Chronic Mesenteric Ischemia: An Update
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COMMENTARY
COMMENTARY
Chronic Mesenteric Ischemia: An Update Louis Boyer1,2
Received: 28 May 2020 / Accepted: 20 June 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
Introduction The underappreciation of chronic mesenteric ischemia (CMI), diagnostic delays, underdiagnosis and undertreatment, potentially results in fatal acute mesenteric ischemia (AMI). United European Gastroenterology acknowledged the need for a multidisciplinary guideline providing a comprehensive overview and expert agreement, on behalf of gastroenterological and radiological (CIRSE, ESGAR) societies. In this way, 33 recommendations cover the full multidisciplinary spectrum of CMI and needs of all physicians involved. The GRADE ‘‘evidence to decision’’ framework and modified Delphi method were used to reach and express a consensus recently published in published in the United European Gastroenterology Journal [1]. The absence of the classical clinical CMI triad (i.e., postprandial pain, weight loss and abdominal bruit) does not exclude the diagnosis, which is based on a combination of compatible history, significant mesenteric artery (MA) stenosis on radiological imaging and preferably a positive functional test, discussed in an expert multidisciplinary setting by at least a GastroEnterologist, a surgeon and a radiologist. To exclude alternative diagnosis, at least upper GI endoscopy and CTA (imaging test of choice or CE
& Louis Boyer [email protected] 1
Radiology Department, Clermont-Ferrand University Hospital, PB 69, 63003 Clermont Ferrand, France
2
TGI, Institut Pascal, UMR 6602 UCA/CNRS/SIGMA, Clermont, France
MRA in case of contraindication of CT) must be performed. In symptomatic patients: •
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with single-vessel disease of either the celiac artery (CA) or superior mesenteric artery (SMA), a [ 70% stenosis could be considered relevant; with extensive multivessel mesentery artery (MA) disease, a 50% stenosis of the SMA could be considered relevant.
It might be disadvantageous to increase oral intake, start enteral tube feeding or total parenteral nutrition before revascularization Experts considered that the preferred entry site for MA revascularization is the femoral artery, followed by the left brachial or radial artery, and is dependent of expertise. In atherosclerotic MA lesions, PTA and stenting are recommended over PTA alone. In case of both SMA and CA occlusive disease, both vessels revascularization may be attempted, but SMA is the preferred target. After stenting, dual antiplatelet therapy for at least 1 month is suggested, followed by long life monotherapy; in patient with previous anticoagulation, one antiplatelet agent for 4 weeks has to be added. Surgical mesenteric bypass might be reserved for patient in which endovascular (EV) revascularization is not suitable; there might be no preference for an antegrade or retrograde approach and for venous or prosthetic grafts In patients with symptoms and radi
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