel necrosis and is not beneficial providing chances of early salvage.
3.2 Computer tomography- CT
The axial, coronal, sagittal, and 3D reconstruction in advance is mandatory to be reviewed in the initial diagnostic phases. However, in patients with extensive aortic calcification and ostial calcification, care must be taken to interpret the lumen area and stenosis, because the lumen may be mis-interpretated as patent due to extensive ostial calficaition.
CT findings of bowel necrosis: no enhancement of bowel loop, pneumatosis intestinalis, aeroportia (Figure 7).
4. Consultation
4.1 Consultation process
After our index case, an interventional cardiologist (Mu-Yang Hsieh) wrote a draft. The draft was reviewed and completed by an interventional radiologist (Chih-Horng Wu). The interventional radiologist trained the interventional cardiologist to perform selective bowel angiography to reduce time delay in the emergency scenario. The protocol was revised from the acute coronary syndrome protocol. For patients with evident bowel necrosis and peritoneal signs, direct consultation with a surgical team was mandatory (group 1 patients). The endovascular team was contacted after the surgical procedure. For patients with no evident bowel necrosis by CT, any team members can activate the protocol in the emergency department (group 2 patients). In suspected patients with possible CT findings (group 3 patients), the team votetd if proceeding with diagnostic angiography is beneficial to the patient Figures 8–10.
4.2 Surgical consultation
When the patient developed peritoneal signs or when bowel necrosis was evident by CT, the patient will be sent to the operation room first, and open thrombectomy 及 retrograde open mesenteric stenting (ROMS) should be considered
4.2.1 Experience in the Hsinchu
Since 2016, we performed emergent angiography for case 9 and case 10 before the emergent open laparotomy. Direct stenting was performed on SMA. The potential benefit is to shorten the ischemic time
(Figures 12 and 13).
5. Critical statistics for patient explanation and the results pro- vided to the family for rapid briefing of acute mesenteric ischemia
Treatment results (historical results) were provided to the patient family at the emergency department.
Angiographic (technical) success rate: 6/8 (75%)
Survival at 30 days: 75%
Survival at 7 days, In angiographic success patients: 100%
Survival at 7 days, In angiographic failure patients: 0%
Long-term follow-up survival at 2-year: 50% (due to multiple comorbidities) (Figure 14).
Poster prepared and mounted in the emergency department and at the waiting area of intensive care units (Figure 15).
6. Angiography and treatment
Abdominal angiography was performed emergently in the cath room (cardiology department) angiography room (radiology department). The vascular access was set with a 6-Fr sheath. To perform diagnostic angiography, a 5-Fr diagnostic catheter (RC-1 or JR) was used. In our protocol, the flow was rated using the coronary grading system: TIMI (thrombolysis in myocardial infarction) flow scale. Mesenteric artery disease was defined if there was diameter stenosis over 50%, and mesenteric artery occlusion was defined if there was 100% stenosis with 0 TIMI flow.
6.1 Endovascular treatment
Thrombosuction, balloon angioplasty, and stenting were performed sequentially or by the discretion of the interventional cardiologist. First, the femoral sheath was changed to a 7-Fr sheath (10 cm), and a guiding catheter (7-Fr JR4 or IMA) was used according to the angle between of SMA ostium and aorta after reviewing the sagittal view on the CT. For ostial lesion, a guide catheter with side hole was used. We usually give a bolus of heparin (3000–5000 U) to achieve activated clotting time of at least 250 seconds. A workhorse 0.014-inch soft coronary wire was used to cross the lesion. With a dedicated coronary thrombosuction catheter, distal contrast injection can be done to confirm that true lumen was reached in cases with SMA occlusion. Thrombosuction was performed (Thrombuster, Terumo, Tokyo, Japan). Balloon angioplasty was done after successful establishment of antegrade flow. Ifpersistentt recoil or restenosis had been noted, the operator could perform bail-out stenting (usually with a coronary bare-metal stent. Thrombolytic agent was not used in our protocol because it was declined by our team (GI man). Because the National Health Insurance did not cover distal protection device in the treatment of acute mesenteric ischemia, the distal protection device was not used.
