Acute mesenteric arterial occlusion
- Gregory Pearl, MD
Gregory Pearl, MD
- Professor of Surgery
- Texas A&M Health Sciences Center
- Chief, Division of Vascular Surgery
- Baylor University Medical Center
- Ramyar Gilani, MD
Ramyar Gilani, MD
- Assistant Professor of Surgery
- Baylor College of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Acute mesenteric ischemia refers to the sudden onset of small intestinal hypoperfusion, which can be due to reduction or cessation of arterial inflow. Ischemia due to acute mesenteric arterial occlusion can be caused by embolic obstruction of the intestinal blood supply, most commonly to the superior mesenteric artery (SMA). Acute ischemia can also occur due to acute thrombotic obstruction, often in the setting of an already diseased mesenteric vessel (eg, atherosclerosis).
Acute mesenteric ischemia due to acute arterial obstruction involving the small intestine will be reviewed here. Colonic ischemia, chronic mesenteric ischemia, and other forms of mesenteric ischemia, including mesenteric venous occlusion and nonocclusive mesenteric ischemia, are reviewed elsewhere. (See "Mesenteric venous thrombosis in adults" and "Chronic mesenteric ischemia" and "Colonic ischemia" and "Nonocclusive mesenteric ischemia".)
MESENTERIC ANATOMY AND PHYSIOLOGY
The arterial anatomy of the intestinal circulation is given in the figures (figure 1 and figure 2 and picture 1). Ischemic injury to the intestine develops when there is insufficient delivery of oxygen and nutrients required for cellular metabolism. An overview of intestinal anatomy, normal intestinal vascular physiology, and the response to acute ischemia are discussed in detail elsewhere. (See "Overview of intestinal ischemia in adults", section on 'Intestinal vascular anatomy' and "Overview of intestinal ischemia in adults", section on 'Physiology and mechanisms of ischemia'.)
The intestine may be able to compensate to some extent because of increased oxygen extraction as well as the presence of collateral flow pathways (figure 3) . The status of the collateral circulation is particularly important in determining the severity of symptoms . Acute superior mesenteric arterial occlusion, in the absence of preexisting stenosis such as with embolism, causes a greater reduction in blood flow compared with other causes of intestinal ischemia. This is due to the lack of collateralization in the presence of relatively normal arterial vasculature. By contrast, acute thrombosis of atherosclerotic lesions may have had the opportunity to develop collateral pathways to provide some degree of perfusion even in the setting of complete occlusion. Inciting factors such as dehydration or low cardiac output states can lead to acute thrombosis of even modest stenosis, causing typical signs and symptoms of acute mesenteric ischemia with no prior history. For some patients, progression from stenosis to occlusion can be asymptomatic due largely to a sufficient time course to develop these collaterals.
ETIOLOGY OF MESENTERIC ARTERIAL OCCLUSION
The two major causes of acute mesenteric arterial occlusion are mesenteric arterial embolism and mesenteric arterial thrombosis. In an autopsy study, the ratio of superior mesenteric embolus to thrombus ratio was 1.4:1 .
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- MESENTERIC ANATOMY AND PHYSIOLOGY
- ETIOLOGY OF MESENTERIC ARTERIAL OCCLUSION
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL FEATURES
- DIFFERENTIAL DIAGNOSIS
- Approach to treatment
- Surgical versus endovascular intervention
- ENDOVASCULAR INTERVENTION
- Pharmacomechanical thrombolysis
- Mesenteric angioplasty/stenting
- - Retrograde open mesenteric stenting
- Abdominal exploration/damage control
- - Embolectomy
- - Mesenteric bypass
- Bowel and abdominal closure
- POSTPROCEDURE CARE AND FOLLOW-UP
- Second-look laparotomy and abdominal wall closure
- Long-term medical management
- Stent surveillance
- MORBIDITY AND MORTALITY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS