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LITHUANIAN UNIVERSITY OF HEALTH
SCIENCES
Clinic of Radiology
Department of Interventional Radiology
Liron Larisa Smolar
Literature Review
Clinical Efficiency of Endovascular Treatment of Acute
Superior Mesenteric Artery Occlusion
Master’s Thesis
Thesis Supervisor
Doc. Rytis Kaupas
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TABLE OF CONTENTS
1. SUMMARY……….3
2. CONFLICT OF INTEREST………4
3. CLEARANCE ISSUED BY THE ETHICS COMMITTEE………...5
4. ABBREVIATIONS……….6
5. TERMS………7
6. INTRODUCTION………...8
7. AIM AND OBJECTIVES………...9
8. RESEARCH METHODOLOGY AND METHODS………...10
9. RESULTS AND DISCUSSION………13
9.1 Diagnosis of acute SMA occlusion and relation to EVT choice………
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9.2 EVT modalities in acute SMA occlusion………...
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9.3 Complications and mortality rates related to EVT……….
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10. PRACTICAL RECOMMENDATIONS………...26
11. CONCLUSIONS………...27
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1. SUMMARY
1.1 Author: Liron Larisa Smolar
1.2 Title: Clinical Efficiency of Endovascular Treatment of Acute Superior Mesenteric Artery Occlusion.
1.3 Aim: To review the current literature about diagnosis and treatment of ATOSMA and to analyze the efficiency of endovascular therapy.
1.4 Objectives:
1. Analyze the diagnostic variables of ATOSMA and its relation to endovascular therapy. 2. Analyze treatment modalities and technical results of endovascular therapy in ATOSMA.
3. Analyze the complications and mortality rates of patients with ATOSMA following endovascular therapy.
1.5 Methods: A systematic review was conducted through PubMed electronic database search and
additional sources. 23 most relevant articles were included based on inclusion criteria of last 10 years, English language and human trials, and from those 10 articles were selected for quantitative analysis.
1.6 Results: 10 studies were included in this literature review, with sum of 302 patients with ATOSMA (mean age 73±7 years). On most of the studies, etiology of ATOSMA was embolus 52% and thrombus 45%. The main diagnostic tool that has been used is CTA 93%. The most common primary treatment is thrombectomy 50%. Thrombolysis is the second most common primary treatment 30%, while
PTA/stenting is secondary treatment most common 17%. Successful EVT was achieved in 80%. EVT required LPT in 51%. The most common complications following EVT are arterial perforations 4.3%, which are related to thrombectomy. In-hospital mortality rate is 27%, 30-day mortality rate is 25% and 1-year mortality rate is 40%.
1.7 Conclusions: Endovascular therapy has altered the management of ATOSMA, and there are
measurable advantages to this approach. Using endovascular therapy as the primary modality for ATOSMA reduces complications and reduces mortality rates.
1.8 Keywords: acute SMA occlusion, endovascular treatment, revascularization techniques, thrombolysis, thrombectomy, PTA/stent.
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2. CONFLICT OF INTEREST
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3. CLEARANCE ISSUED BY THE ETHICS COMMITTEE
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4. ABBREVIATIONS
ATOSMA- acute thromboembolic occlusion of superior mesenteric artery CT- computed tomography
CTA- computed tomography angiography EVT- endovascular treatment/therapy LPS- laparoscopy
LPT- laparotomy NS- non-specified
PTA- Percutaneous transluminal angioplasty SBS- short bowel syndrome
SMA- superior mesenteric artery SMI- superior mesenteric ischemia US- ultrasound
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5. TERMS
Clot- a thick mass of coagulated liquid, especially blood, that may lead to blood vessel occlusion
Embolization- development of an embolus
EVT strategies- types of endovascular treatment techniques
Laparoscopy- a surgical procedure in which an instrument is inserted through the abdominal wall to view the abdominal organs
Laparotomy- a surgical procedure in which an instrument is inserted through the abdominal wall in order to resect pathological abdominal organs (example: bowel necrosis)
Preoperative Variables- the factors which are presented before the operative therapy, on the stage of
diagnosis
Primary Treatment- the first line therapy
Secondary Treatment- the second line therapy, once the primary treatment has failed Thromboembolic Occlusion- Any vascular blockage caused by a thrombus or an embolus
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6. INTRODUCTION
Acute thromboembolic occlusions of the superior mesenteric artery (ATOSMA) is a life-threatening disease that is associated with pretty high mortality rate (60-90%) (1). This disease is
characterized by strangulated obstruction and maybe complicated by bowel necrosis, which has very poor prognosis. Although the improvements in treating acute thromboembolic occlusions, it is still associated with high morbidity and mortality, mainly due to unspecified symptoms and consequently delayed diagnosis.