6.2 Procedure details
6.2.1 Percutaneous endovascular intervention
A coronary system with 0.014-inch wire, balloon, and stents are used in our protocol. Usually, the vascular access is at the common femoral artery (7 Fr sheath). We used a JR4 diagnostic coronary catheter with 0.035-inch wire (Terumo GlideWire) to perform diagnostic angiography. During the intervention, a 0.014-inch coronary wire with length of 180 cm is used (Sion, BMW-U2).
6.2.2 Guiding catheter choices
The angle between SMA ostium and aorta can help to choose the suitable guide sheath or guiding catheter to engage SMA. The choices included angled sheath (6 or 7 Fr), IMA, or JR4 guide catheters.
6.2.3 Thrombosuction
Thrombosuction: we used coronary system, Thrombuster (6 Fr), or Export catheter.
6.2.4 Balloon angioplasty
Most commonly used balloons: Trek, Maverick, and Sapphire, with 6–8 atm.
6.2.5 Bail-out stenting
Bail-out stenting should be considered: when thrombosuction, or balloon angioplasty failed, stenting may still be tried.
Before performing bail-out stenting, we should always use thrombosuction catheter to perform distal injection in order to confirm the adequate distal landing zone.
Rotational Thrombectomy Device can be considered and has reported successful to salvage patients with acute mesenteric ischemia in a single center study [21].
7. Surgery
7.1 Inportant notices for surgeons
Surgery and revascularization are both mandatory to provide optimal survival chances in patients with extensive bowel necrosis.
For patients who received stenting to SMA before surgery, care must be taken not to manipulate the SMA forcefully to avoid inadvertent crush of the stent.
8. Post-stenting care
ICU care after the endovascular procedure is mandatory. The electrolyte, urine output, and arterial pressure are to be monitored. An infection specialist is consulted at the discretion of the critical care specialist. The general surgeon will check the abdominal physical exams to detect changes in peritoneal signs. As- pirin (100 mg) and clopidogrel (75 mg) are initiated if no bleeding is noted after overnight observation. For patients with atrial fibrillation, an oral anticoagulant is started at the discretion of the operator and the caring cardiologist.
8.1 Definition of treatment success
Important definition: [22].
Primary clinical success was defined as complete resolution of symptoms.
Partial clinical success was defined as resolution of some or most of the symptoms, but persistence of some symptoms after the procedure.
Primary clinical failure was defined as the lack of any or minimal symptom relief.
Technical success: the successful revascularization of all arteries that were treated in which there was less than a 30% residual diameter stenosis.
Partial technical success per patient (who had multiple mesenteric arteries treated) was defined as at least one mesenteric artery treated successfully.
Technical failure was defined as the inability to treat at least one mesenteric artery per patient
8.2 Antibiotics
Oral digestive decontamination: PO gentamicin 80 mg/day, PO metronidazole 1.5 g/day [23].
What Is the Role of Empiric Treatment for Suspected Invasive Candidiasis in Nonneutropenic Patients in the Intensive Care Unit?
8.2.1 Invasive candidiasis
Preferred empiric therapy for suspected candidiasis in non-neutropenic patients in the intensive care unit (ICU) is an echinocandin (caspofungin: loading dose of 70 mg, then 50 mg daily; micafungin: 100 mg daily; anidulafungin: loading dose of 200 mg, then 100 mg daily) (strong recommendation; moderate-quality evidence) [24].
8.3 ICU care
Mandatory medical protocol: blood volume resuscitation, with mean arterial pressure > 65 mmHg, urine output >0.5 ml/kg/hour.
Curative unfractionated heparin therapy with aPTT 50–70 seconds.
IV proton pump inhibitors: IV pantoprazole 80 mg/day
Oxygen therapy
Food resting, PN if prolonged >5 days.
