Chronic Mesenteric Ischemia: A Curable Cause of Failure to Thrive : Page 2 of 2
Angiography is considered the gold standard for diagnosing CMI. It provides a high degree of clinical accuracy and offers the possibility of intervention; however, it is an invasive procedure, with an overall complication rate of 1.9% to 2.9%. The literature includes reports of external iliac artery dissection and deep vein thrombosis with angiography.16 Despite these risks, angiography may be the procedure of choice, especially for patients whose symptoms are significant.
Duplex ultrasonography, magnetic resonance angiography (MRA), and CT angiography (CTA) are other modalities used in diagnosing CMI. Color duplex ultrasonography is becoming the first choice for initial screening of the mesenteric vasculature. It has a comparatively low cost compared with angiography and is quick to perform, noninvasive, and portable; it can even be performed at the bedside. Ultrasonography has a reported sensitivity of 92% to 100% and a specificity of 92%, and it allows visualization of the celiac and superior mesenteric arteries in 80% to 90% of patients.1,16 However, results are limited by the operator’s skill and the presence of gas in the bowel.13 Even if ultrasonography reveals stenosis of the mesenteric vasculature and decreased blood flow, CMI remains a clinical diagnosis.
Studies of contrast-enhanced MRA have a sensitivity of 95% and a specificity of 90%; however, the grading of stenosis varies greatly by reviewer, which is a drawback of this modality.17 Additional drawbacks include its cost and the need for the patient to hold his or her breath during the procedure. Like duplex ultrasonography, MRA is not good at imaging the inferior mesenteric artery.
CTA—also known as multidetector row CTA—is becoming more widely available and can render three-
dimensional images of the vasculature. For acute mesenteric ischemia, its sensitivity and specificity are 96% and 94%, respectively18; we are unaware of any study comparing angiography with CTA. Compared with MRA, CTA is easier and quicker to perform and also less costly. CTA is increasingly used to help diagnose CMI, and its ability to depict the superior mesenteric and celiac arteries is comparable to that of ultrasonography and MRA.
Diagnosis of CMI is solely based on the patient’s presentation and findings on imaging studies. While laboratory studies may reveal malnourishment, anemia, hypoalbuminemia, and hypocholesterolemia, these findings are not sensitive nor specific to CMI.12 There has been testing looking at early serologic markers for CMI, such as lactate, lactate dehydrogenase, intestinal fatty acid binding protein, and D-dimer, but none of these have been proven helpful in making the diagnosis.13
Management of CMI
Treatment of CMI has evolved over the past two decades and is recommended for symptomatic patients. Primary interventions include surgery and endovascular therapies (with or without stenting). Surgeons sometimes hesitate to attempt these interventions in frail elderly patients with CMI, but the disease process often causes their frailty. Intervention could modify the disease process and help prevent or reverse frailty in these patients, as shown by the case 1 patient.
Success rates reported with open surgical procedures are as high as 90%, and surgical intervention has been associated with a 5-year survival rate of up to 80%.1,2,12 However, open surgical repair is known to have significant morbidity (5%-30%) and mortality (5%-12%) associated with it.4 Whereas surgery was once considered first-line therapy for CMI, endovascular therapies are becoming more common and now account for more than 70% of interventions performed.14 Outcomes are improving as institutions are becoming practiced in endovascular procedures. Endovascular repair is reported to have an overall high success rate, ranging from 80% to 100%, and a 9% morbidity rate and a 3% mortality rate.4 Studies comparing open versus endovascular procedures for CMI have shown open procedures to have higher mortality rates (15% vs 4%, respectively).19,20
Because surgical treatment is more invasive and associated with longer hospitalizations and higher rates of morbidity and mortality than endovascular repair,19,20 the latter option is considered a more acceptable intervention for frail elders.21-24 Studies suggest that more patients who undergo endovascular repair than surgery are discharged to home versus a nursing facility despite these patients having a greater incidence of frailty than their surgical counterparts.25
Medical management alone should be an option only if surgery or endovascular treatment is deemed too risky. Medical therapy can also be administered in conjunction with endovascular or surgical repair, and typically involves treatments for atherosclerosis (eg, statins) and interventions or lifestyle changes to help patients control hypertension and diabetes and to stop smoking.3
Following stent placement, 4 weeks of dual antiplatelet therapy has become the standard of care to decrease the risk of acute thrombosis, followed by daily aspirin doses of 100 mg to 325 mg thereafter.3 Medications such as warfarin, antiplatelet agents, and antispasmodics may help prevent thrombosis, as well as control and palliate symptoms. These agents have been shown to reduce mortality and recurrence in mesenteric vein thrombosis, and it is hypothesized that they can do the same for mesenteric artery atherosclerosis/stenosis.4 Although nitrate therapy by inducing vasodilation may relieve intestinal angina, it does not affect the disease process.4,6,8
Patient follow-up should occur at routine intervals and include taking the patient’s history (to determine if symptoms have recurred) and conducting a physical examination. All aspects of secondary prevention should be reviewed, including cholesterol levels, blood pressure control, diabetes management, and smoking cessation.3 Several studies also recommend performing routine duplex ultrasonography every 6 to 12 months.3,4
CMI, which frequently goes undiagnosed, should be included in the differential diagnosis for patients with failure to thrive, especially for those who have atherosclerotic disease or risk factors for atherosclerotic disease. Proper diagnosis requires obtaining a complete history and using the appropriate imaging modalities. Although angiography remains the gold standard, duplex ultrasonography, MRA, and CTA—which have varying degrees of sensitivity and specificity—are increasingly being used to aid in diagnosis. Failure to treat symptomatic CMI can have serious consequences for the patient, such as starvation, bowel infarction, sepsis, and death. Treatment goals in frail elderly patients should focus on relieving symptoms, resolving weight loss, and preventing acute mesenteric ischemia.
At the time of presentation, the two patients whose cases we discuss would have been appropriate hospice candidates. Although one patient was successfully treated with endovascular stenting, which resolved her symptoms and significantly restored her quality of life, the other was considered too frail for immediate surgery. While undergoing hyperalimentation, she suffered a stroke and died before surgery could be performed. Had she received a diagnosis of CMI prior to progressing to cachexia, she might have had a better outcome.
The authors report no relevant financial relationships.
Dr. Snyder is a geriatrician and palliative medicine physician, and Dr. Baum is the associate director, Geriatric Fellowship Program, Summa Health System, Akron, OH.
The authors thank Kathleen Senger, MD, for providing one of the contrasting cases, and Aileen Jencius, MLIS, for her assistance with manuscript preparation.
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