This review of a single article includes pearls on the author’s approach to diagnosis, medical management and endovascular management of mesenteric ischemia.
Avoid pressors which worsen ischemia.
Fluid resuscitate as much as possible.
For Mesenteric Vein Thrombosis, treat with aggressive anticoagulation.
Thrombolytics are rarely helpful but can be given in patients with know embolic or thrombotic disease and no signs of peritonitis or bowel necrosis (1). Only useful if given within 8 hours of onset, and should result in symptomatic improvement within 4 hours of initiation (1). Tpa dose is 0.9mg/kg IV given over 60 minutes, with 10% of total dose given in first 1 minute, NTE 90mg (1).
Starts with quality diagnostic 3 vessel angiogram.
Consider vasodilators for all etiologies of symptomatic acute mesenteric ischemia (1). 30-60mg/h IA for 24 hours. Do not use heparin at same time as papaverine. Watch for profound hypotension which can occur when catheter slips into aorta(1).
NOMI should definitely be treated with papaverine infusion as above.
IA tpa? Not aware of any data, but reasonable to assume it may work for known embolic/thrombotic ischemia of recent onset, if administered similar to IA stroke therapy. Must not have clinical signs of peritonitis or bowel necrosis.
Stenoses can be treated with angioplasty (20-50% restenosis rates), or stenting (1).
1. Dang, et al; Acute Mesenteric Ischemia: Treatment and Medication. Emedicine, 2010.
Jason E. Himmel, M.D.
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