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Image of the Month—Diagnosis
Arch Surg. 2007;142(8):798.
Answer: Visceral Aortic Atherosclerosis
Mesenteric ischemia is a morbid disease affecting an increasing number of individuals, possibly as a result of the aging of the population. While angioplasty and stenting have assumed a primary role in the treatment of orificial disease of the renal arteries, the role of angioplasty and stenting in the treatment of atherosclerotic disease affecting the celiac and superior mesenteric vessels is less defined. Comparative studies of modern open and endovascular revascularization are now emerging,1-2 but randomized data are not likely to come to fruition because of relative infrequency of the condition and the perceived risk of open surgery for patients with acute and chronic ischemia of the mesenteric vasculature. Indeed, approximately half of patients with mesenteric ischemia will have significant coronary disease (the patient of this case, for example, had 19 coronary stents) or peripheral vascular disease.3-4 Weight loss is very common in patients with chronic mesenteric ischemia (84%-100%) but may be less often appreciated in acute mesenteric ischemia.1 Such weight loss is a major contributor to increased major morbidity and mortality seen in open mesenteric revascularization. Whether open or endovascular revascularization is chosen, several important differences between the two deserve mention. While both therapies are associated with high technical success rates (92%-100%), endovascular revascularization has a much higher rate of recurrent symptoms, restenosis of the placed stents, and need for reintervention (30%-50% at 1 year).1-2 However, as most of these secondary interventions remain endovascular in nature, the avoidance of major morbidity and long hospitalizations is preserved. Given the favorable safety profile, the avoidance of major cavitary incisions, and the reduced physiologic stress on the patient (many of whom have significant coronary disease), it is likely that endovascular approaches to acute and chronic mesenteric ischemia will assume increasing importance in the triage of patients presenting with mesenteric vascular disease. For the low-risk patient, open surgical revascularization of mesenteric vascular disease may be strongly considered given its established durability and freedom from recurrent symptoms.
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Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgery has temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid 2008. Thank you.
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AUTHOR INFORMATION
Correspondence: James Hamilton Black III, MD, Department of Surgery, Harvey 611, 600 N Wolfe St, Baltimore, MD 21287 (jhblack{at}jhmi.edu).
Accepted for Publication: August 26, 2006.
Financial Disclosure: None reported.
REFERENCES
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1. Brown DJ, Schermerhorn ML, Powell RJ; et al. Mesenteric stenting for chronic ischemia. J Vasc Surg. 2005;42(2):268-274.
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2. Oderich GS, Sullivan TM, Bower TC; et al. Open vs endovascular revascularization for chronic ischemia: risk-stratified outcomes. Paper presented at: Society for Vascular Surgery Annual Meeting; June 3, 2006; Philadelphia, PA.3. McAfee MK, Cherry KJ Jr, Naessens JM; et al. Influence of complete revascularization on chronic mesenteric ischemia. Am J Surg. 1992;164(3):220-224.
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4. Johnston KW, Lindsay TF, Walker PM, Kalman PG. Mesenteric arterial bypass grafts: early and late results and suggested approach for chronic and acute mesenteric ischemia. Surgery. 1995;118(1):1-7.
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SECTION EDITOR: GRACE S. ROZYCKI, MD
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Image of the Month—Quiz Case
James Hamilton Black, III
Arch Surg. 2007;142(8):797.
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