On the last decade, it has been shown by the articles and their amount, that there is an increase in using endovascular procedures as the first line therapy of acute thromboembolic occlusions in SMA, when there are no clinical and imaging signs of peritonitis. The advantages of endovascular therapy (EVT) are
significantly important for the patient’s prognosis, as it is shown that the endovascular revascularization leads to more rapid blood flow in the SMA and that there are fewer postoperative complications,
compared with open surgery.
On this systematic review, there have been efforts to review as many as cases and literature reviews, in order to assess and analyze the efficiency of EVT in various aspects. Firstly, it was assessed if diagnostic variables of patients with ATOSMA affect the choice of treatment, and if the treatment was efficient in means of those variables. Secondly, it was assessed which types of endovascular therapy are accessible, which of them is the most efficient, and for which cases. Thirdly, postoperative complications and mortality rates of SMA occlusions following EVT were also assessed.
In generally, it looks like in the near future more researches will be conducted about acute SMA
occlusions and their treatment plan, focusing on enhancing the different types of endovascular procedures. I assume that more researches will be published in order to get better understanding about which treatment is the most efficient and on which conditions, in order to improve the algorithms and protocols that are withheld these days. My thesis aim is to review the diagnosis variables, types of EVT, outcomes following EVT, and to analyze their effect on EVT efficiency and vice versa.
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7. AIM AND OBJECTIVES
7.1 Research Aim:
To review the current literature about diagnosis and treatment of ATOSMA and to analyze the efficiency of endovascular therapy.
7.2 Objectives:
1. Analyze the diagnosis of ATOSMA and its relation to endovascular therapy.
2. Analyze treatment modalities and technical results of endovascular therapy in ATOSMA.
3. Analyze the complications and mortality rates of patients with ATOSMA following endovascular therapy.
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8. RESEARCH METHODOLOGY AND METHODS
8.1 Search strategy:
The literature search was performed by screening different electronic databases including PubMed, SpringerLink, ScienceDirect, JVS (Journal of Vascular Surgery) and ESVS (European Society for Vascular Surgery). It was conducted following the PRISMA (preferred reporting items for systematic reviews and meta-analysis) statement. Total of 41 literature sources were reviewed fully. 23 most relevant (by abstracts and full text review) articles were selected, and from them 10 articles for quantitative
analysis. The search was restricted to English and last 10 years articles only (with an exception of 2 articles: Wyers et al. from 2007, Berczi et al. 2002).
8.2 Types of publication and studies:
This review included systematic reviews and clinical trials published in English during the last 10 years, and which done on humans only.
8.3 Information source:
The information sources are PubMed, SpringerLink, ScienceDirect, JVS (Journal of Vascular Surgery) and ESVS (European Society for Vascular Surgery.
8.4 Selection criteria:
The search terms and keywords used include: - “EVT and acute SMA occlusion”
- “EVT of acute SMA occlusions and/or diagnosis and/or age and/or etiology and/or duration of symptoms and/or perioperative imaging.”
- “EVT strategies in acute SMA occlusions and/or thrombolysis and/or thrombectomy and/or PTA/stent.” - “EVT of acute SMA occlusions and/or complications and/or mortality rate.”
8.5 Exclusion criteria:
- More than 10 years publication.
11 - Patients who had acute mesenteric ischemia secondary to mesenteric venous thromboembolism, non-occlusive mesenteric ischemia, aortic dissection complicated by visceral ischemia, and visceral ischemia occurring due to iatrogenic circumstances.
- Patients who had chronic mesenteric ischemia.
8.6 Data collection process:
The search results provided 107 articles in total, from all information sources. After reduction based on duplication of articles, were left 71 articles. Articles which were more than 10 years, not human trials and not English language were not included, and 41 articles were left. Finally, 23 articles were selected based on abstract and full text review for qualitative synthesis, and from that-10 articles for quantitative analysis. Figure 1. Shows Flow chart for articles exclusion and inclusion processes in the study.
