Arterial occlusive disease of chronic visceral arteries K55.1

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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chronic mesenteric ischemia; Chronic mesenteric ischemia; Chronic occlusion processes of the intestinal arteries; CMI

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Chronic peripheral arterial occlusive disease of visceral and retroperitoneal arteries includes all stenosing and occluding changes in these vessels, which may be of atherosclerotic or inflammatory origin.

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Based on the classification of pAVK according to Fontaine), chronic mesenteric ischemia can be divided into 4 stages:

  • I no clinical symptoms (incidental findings on imaging)
  • II Intermittent abdominal complaints (angina abdominalis, intermittent postprandial abdominal pain)
  • III Intermittent abdominal pain at rest with malabsorption syndrome
  • IV ischemic organ lesion (infarction) with acute severe abdominal pain, pain at rest and subsequent paralytic ileus.

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The incidence of chronic mesenteric ischemia (CMI) is age-related. Approximately 50% of >50-year-olds show chronic occlusion of the visceral arteries; m>f ;

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Common causes:

  • The vast majority of those affected suffer from general progressive arteriosclerosis (often nicotine abuse) and the associated complications (plaque embolism, arterial thrombosis, dissection).

Rare causes:

  • arterial embolism (e.g. in atrial fibrillation, endocarditis)
  • Aortic aneurysm
  • Aortitis (Takayashu arteritis, periarteritis nodosa)
  • Truncus coeliacus syndrome (compression syndrome caused by the medial ligamentum arcuatum of the diaphragm)
  • Functional circulatory disorders in the area of the visceral and retroperitoneal arteries can be a consequence of your
  • low-cardiac output syndrome in circulatory insufficiency and lead to non-occlusive disease with ischemic damage to the intestinal mucosa.
  • Connatal stenoses of visceral arteries are rare and affect the truncus coeliacus, the superior mesenteric artery and the inferior mesenteric artery in decreasing frequency.

Autopsy studies in >50 year olds show high-grade stenoses in the area of the coeliac trunk in 27%, in the area of the superior mesenteric artery in 19% and in the inferior mesenteric artery in 12%. These stenoses are mostly asymptomatic. Remark: Only high grade vascular stenosis (>70%) lead to a clinically effective reduced perfusion of the successful organs. In most cases at least 2 main intestinal arteries must be affected to cause ischemic symptoms.

About 5% of all patients with unclear abdominal pain have chronic mesenteric ischaemia (CMI). In this respect, clarification of the intestinal vascular morphology is an essential step in the diagnosis of an unclear abdomen.

Clinical features
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The classical symptom triad consists of:

  • abdominal pain: The diagnostic basis is postprandial abdominal pain, which begins about 20 minutes after eating and lasts 3-4 hours. This colicky angina abdominalis leads to a switch to smaller and more easily digestible meals, whereby finally only liquid food can be tolerated.
  • Weight loss: Initially there is inappetence and food intolerance. Constipations alternate with diarrhoea.
  • parumbilical vascular noise.

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Medical history, clinic, duplex sonography, CT, MRI. Intra-arterial angiography is the gold standard in the presentation of inta-arterial angiography.

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Acute Complicated Mesenteric Artery Occlusion (AMI). This can suddenly occur without warning as occlusive mesenteric ischemia (OMI). The causes are arterial embolisms (70%), arterial thromboses (30%) or the final stage of CMI which can no longer be compensated.

Acute complicative mesenteric artery occlusion occurs in 3 phases:

  1. Initial severe colicky abdominal pain, nausea
  2. Relatively symptom-free interval of several hours
  3. Acute abdomen with paralytic ileus, peritonitis, diffuse tenderness.

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Vasodilating agents (medication, coffee, alcohol) initially have a soothing effect.

Operative therapie
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Operative treatment indications only arise in the case of clinical complaints. In case of symptomatic random findings in stage I, there is no operative indication for treatment.
In stage II and III there is an absolute surgical indication for treatment.

Necrosis stage IV refers to acute mesenteric ischemia and is considered an emergency. The open surgical reconstruction of arteries is still considered the main

Methods of treatment: Surgery of chronic occlusion of the intestinal arteries is standardized today and should reach a lethality below 3%. Due to the large access trauma and the associated morbidity, modern endovascular procedures are increasingly used. Special indications arise in inoperable patients with threatening mesenteric ischemia and for the correction of insufficient surgical reconstructions.
Since the restenosis rate of a transfemoral or transbrachial PTA of the intestinal arteries is up to 30 % after 1 year, the dilatation result should be stent protected. Due to the rapid in-stent stenoses and the recurrence of symptoms in every 4th patient, a close imaging control is absolutely necessary to minimize the risk of an infarction-triggering stent occlusion.

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The danger of chronic mesenteric ischemia is its progression. The consequences of the disease are massive weight loss and a reduction in physical performance. Occupational activity may no longer be possible. Untreated, the disease develops over many years with malassimilation syndrome, therapy-resistant chronic organ inflammation and gastroduodenal ulcerations.

The progression of arteriosclerosis ultimately leads to insufficiency of the collateral circulation and to acute mesenteric artery occlusion (K55.01) with mesenteric infarction (acute upon chronic visceral ischemia).

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Last updated on: 29.10.2020