Antibiotics: empirical, not prophylaxis. Tazocin and possible Candida coverage (no evidence of presence)
No | Age | Sex | Comirbidities | CHADS2-VASc | Shock | Resting dyspnea | Food avoidance | Diarrhea | Nausea/vomiting | Ileus, diffuse | Ileus, localized | Lactate (mmol/L) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 79 | Female | Cirrhosis, gout | 2 | + | + | — | — | — | — | + | 8.8 |
2 | 61 | Male | PAOD, ESRD, DM, dyslipidemia, smoking | 2 | + | — | — | + | + | — | + | 2.5 |
3 | 74 | Female | HTN, dyslipidemia, gout | 2 | — | — | — | + | — | — | + | 1.7 |
4 | 72 | Female | DM, HTN | 3 | −+ | — | — | — | + | — | 7.4 | |
5 | 63 | Female | Afib, VHD, mechanical valve, CVA, DM, HTN, dyslipidemia | 5 | — | + | — | — | — | — | + | 2.4 |
6 | 74 | Female | CAD, old MI, PAOD, ESRD, DM, HTN, dyslipidemia | 4 | + | + | — | — | — | — | + | 5 |
7 | 86 | Male | CAD, Afib, VHD, DM, HTN | 3 | — | — | — | — | — | — | + | 2.6 |
8 | 80 | Female | CAD, ESRD, DM, HTN | 4 | — | — | + | — | — | — | + | 1 |
Category | No | Culprint vessel | Lesion | Diameter (mm) | Length (mm) | Calcification | Time from ER to angiography | Treatment | Stenting | Angio / Clinical success | Laparotomy required | Angio to Discharge (days) | F/U durations (days) | Survival at 30 days | Outcome at 12 montsh |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 1 | SMA | 100% occlusion, main trunk | 4 | 28 | Minimal | 24.5 | Aspiration/stenting | BMS | Yes/Yes | Yes (after stenting) | 45 | 33 | Yes | Moratlity |
1 | 6 | SMA | 50% stenosis, ostium | 4 | 5 | Moderate | 12.1 | Direct stenging | BMS | Yes/Yes | Yes (before stenting) | 21 | 166 | Yes | Moratlity |
2 | 4 | SMA | 100% occlusion, main trunk | 2.5 | 40 | Minimal | 16.3 | Aspiration only | NA | No/No | No | NA | 1 | No | Mortality |
2 | 5 | SMA | 100% occlusion, main trunk | 4 | 30 | Minimal | 3.4 | Aspiration/stenting | BMS | Yes/Yes | No | 2 | 341 | Yes | Survival |
2 | 7 | SMA | 100% occlusion, main trunk | 4.5 | 50 | Minimal | 5.5 | Aspiration/stenting | BMS | Yes/Yes | No | 3 | 187 | Yes | Survival |
3 | 2 | SMA & celiac trunk | 100% occlusion, from ostium | 3 | NA | Severe | 11.9 | Wiring only | NA | No/No | No | NA | 1 | No | Mortality |
3 | 3 | IMA | 80% stenosis, ostium | 3 | 15 | Minimal | 22.2 | Direct stenting | BMS | Yes/Yes | No | 2 | 465 | Yes | Survival |
3 | 8 | SMA | 90% stenosis, ostium | 4.5 | 8 | Moderate | 9 | Direct stenting | BMS | Yes/Yes | No | 2 | 90 | Yes | Survival |
References
- 1.
Acosta S, Bjorck M. Acute thrombo-embolic occlusion of the superior mesenteric artery: A prospective study in a well defined population. European Journal of Vascular and Endovascular Surgery. 2003; 26 :179-183 - 2.
Blauw JT, Bulut T, Oderich GS, et al. Mesenteric vascular treatment 2016: From open surgical repair to endovascular revascularization. Best Practice & Research. Clinical Gastroenterology. 2017; 31 :75-84 - 3.
Karkkainen JM, Acosta S. Acute mesenteric ischemia (Part II) - Vascular and endovascular surgical approaches. Best Practice & Research. Clinical Gastroenterology. 2017; 31 :27-38 - 4.
Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesen- teric, renal, upper and lower extremity arteries endorsed by: The European stroke organization (ESO)the task force for the diagnosis and treatment of peripheral arterial diseases of the Eu- ropean Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). European Heart Journal. 1 Mar 2018; 39 (9):763-816. Doi: 10.1093/eurheartj/ehx095 - 5.
Campion EW, Clair DG, Beach JM. Mesenteric Ischemia. New England Journal of Medicine. 2016; 374 :959-968 - 6.
