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Chronic Intestinal Ischemia due to Multiple Severe Stenoses Treated by Endovascular Surgery in a High Risk Patient
Isquemia intestinal crónica por estenosis severa múltiple resuelta mediante cirugía endovascular en paciente de alto riesgo
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] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Isquemia intestinal crónica por estenosis severa múltiple resuelta mediante cirugía endovascular en paciente de alto riesgo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1144 "Ancho" => 850 "Tamanyo" => 99037 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Repermeabilization after stent placement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic intestinal ischemia is a very rare condition, generally caused by occlusive atherosclerotic disease (95%). The main symptom is postprandial abdominal pain, and diagnosis is based on symptoms and angiographic examinations of arterial lesions. Massive intestinal infarction is the most important complication.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 69-year-old male with a medical history that included active chronic smoking, left iliofemoral<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>left-right femoral-femoral bypass due to atherosclerosis in 1996, TURP for BPH and TURED because of a neoplasm one month earlier. The patient was hospitalized in order to study a poorly defined abdominal pain in the left iliac fossa that had made him come to the emergency department on several occasions over the course of the previous 2 months. The patient reported no alteration in bowel habit, although the family stated that he had lost an important amount of weight.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We ordered several tests in order to rule out any possible neoplastic processes. Abdominal CT demonstrated a nodule in liver segment III. The abdominal ultrasound results recommended extending the study with MRI. Given the non-specific mass, FNA was suggested, which was negative for malignant cells. At the same time, chest radiography showed nodules in the right lung; thoracic CT was ordered, which was normal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">It should be mentioned that, while hospitalized, the patient did not comply with the <span class="elsevierStyleItalic">nil per os</span> treatment and committed dietary transgressions without either the knowledge or consent of the medical personnel. As a result, it was very difficult for us to establish the diet/onset of pain correlation, which was triggered 15–60<span class="elsevierStyleHsp" style=""></span>min after oral intake.</p><p id="par0025" class="elsevierStylePara elsevierViewall">For this reason, we suspected possible intestinal ischemia. Abdominal aortoiliac CT angiography detected severe stenosis in the proximal end of the celiac trunk, complete obstruction of the proximal segment of the superior mesenteric artery and 70%–80% stenosis of the inferior mesenteric artery, which drained through the arc of Riolan. Colonoscopy showed the mucosa did not have an ischemic appearance, with isolated diverticula.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We arrived at the diagnosis of chronic intestinal ischemia affecting the 3 blood vessels.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In a multidisciplinary session with vascular surgery, radiology and general surgery specialists, and while considering the patient's high surgical risk, it was decided that we should perform angiography and attempt to place stents in the 3 affected blood vessels. However, only one stent was successfully inserted (7<span class="elsevierStyleHsp" style=""></span>mm×18<span class="elsevierStyleHsp" style=""></span>mm expandable balloon) in the inferior mesenteric artery, after which good permeabilization was achieved with quite an improvement in the patient's usual symptoms (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). In case of failure, we had considered an inferior aortomesenteric bypass as it had a good caliber posterior to the stenosis and a good arc of Riolan, although this would have entailed very high surgical risk.