12 Figure 1. Flow chart for articles exclusion and inclusion processes in the study
Records identified through database searching (n =78) Scre e n in g In clu d e d El ig ib ili ty Id e n ti fi ca ti o n
Additional records identified through other sources
(n = 29)
Records after duplicates removed (n = 71)
Potentially relevant articles (n = 71)
Records excluded based on more than 10 years, non-human trials and non-English
(n = 30)
Full-text articles assessed for eligibility
(n =41)
Full-text articles excluded, with reasons
(n =18) Studies included in qualitative synthesis (n = 23) Studies included in quantitative synthesis (meta-analysis) (n =10)
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9. RESULTS AND THEIR DISCUSSION
9.1 Diagnosis of Acute SMA Occlusion and Relation to EVT Choice
In the following table 1, there are 10 studies which are summarized and are presenting the
preoperative variables of patients with acute superior mesenteric occlusion and the type of endovascular therapy they received. In total there are 302 patients (added from all 10 studies) who had acute
thromboembolic occlusion and undergo endovascular treatment during 2009-2018.
The mean age of the patients is 73 years old (60.2-80 years). The etiologies which were presented are occlusions secondary to thrombosis from preexisting calcifies lesions or stenosis, and embolus which is a clot surrounded by non-calcified artery, due to cardiac arrhythmias and other non-occlusive reasons. Embolus was the most frequent reason of ATOSMA in most of the studies with mean of 52% (n=128) while thrombus 45% (n=111). Most studies have been shown that there is a statistical significance (P<0.05) between etiology and EVT choice of treatment.
Abdominal pain was the most common presenting symptom 80% (n=145).
Almost all patients were evaluated with contrast tomography angiography (CTA), because it is the golden standard for blood vessels occlusions 93% (n=164). If any signs of peritonitis were revealed by clinical abdominal examination on admission and CT, laparotomy should be performed, in order to evaluate the extent of bowel ischemia and maybe necrosis, and to perform bowel resection if needed (3).
The time from symptoms onset to the intervention is ranging from 8.7 hours to 97 hours with mean of 32 hours. By the study of Okamura et al. (4) the “golden hour”, which is the time that essential for preserving the ischemic bowel, and it is dependent on the extent and portion of occlusion. The golden hours for selective thrombolytic therapy are 5 hours for occlusion of the SMA main trunk and 12 h for the occlusion of the distal SMA. Though, after 48 hours there is increased risk for complications, which means that most of the studies have accomplished doing it on time by this golden hour.
On Arthurs et al. (8) which is the largest study that have been done on patients (n=70) with ATOSMA has been shown that EVT was the preferred primary choice of treatment 56 (81%) compared to open surgery 14 (19%). Although, there was not found a preference for a specific EVT strategy, because the modalities were different in each study center. The difference of EVT strategy choice might be explained by the interventional radiologist’s preference.
14 Table 1. preoperative variables and EVT modalities
15 Reference Number of patients Age (median age in years)
Etiology % (N) Symptoms Duration of symptoms onset to intervention (median hours) Diagnosis Treatment Embol-us
Thrombus Other
Thrombo-lysis Thrombe ctomy PTA/stent Acosta 2009 (5) 21 73 48% (10) 52% (11) 0% (0) NS 97 NS 10% 38% 24% Block 2010 (6) 42 77 29% (12) 62% (26) 9% (4) Abdominal pain, Vomiting (46%), Diarrhea (51%), Hematochezia (11%) 36 CTA: 62% 38% 9% 53% Bjornsson 2011 (7) 34 78 82% (28) 18% (6) 0% (0) Acute abdominal pain 30% (10), Sudden abdominal pain 36% (12), Bloody stools 3% (1), Diarrhea 36% (12), Vomiting 62% (21), Atrial fibrillation 62% (21) 15 CTA: 94% 100% 0% 0% Arthurs 2011 (8) 56 65 35% (20) 65% (36) 0% (0) Abdominal pain 92%, Nausea 69%, Emesis 51%, Bloody diarrhea 31% 26 CTA 82%, Angiography 7%, DUS 11% 48% 11% 32% Kuhelj 2013 (9) 3 80 100% (3) 0% (0) 0% (0) Acute abdominal pain 100%, Thoracic pain 33.3% NS CTA 100% 0% 100% 0% Jia 2014 (10) 21 71 NS NS 0% (0) Abdominal pain and no evidence of advanced bowel ischemia sign 8.7 Serum D-dimmer 66.7%, CTA 67% 0% 100% 0%
16 Karkkaine -n 2015 (11) 50 79 36% (18) 64% (32) 0% (0) Abdominal pain 94%, Abdominal distension 26%, Diarrhea 48%, Vomiting 56%, Paralytic ileus 20%, GI bleeding 14%, NS NS 0% 40% 60% Raupach 2016 (12) 37 76 100% (37) 0% (0) 0% (0) Abdominal pain Diarrhea, Bloody diarrhea, Nausea, Emesis NS NS 0% 100% 0% Zhang 2017 (1) 18 60.2 NS NS NS Abdominal pain 100%, abdominal tenderness and rebound 11% 12 NS 100% 0% 0% Freitas 2018 (13) 20 69.8 NS NS 0% Abdominal pain 65%, Ileus 35%, sepsis 25% NS CT 75% 0% 100% 0% Total Mean% (Number) N=302 N=73 52% (128) 45% (111) 3% (4) Abdominal pain 80% (145) N=32 CTA 93% (164) Serum D-dimer 11% (19) DUS 2% (4) Angiography 1% (2) 30% (90) 50% (151) 17% (51)
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9.2 EVT modalities in acute SMA occlusion
The most important goal of treating acute SMA occlusion is restoring the blood flow as soon as possible. Early diagnosis and treatment have been shown prevention of intestinal infarction and further laparotomy.
In the following table 2, have been shown the same 10 studies as in table 1, but with the
operative strategy aspects. The types of the primary treatments which are shown, means that it is the first-line therapy for patients with ATOSMA. The secondary treatments were given as a second-line therapy, in case the first ones have failed. Secondary treatment is defined on some studies as “adjuvant therapy”, as it was additional treatment for the primary one.
From the table 2, it has been shown that the most common endovascular treatment that have been used as the primary therapy is thrombectomy 50% (151). It might be due to the preference of performing interventional radiologist, who has better skills in treating with thrombectomy devices. Two main methods of Percutaneous thrombectomy are aspiration thrombectomy, in which the occlusion is removed by suction and mechanical thrombectomy, in which different automated devices fragment the clot and remove it.
9.2.1 Thrombectomy
There are two thrombectomy methods: aspiration thrombectomy, in which thrombus is removed by suction, and mechanical thrombectomy, using different automated devices to fragment and remove embolus (9).
The main mechanical thrombectomy devices are Aspirex S® and Rotarex S® (Straub Medical, Wangs, Switzerland). These are rotating over-the-wire devices, which their rotations produce a continuous vacuum, inside the catheter. This leads to aspiration of the material into the catheter and the following collecting bag. Both are 6 French gauge (Fr, F) and 8 Fr systems, suitable for the use in arteries with a diameter larger than 3 mm (15). The main advantage of this procedure is rapid and effective removal of large thrombus without the need of local thrombolysis.
18 The main disadvantage of thrombectomy is the revascularization of completely occluded SMA ostium, due to the risk for distal arterial embolization, and subsequent a risk for a rupture by the mechanical device. In some cases there is a need for adjuvant thrombolysis, in order to get rid of the distal embolization, and avoid risk of rupture with the mechanical device, as in the case of Björnsson et al.(7).
AngioJet (Possis Medical, Minneapolis, Minnesota, USA)(14) is a suction/aspiration device. This thrombectomy method is accomplished by inserting saline jet stream with pressure through the directed orifices in the catheter tip. The saline and clot particles are then sucked back into the exhaust lumen of the catheter and out of the body for disposal.
Percutaneous aspiration thrombectomy mainly suits cases where there is an acute embolic
occlusion. The advantages of this procedure are that aspiration thrombectomy is a rapid, low-cost and with high technical success rates (16). The main disadvantages of this procedure are that it’s not suitable for high adherent thrombi, sometimes requires several passes, and it may be
complicated with ante grade dissections (15,17).
9.2.2 Thrombolysis
By table 2 it is shown that thrombolysis technique was used as the second most common 30% (90) (after thrombectomy) for primary treatment. Pharmacological thrombolysis means a local infusion of thrombolytic agent by a catheter. As this procedure may take a long time and the ischemia might lead eventually to necrosis, those patients who are applied for this therapy should be in the early stages of ischemia. This procedure includes access through femoral artery; brachial artery or both. Local thrombolysis is achieved by administration of recombinant tissue plasminogen activator at a rate of 0,5–1 mg/h, checking progress angiographically once or twice per day. Small peripheral residual emboli can be treated conservatively with heparin
anticoagulation as the marginal arteries in the mesentery may provide sufficient collateral circulation to the affected intestinal segment (18).
One of the advantages of thrombolysis is regarding the source of the occlusion- acute emboli were mostly treated by pharmacological thrombolysis, as it seems more suitable for this etiology.
19 Emboli usually dislodged to the peripheral subdivisions of the SMA and can be treated
effectively by thrombolytic agent from a catheter, which is placed above or within the clot. In this way the lysis is exerted downstream, into more distal branches (7).
Another advantage is regarding its invasiveness, which is much less invasive than the other EVT techniques, and it enables accurate evaluation of intestinal blood flow during the procedure itself. Some patients have adjunctive endovascular procedures at the time of the local intra-arterial thrombolysis. Adjunctive endovascular procedures include aspiration thrombectomy, mechanical thrombectomy, PTA/stenting. The aim of adjunctive procedures is to reduce the occlusion mass, in order to reduce the need of local thrombolysis, to restore the blood flow faster, and to avoid risk of bleeding.
9.2.3 Percutaneous Transluminal Angioplasty (PTA)/Stenting
By table 2 it is shown that PTA or stenting procedure were merely used as the primary treatment 17% (51), although on the secondary treatment 18% (vs. thrombolysis 14%;
thrombectomy 15%) it was chosen firstly. It is mainly used when local thrombolysis or thrombectomy were tried beforehand. In most of cases, ante grade approach is achieved by inserting a guide wire into brachial or radial access (19), followed by dilatation with an expandable balloon. When eventually a stable wire has been placed in the ileocolic artery, an introducer is placed on the atherosclerotic lesion. Then the balloon expandable stent is placed at the treatment site, followed by retraction of the protective introducer sheath, which eventually exposing the stent.
One of the main disadvantages of this procedure is artery angulation or a potential risk of arterial dissection at the end of the stent. Though, it is treated by extension with a self-expanding stent into the middle SMA. If the angiography shows that there is a residual pressure gradient across the stent which exceeding 10 mmHg, additional angioplasty and/or stenting is performed (18).
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9.2.4 Results of EVT Strategies
It has been shown on table-2 additional data about technical success, clinical success and laparotomy (LPT)/ laparoscopy (LPS) and/or bowel resection rates. Technical success is defined as the restoration of the blood flow in SMA without the need for re-intervention (endovascular or vascular surgical intervention) on the moment of the actual procedure (short-term success). Clinical success defined as the success of revascularization on the long term, with low reoccurrence rate (2). Technical success in most of the studies reached high percentages with mean of 80%, mainly on the studies where Thrombectomy was mostly used. While clinical rates with mean of 88% (collected only from 1 study, as this information is collaborated
retrospectively and is not easy to be managed).
In some cases, laparotomy (51%) was used in patients who presented with clinical and laboratory signs of peritonitis. Also, patients who failed to be treated with primary therapy, due to signs of bowel necrosis, were directly managed with laparotomy and sometimes open bowel resection (36%). Thus, in some studies there was no use in secondary treatment.
Wyers et al. (20) focused on the benefits of combining laparotomy (direct bowel examination to confirm viability) with endovascular therapy, in order to avoid an unnecessary open bowel operation. Moreover, successful recanalization doesn’t firmly avoid a following laparotomy, due to the purpose of checking and/or resects the bowel. Necrotic bowel must be resected as soon as possible at the moment it is diagnosed, in order to prevent deadly septic shock (2).
Laparoscopy is used in fewer percentages (2%), and mainly used for reducing the risk of short bowel syndrome, which occurs due to extensive bowel resection and unnecessary laparotomy.