Kassahun WT, Schulz T, Richter O, et al. Unchanged high mortality rates from acute occlusive intestinal ischemia: Six year review. Langenbeck's Archives of Surgery. Mar 2008; 393 (2):163-171. Doi: 10.1007/s00423-007-0263-5. Epub 2008 Jan 3 - 7.
Schoots IG, Koffeman GI, Legemate DA, et al. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. The British Journal of Surgery. 2004; 91 :17-27 - 8.
Park WM, Cherry K, Chua HK, et al. Current results of open revascularization for chronic mesenteric ischemia: A standard for comparison. Journal of Vascular Surgery. 2002; 35 :853-859 - 9.
Erben Y, Protack CD, Jean RA, et al. Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia. Journal of Vascular Surgery. Aug 2018; 68 (2):459-469. Doi: 10.1016/j.jvs.2017.11.078 - 10.
Zhang Z, Wang D, Li G, et al. Endovascular treatment for acute thromboembolic occlusion of the superior mesenteric artery and the outcome comparison between endovascular and open surgical treatments: A retrospective study. BioMed Research International. 2017; 2017 :1-10 - 11.
Lim S, Halandras PM, Bechara C, et al. Contemporary Management of Acute Mesenteric Ischemia in the endovascular era. Vascular and Endovascular Surgery. 2019; 53 :42-50 - 12.
Forbrig R, Renner P, Kasprzak P, et al. Outcome of primary percutaneous stent-revascularization in patients with atherosclerotic acute mesenteric ischemia. Acta Radiologica. 2017; 58 :311-315 - 13.
Miura Y, Araki T, Terashima M, et al. Mechanical recanalization for acute embolic occlusion at the origin of the superior mesenteric artery. Vascular and Endovascular Surgery. 2017; 51 :91-94 - 14.
Mendes BC, Oderich GS, Tallarita T, et al. Superior mesenteric artery stenting using embolic pro- tection device for treatment of acute or chronic mesenteric ischemia. Journal of Vascular Surgery. Oct 2018; 68 (4):1071-1078. Doi: 10.1016/j.jvs.2017.12.076. Epub 2018 Apr 21 - 15.
Morbi AH, Nordon IM. Emergency revascularisation in a patient with acute mesenteric is- chaemia: The role of open revascularisation and compensatory blood flow. Acta Chirurgica Belgica. 2016; 116 :234-238 - 16.
Gobble RM, Brill ER, Rockman CB, et al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. Journal of Vascular Surgery. 2009; 50 :1326-1332 - 17.
Loeffler JW, Obara H, Fujimura N, et al. Medical therapy and intervention do not improve un- complicated isolated mesenteric artery dissection outcomes over observation alone. Journal of Vascular Surgery. 2017; 66 :202-208 - 18.
Kimura Y, Kato T, Inoko M. Outcomes of treatment strategies for isolated spontaneous dis- section of the superior mesenteric artery: A systematic review. Annals of Vascular Surgery. 2018; 47 :284-290 - 19.
Liu Q , Li TJ, Zeng R, et al. Effect of adequate Anticoagulantion therapy on the outcome of Spon- taneous isolated dissection of superior mesenteric artery. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2018; 40 :21-25 - 20.
Goldman MP, Reeve TE, Craven TE, et al. Endovascular treatment of chronic mesenteric ischemia in the setting of occlusive superior mesenteric artery lesions. Annals of Vascular Surgery. 2017; 38 :29-35 - 21.
Freitas B, Bausback Y, Schuster J, et al. Thrombectomy devices in the treatment of acute Mesen- teric ischemia: Initial single-center experience. Annals of Vascular Surgery. 2018; 51 :124-131 - 22.
Turba UC, Saad WE, Arslan B, et al. Chronic mesenteric ischaemia: 28- year experience of endovas- cular treatment. European Radiology. 2012;22 :1372-1384 - 23.
Roussel A, Castier Y, Nuzzo A, et al. Revascularization of acute mesenteric ischemia after creation of a dedicated multidisciplinary center. Journal of Vascular Surgery. 2015; 62 :1251-1256 - 24.
Pappas PG, Kauffman CA, Andes DR, et al. Executive summary: Clinical practice guideline for the Management of Candidiasis: 2016 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2016; 62 :409-417