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The patient reinitiated oral intake with no new episodes of abdominal pain. He was discharged with treatment including clopidogrel and pantoprazole. One year later, he has not returned to the emergency department, and periodic outpatient follow-up visits in the outpatient consultation have been satisfactory.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Chronic intestinal ischemia is an uncommon condition, given the large quantity of collateral arteries and variant vessels that supply blood to the intestine. It is associated with high morbidity and mortality as its main complication is massive intestinal infarction. Its main etiology is occlusive atherosclerotic disease (95%), especially in the ostia of the 3 main trunks that supply the intestines: celiac trunk, superior mesenteric artery and inferior mesenteric artery.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The most common symptom is postprandial abdominal pain that appears 10–30<span class="elsevierStyleHsp" style=""></span>minutes after oral intake and lasts 1–3<span class="elsevierStyleHsp" style=""></span>h. As the pain progressively increases, the patient eats less and loses weight as a result.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The diagnosis is based on symptoms and the angiographic examinations of the arterial lesions. The differential diagnosis includes gastroesophageal reflux disease, irritable bowel syndrome, peptic ulcer or gastritis, chronic pancreatitis, visceral cancer and vasculitis, such as polyarteritis nodosa.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In chronic intestinal ischemia, angiography, which can be therapeutic, is still the exploration of choice. It should be mentioned, however, that in many instances the diagnostic suspicion arises from abdominal CT, CT angiography or MRA.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Traditionally, the treatment of this disease has been surgical revascularization of the visceral arteries. Endarterectomy and artery implants have also been used. Each of these treatments has important morbidity and mortality associated with advanced age, cardiovascular state and, to a lesser degree, failed revascularization.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,6</span></a> It is still the treatment of choice for patients who are fit or whose physical condition can be improved before surgery.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the 1980s, this disease started to be treated with balloon angioplasty and stents, a minimally invasive percutaneous technique with lower morbidity and mortality rates than traditional surgery. When the literature is reviewed, the results obtained give mean success rates above 90% and good immediate clinical results in 85%. There has been greater success obtained in non-ostial than in ostial lesions. Stent implantation should always be considered the first option after successful angioplasty.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,6–9</span></a> The technique is performed with local anesthesia and the patient can be discharged 24<span class="elsevierStyleHsp" style=""></span>h later, which reduces hospitalization times and increases patient comfort.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,10</span></a> Nevertheless, even though the results are initially good, there is a greater percentage of restenosis and higher symptoms recurrence than in revascularization surgery.</p><p id="par0070" class="elsevierStylePara elsevierViewall">When treating such cases, it is very important to understand the natural history of the disease while taking into account patient age, comorbidities and surgical risk. The decision-making process should be multidisciplinary and aimed at finding the best possible therapeutic option.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palau Figueroa T, Roura Agell M, González Martínez V, Medarde Ferrer M, De Caralt Mestres E. Isquemia intestinal crónica por estenosis severa múltiple resuelta mediante cirugía endovascular en paciente de alto riesgo. Cir Esp. 2015;93:48–50.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1172 "Ancho" => 851 "Tamanyo" => 78941 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Stenosis at the beginning of the inferior mesenteric artery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1144 "Ancho" => 850 "Tamanyo" => 99037 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Repermeabilization after stent placement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic meseneric ischemia. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 1 | 4 |