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Reference
Primary Treatment Secondary Treatment Technical success Clinical success LPT/LPS or/and resection Thrombo -lysis
Thrombectomy PTA/stent Thrombo -lysis Thrombecto my PTA/stent LPT LPS Resection Acosta 2009 (5) 10% 38% 24% 25% NS NS NS NS 67% 8% 43% Block 2010 (6) 38% 9% 53% 12% NS NS 79% NS 73% 0% 40.5% Bjornsson 2011 (7) 100% 0% 0% 0% 35.2% 8.8% 88% NS 38% 0% 24% Arthurs 2011 (8) 48% 11% 32% 0% 12% (Of thrombolysis) 33% (of thrombolysi s) 22% (of thrombecto my) 87% NS 69% NS NS Kuhelj 2013 (9) 0% 100% 0% 0% 0% 0% NS NS 0% 0% 0% Jia 2014 (10) 0% 100% 0% 67% 0% 5% NS 88% NS NS NS Karkkaine-n 2015 (11) 0% 40% 60% NS NS NS 88% NS 40% NS 34% Raupach 2016 (12) 0% 100% 0% 4.9% 0% 5% 91.9% NS 73% NS 40.5% Zhang 2017 (1) 100% 0% 0% 0% 50% 17% 44.4% NS 33% NS 33% Freitas 2018 (13) 0% 100% (mechanical) 0% 20% 10% (aspiration) 60% NS NS 70% 0% 70% Total Mean% (Number) 30% (90) 50% (151) 17% (51) 14% 15% 18% 80% 88% 51% 2% 36%
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9.3 Complications and Mortality Rates related to EVT
9.3.1 Complications
According to table-3, there are few EVT-related complications, which are common to all endovascular techniques. By the results, it was found that perforation (4.3%) of the distal SMA branches has the highest risk to occur following EVT, and mainly is related to thrombectomy use. Other complications which are related to trauma of the vessels by different EVT techniques are: Access-site thrombosis (0.9%), SMA dissections (1.1%), distal embolization (1.9%), internal (1.8%) and access-site bleeding (2.1%).
The use of distal embolic protection devices may minimize the risk of bowel necrosis as a consequence of distal embolization (2). Moreover, studies have been shown that small distal perforations were managed by simple coiling, while SMA dissections were mainly treated by conservative treatment (antiplatelet therapy, blood pressure control, bowel rest, intravenous fluids, and nutritional support with or without antithrombotic therapy (22)).
The second leading high-risk complication is bleeding. It has been shown that bleedings can be from the access site or from internal site, which can eventually be fatal. By the results, access-site bleeding is presented in most of the studies, without any relation to specific EVT technique. On the other hand, internal bleeding was highly related to endovascular thrombolysis use. In general, bleeding complication was more common in patients who were treated with systemic anticoagulants, and it was defined as a complication on the cases where transfusions and surgical intervention were required. The Bjornsson et al. study, which focused on thrombolysis as the main EVT, declaimed that the risk of bleeding during the procedure should not avoid the clinician’s decision to use it as the primary treatment of acute SMA occlusion. In case of moderate bleeding, explorative laparotomy can be followed and reversal of heparin with
Protamine Sulfate. In case of severe bleeding, reversal of alteplase is not required due to its short mode of action, while reversal of heparin is obligatory (7).
Post-operative infection (1.6%) and stroke (0.2%) were found in two different single studies, which mean it is not so common complications.
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9.3.2 Mortality Rate
Acute thromboembolic occlusion of SMA is associated with a high rate of morbidity and mortality despite many improvements in the diagnosis and treatment of this condition. On the following table 3, it has been shown that there are high mortality rates that are also dependent on the time of period since the initial ATOSMA treatment.
In-hospital mortality rate (27%) is defined as an early death, before discharge from hospital. It might be due to persistent ischemia, complications related to persistent ischemia, or hemorrhagic complications related to massive anticoagulant therapy (2). Short term mortality is defined as death within a 30-day period following discharge from the hospital (25%). Long term mortality is defined as death within a 1-year period following discharge from the hospital (40%).
On some studies it was found that there is an association between increased length of the resected bowel with 30-day mortality rate. The increased length of resected bowel usually resulted with short bowel syndrome (SBS), a malabsorptive state. It was not defined as EVT-related complication, but because of the superior mesenteric ischemia (SMI) and a main factor affecting the mortality rate. In addition, studies which compared EVT to open surgery show that there is a significantly less bowel resection in EVT group and consequently a lower mortality rate (21). Other factors which may be associated with lower mortality rate are successful
primary endovascular revascularization, correct diagnosis on CT in early stages of the ischemia,
and absence of SBS. Age, onset of abdominal pain and comorbidities were found to be independent variables that did not affect the mortality rate.
