Chronic Mesenteric Ischemia

Publication Date: December 31, 2020
Last Updated: May 23, 2022

Summary of the Guidelines

Diagnosis

In patients with abdominal pain, weight loss, and food fear, we recommend an expedited workup to exclude gastrointestinal malignancies and other potential causes. The expedited workup may include an esophagogastroduodenoscopy, a colonoscopy, an abdominal CT scan, and an abdominal ultrasound. (S – Strong, M)
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We recommend making a diagnosis of CMI in patients with the appropriate clinical scenario and the presence of significant stenoses (>70%) within the celiac axis and superior mesenteric artery (SMA). The diagnosis may also be made in patients with the appropriate clinical scenario and a significant stenosis (>70%) in either the celiac axis or SMA alone. (S – Strong, M)
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We recommend using the mesenteric duplex ultrasound examination as the preferred screening test for mesenteric artery occlusive disease (MAOD). (S – Strong, M)
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We recommend using CT arteriography (CTA) as the preferred definitive imaging test for MAOD unless unusual anatomic features obscure the anatomy such that a catheter-based arteriogram may be required. (S – Strong, M)
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Treatment

Indications for Treatment

We recommend revascularization in patients with CMI to reverse their presenting symptoms (i.e., weight loss, food fear, diarrhea, postprandial pain) and improve their overall quality of life. (S – Strong, H)
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We recommend that total parenteral nutrition is not an acceptable alternative to revascularization for patients with CMI owing to the risk of clinical deterioration, bowel infarction, and catheter-related complications. (S – Strong, M)
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We suggest that the SMA is the primary target for revascularization. (W – Weak, M)
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We suggest that the celiac axis and inferior mesenteric artery are secondary targets for revascularization and that revascularization may aid in symptom relief if the SMA is not suitable for intervention or the technical result is not acceptable. (W – Weak, M)
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In patients with symptoms consistent with CMI and occlusive disease isolated to a single mesenteric vessel, particularly the SMA, we suggest a shared decision-making approach between the patient and provider to discuss revascularization as a treatment option. (W – Weak, L)
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In patients with symptoms consistent with CMI and occlusive disease isolated to a single mesenteric vessel, particularly the SMA, we suggest a shared decision-making approach between the patient and provider to discuss revascularization as a treatment option. (W – Weak, L)
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We recommend that asymptomatic patients with severe MAOD be closely followed for symptoms consistent with CMI. A possible follow-up schedule includes an annual evaluation with a mesenteric duplex ultrasound. (S – Strong, L)
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In patients with severe MAOD involving the SMA undergoing aortic reconstruction, both open and endovascular, we suggest a shared decision-making approach between the patient and provider to discuss revascularization as a treatment option. (W – Weak, L)
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In patients with combined MAOD and mesenteric artery aneurysms, we recommend revascularization at the time of treatment for their mesenteric artery aneurysms if the repair alone would disrupt the collateral network. (S – Strong, L)
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Choice of Treatment

The choice of treatment for patients with CMI should be a shared decision-making process between the patient and provider considering the risks/benefits of the various options and the patient’s goals of care. (G-U, )
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We recommend endovascular revascularization as the initial treatment for patients with CMI and suitable lesions. (S – Strong, M)
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We recommend reserving open surgical revascularization for patients with CMI who have lesions that are not amenable to endovascular therapy, endovascular failures, and a select group of younger, healthier patients for whom the long-term benefits may offset the increased perioperative risks. (S – Strong, M)
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Preoperative Evaluation

Patients undergoing revascularization for CMI should be optimized from a medical standpoint before intervention, although their preoperative evaluation should be expedited. (G-U, )
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We recommend obtaining a CTA to delineate the vascular anatomy before any revascularization. A catheter-based arteriogram may be an alternative if the anatomy is not clear on the CTA. (S – Strong, H)
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Endovascular Revascularization

We suggest using balloon-expandable covered intraluminal stents for the treatment of the MAOD in patients with CMI. (W – Weak, L)
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Open Surgical Revascularization

The choice of open surgical revascularization for CMI should be determined by anatomy, comorbidities, prior interventions, and provider preference. (G-U, )
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Recommendation Grading

Overview

Title

Chronic Mesenteric Ischemia

Authoring Organization

Society for Vascular Surgery

Publication Month/Year

December 31, 2020

Last Updated Month/Year

October 14, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Patient Population

Patients with Chronic mesenteric ischemia (CMI)

Inclusion Criteria

Male, Female, Older adult

Health Care Settings

Ambulatory, Emergency care, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment

Diseases/Conditions (MeSH)

D065666 - Mesenteric Ischemia

Keywords

Chronic Mesentric Ischemia, mesenteric artery, Endovascular revascularization, intraluminal stent

Source Citation

Huber T, Bjorck M, Chandra A, et al. Chronic Mesenteric Ischemia: Clinical Practice Guidelines from the Society for Vascular Surgery. J Vasc Surg. 2020. doi:10.1016/j.jvs.2020.10.029