| 2024 October | 13 | 11 | 24 |
| 2024 September | 47 | 40 | 87 |
| 2024 August | 23 | 3 | 26 |
| 2024 July | 16 | 7 | 23 |
| 2024 June | 23 | 7 | 30 |
| 2024 May | 10 | 4 | 14 |
| 2024 April | 23 | 6 | 29 |
| 2024 March | 30 | 7 | 37 |
| 2024 February | 20 | 5 | 25 |
| 2024 January | 17 | 17 | 34 |
| 2023 December | 22 | 2 | 24 |
| 2023 November | 23 | 4 | 27 |
| 2023 October | 24 | 7 | 31 |
| 2023 September | 20 | 1 | 21 |
| 2023 August | 16 | 3 | 19 |
| 2023 July | 15 | 6 | 21 |
| 2023 June | 13 | 1 | 14 |
| 2023 May | 58 | 5 | 63 |
| 2023 April | 33 | 4 | 37 |
| 2023 March | 18 | 4 | 22 |
| 2023 February | 27 | 4 | 31 |
| 2023 January | 7 | 4 | 11 |
| 2022 December | 25 | 19 | 44 |
| 2022 November | 20 | 14 | 34 |
| 2022 October | 17 | 10 | 27 |
| 2022 September | 25 | 16 | 41 |
| 2022 August | 27 | 17 | 44 |
| 2022 July | 15 | 5 | 20 |
| 2022 June | 29 | 14 | 43 |
| 2022 May | 35 | 8 | 43 |
| 2022 April | 22 | 10 | 32 |
| 2022 March | 27 | 8 | 35 |
| 2022 February | 33 | 6 | 39 |
| 2022 January | 18 | 7 | 25 |
| 2021 December | 15 | 16 | 31 |
| 2021 November | 21 | 6 | 27 |
| 2021 October | 13 | 12 | 25 |
| 2021 September | 13 | 9 | 22 |
| 2021 August | 23 | 9 | 32 |
| 2021 July | 26 | 11 | 37 |
| 2021 June | 28 | 11 | 39 |
| 2021 May | 18 | 6 | 24 |
| 2021 April | 26 | 12 | 38 |
| 2021 March | 24 | 10 | 34 |
| 2021 February | 40 | 8 | 48 |
| 2021 January | 24 | 11 | 35 |
| 2020 December | 18 | 12 | 30 |
| 2020 November | 13 | 11 | 24 |
| 2020 October | 14 | 12 | 26 |
| 2020 September | 32 | 11 | 43 |
| 2020 August | 25 | 8 | 33 |
| 2020 July | 17 | 10 | 27 |
| 2020 June | 15 | 8 | 23 |
| 2020 May | 19 | 10 | 29 |
| 2020 April | 10 | 2 | 12 |
| 2020 March | 19 | 3 | 22 |
| 2020 February | 14 | 4 | 18 |
| 2020 January | 17 | 5 | 22 |
| 2019 December | 19 | 5 | 24 |
| 2019 November | 8 | 7 | 15 |
| 2019 October | 11 | 9 | 20 |
| 2019 September | 27 | 3 | 30 |
| 2019 August | 11 | 1 | 12 |
| 2019 July | 26 | 20 | 46 |
| 2019 June | 36 | 31 | 67 |
| 2019 May | 86 | 45 | 131 |
| 2019 April | 27 | 4 | 31 |
| 2019 March | 6 | 3 | 9 |
| 2019 February | 12 | 9 | 21 |
| 2019 January | 8 | 2 | 10 |
| 2018 December | 10 | 4 | 14 |
| 2018 November | 15 | 2 | 17 |
| 2018 October | 13 | 2 | 15 |
| 2018 September | 8 | 3 | 11 |
| 2018 August | 7 | 1 | 8 |
| 2018 July | 4 | 1 | 5 |
| 2018 June | 5 | 1 | 6 |
| 2018 May | 2 | 1 | 3 |
| 2018 April | 4 | 4 | 8 |
| 2018 March | 10 | 0 | 10 |
| 2018 February | 8 | 1 | 9 |
| 2018 January | 8 | 5 | 13 |
| 2017 December | 3 | 3 | 6 |
| 2017 November | 19 | 2 | 21 |
| 2017 October | 11 | 6 | 17 |
| 2017 September | 12 | 8 | 20 |
| 2017 August | 14 | 11 | 25 |
| 2017 July | 14 | 2 | 16 |
| 2017 June | 17 | 37 | 54 |
| 2017 May | 25 | 2 | 27 |
| 2017 April | 19 | 3 | 22 |
| 2017 March | 21 | 73 | 94 |
| 2017 February | 28 | 5 | 33 |
| 2017 January | 21 | 4 | 25 |
| 2016 December | 29 | 6 | 35 |
| 2016 November | 24 | 5 | 29 |
| 2016 October | 25 | 4 | 29 |
| 2016 September | 24 | 4 | 28 |
| 2016 August | 11 | 3 | 14 |
| 2016 July | 12 | 1 | 13 |
| 2016 June | 23 | 15 | 38 |
| 2016 May | 23 | 6 | 29 |
| 2016 April | 30 | 7 | 37 |
| 2016 March | 38 | 20 | 58 |
| 2016 February | 22 | 14 | 36 |
| 2016 January | 18 | 11 | 29 |
| 2015 December | 22 | 12 | 34 |
| 2015 November | 17 | 3 | 20 |
| 2015 October | 34 | 11 | 45 |
| 2015 September | 24 | 5 | 29 |
| 2015 August | 19 | 7 | 26 |
| 2015 July | 28 | 3 | 31 |
| 2015 June | 11 | 7 | 18 |
| 2015 May | 16 | 2 | 18 |
| 2015 April | 8 | 5 | 13 |
| 2015 March | 2 | 0 | 2 |
| 2015 February | 5 | 1 | 6 |
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