Moreover, on Arthurs et al. (8) which is the largest study that have been done on patients (n=70) with ATOSMA has been shown that mortality rate for EVT was 36% compared with 50% (P<0.05) in patients treated with open surgery. The main reason for the difference is that EVT is less invasive procedure and carries lower rates of procedure-related complications.
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Reference Treatment Complications of EVT procedure In-hospital mortality rate 30 days mortality rate 1-year mortality rate Thrombo-lysis Thrombect omy PTA/stent Acosta 2009 (5) 10% 38% 24% Dissections 9%; Emboli in peripheral branches 5% 14% NS NS Block 2010 (6) 38% 9% 53% Postoperative Infection 16% 27% 24% 38% Bjornsson 2011 (7) 100% 0% 0% Internal bleeding 15%;
Thrombosis at the access site 9%; Distal embolization 9%;
26% 24% 41%
Arthurs 2011 (8)
48% 11% 32% Access site bleeding 9%. Successful EVT
36% Failed EVT 50%
NS NS
Kuhelj 2013 (9)
0% 100% 0% Perforation of small branch of
SMA 33.3%
NS NS NS
Jia 2014 (10) 0% 100% 0% NS 24% 9.5% NS
Karkkainen 2015 (11)
0% 40% 60% Access site Bleeding 4%;
Dissections 2%; Stroke (from brachial access) 2%
30% 32% 42%* (6 months
mortality rate)
Raupach 2016 (12)
0% 100% 0% Access site bleeding 8%;
Peripheral embolization 5.4%; Fatal bleeding 2.7% 27% 27% NS Zhang 2017 (1) 100% 0% 0% NS NS 16.7% NS
25 Freitas 2018
(13)
0% 100% 0% Self-limited small perforations
10% NS 40% NS Total Mean% (Number) 30% (90) 50% (151) 17% (51) Perforations 4.3% Access-site Bleeding 2.1% Embolization 1.9% Internal bleeding 1.8% Post-operative infection 1.6% Dissections 1.1% Access-site Thrombosis 0.9% Stroke 0.2% 27% 25% 40%
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10. PRACTICAL RECOMMENDATIONS
1. The managing of ATOSMA should include team of internal doctors, interventional radiologist, gastroenterologist surgeons and other specialists as indicated and needed. 2. CT angiography should be performed in all patients who are suspected with ATOSMA
(elderly patients with acute abdominal pain presentation always need to be in high suspicion). Also, CT should be used for exclusion of peritonitis/bowel necrosis.
3. Patients who do not have peritonitis/bowel necrosis signs, should be approached to EVT. Patients who do have peritonitis/bowel necrosis signs should be taken directly to the operating room for laparotomy in order to evaluate the bowel and treat it.
4. CTA should also be used to identify the type of the occlusion (embolic/thrombotic). 5. EVT modality should be chosen by the preference of the interventional radiologist, with
some attention to the etiology of occlusion.
6. Aspiration thrombectomy with adjuvant thrombolysis should be considered in acute embolic occlusion. Mechanical thrombectomy with adjuvant thrombolysis/ stent placement, should be considered in acute thrombosis.
7. For those who undergo EVT, there should be a low threshold to convert to open surgery at any time if problems arise or the patient's clinical condition deteriorates.
8. A palliative therapy may be the best option for poor-risk surgical candidates with extensive transmural infarction.
9. Patients after mesenteric revascularization who show no improvement, should undergo a second-look laparotomy 24 to 48 hours after the initial operation, in order to reevaluate the bowel.
10. Long-term management is aimed at preventing future embolic events with
anticoagulation, and cardiovascular risk reduction strategies in those with thrombotic arterial occlusion related to atherosclerosis.
11. Patients who undergo mesenteric artery stenting should have a periodic follow-up. Duplex ultrasound or CT angiography, at periods of 3 months post-intervention, then every 6 months for up to 2 years, and annually thereafter. For those with recurrent stenosis, reintervention may be needed to prevent stent occlusion, which can lead to recurrent symptoms.
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11. CONCLUSIONS
ATOSMA remains one of the most difficult diseases to diagnose. Early detection of the disease and open surgery approach have limited possibilities to increase patients’ survival rates. On the recent decade, endovascular treatment has changed the approach to ATOSMA treatment by reducing laparotomy use, hence reducing length of bowl resection and following mortality rates. Endovascular therapy in acute mesenteric artery occlusion shows high technical and clinical success rates with few complications.
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12. REFRENCES
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