Could risk factors be better predictors of early acute mesenteric ischemia than laboratory and imaging studies? Retrospective study and algorithm for the early intervention
Abstract
Objectives The aim is to delineate relevant risk factors and construct an algorithm for earlier performance of selective mesenteric angiography, thus lowering mortality rates of acute mesenteric ischemia. Methods During a 5-year period 31 patients were examined. Thirteen risk factors were analysed and compared to standard diagnostic procedures. Results Only one patient did not have arterial hypertension. The second most common risk factor is atrial fibrillation with the incidence rate of 64.5%. The largest group of patients (38.7%) had two risk factors and there were 6.5% patients with six risk factors and 87.2% of all patients had two or more risk factors. In 67.7% of the patients we only performed emergency laparotomy due to inoperable state. Hospital mortality was 74.2%. Conclusions Combination of age over 70, hypertension and two or more risk factors associated with elevated D-dimers, in a patient with severe abdominal pain and minimal clinical findings with nonspecific laboratory findings and plain abdominal radiographs, could be an indication for early selective mesenteric angiography.
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References
Schneider TA, Longo WE, Ure T, Vernava AM III. Mesenteric ischemia: acute arterial syndromes. Dis Colon Rectum 1994;37: 1163–1174.
Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. Gastroenterology 2000;118: 954–968.
Lock G. Acute intestinal ischaemia. Best Pract Res Clin Gastroenterol 2001;15: 83−98.
Corder AP, Taylor I. Acute mesenteric ischaemia. Postgrad Med J 1993;69: 1–3.
Bjorck M, Troeng T, Berqvist D. Risk factors for intestinal ischemia after aortoiliac surgery: a combined cohort and case control study of 2824 operations. Eur J Vasc Surg 1997;13: 531–539.
Smerud MJ, Johnson CD, Stephens DH. Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. Am J Radiol 1990;154: 99–103.
Lund EC, Han SY, Holley HC, Berland LL. Intestinal ischemia: comparison of plain radiographic and computed tomographic findings. Radiographics 1988;8: 1083−1108.
Wolf EL, Sprayregen S, Bakal CW. Radiology in intestinal ischemia: plain film, contrast, and other imaging studies. Surg Clin North Am 1992;72: 107−124.
Kaleya RN, Boley SJ. Acute mesenteric ischemia. Crit Care Clin 1995;11: 479–512.
Harward TR, Green D, Bergan JJ, Rizzo RJ, Yao JS. Mesenteric venous thrombosis. J Vasc Surg 1989;9: 328−333.
Vogelzang RL, Gore RM, Anschuetz SL, Blei AT. Thrombosis of the splanchnic veins: CT diagnosis. Am J Roentgenol 1988;150: 93−96.
Oldenburg WA, Lau LL, Rodenburg TJ, Edmonds HJ, Burger CD. Acute mesenteric ischemia: a clinical review. Arch Intern Med 2004;164:1054−1062.
Bulkley GB, Zuidema GD, Hamilton SR, O’Mara CS, Klacsmann PG, Horn SD. Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (Doppler and fluorescein) compared with standard clinical judgment. Ann Surg 1981;193: 628−637.
Saito T, Tsuchiya M, Shikata C, et al. Microscopic polyangiitis associated with marked systemic bleeding tendency caused by disseminated intravascular coagulation. Intern Med 2003;42:850−855.
Kario K, Matsuo T, Kobayashi H. Which factors affect high D-dimer levels in the elderly? Thromb Res 1991;62: 501−508.
Maeda K, Hirota M, Ichihara A, et al. Applicability of disseminated intravascular coagulation parameters in the assessment of the severity of acute pancreatitis. Pancreas 2006;32: 87−92.
Di Micco P, Romano M, Miglio A, et al. Alteration of haemostasis in non-metastatic gastric cancer. Dig Liver Dis 2001;33: 546−550.
Oya M, Akiyama Y, Okuyama T, Ishikawa H. High preoperative plasma D-dimer level is associated with advanced tumor stage and short survival after curative resection in patients with colorectal cancer. Jpn J Clin Oncol 2001;31: 388−394.
Acosta S, Nilsson TK, Bjorck M. Preliminary study of D-dimer as a possible marker of acute bowel ischaemia. Br J Surg 2001;88:385−388.
Li-Saw-Hee FL, Blann AD, Lip GY. Effects of fixed low-dose warfarin, aspirin-warfarin combination therapy, and dose-adjusted warfarin on thrombogenesis in chronic atrial fibrillation. Stroke 2000;31: 828–833.
Couturand F, Kearon C, Bates SM, Ginsberg JS. Decrease in sensitivity of D-dimer for acute venous thromboembolism after starting anticoagulant therapy. Blood Coagul Fibrinolysis 2002;13: 241–246.
Inoue H, Nozawa T, Okumura K, et al. Prothrombotic activity is increased in patients with nonvalvular atrial fibrillation and risk factors for embolism. Chest 2004;126: 687−692.
Newman AB, Siscovick DS, Manolio TA, et al. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation 1993;88: 837−845.
Newman AB, Sutton-Tyrrell K, Vogt MT, Kuller LH. Morbidity and mortality in hypertensive adults with a low ankle/arm blood pressure index. JAMA 1993;270: 487−489.
McKenna M, Wolfson S, Kuller L. The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis 1991;87: 119−128.
Sikkink CJ, Van Asten WN, Van’t Hof MA, et al. Decreased ankle/brachial indices in relation to morbidity and mortality in patients with peripheral arterial disease. Vasc Med 1997;2: 169−173.
Qamar MI, Read AE, Skidmore R, et al. Transcutaneous Doppler ultrasound measurement of superior mesenteric artery blood flow in man. Gut 1986;27: 100–105.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease. Circulation 2006;113: e463−e654.
Taourel PG, Deneuville M, Pradel JA, et al. Acute mesenteric ischemia: diagnosis with contrast-enhanced CT. Radiology 1996;199: 632–636.
Stoney RJ, Cunningham CG. Acute mesenteric ischemia. Surgery 1993;114: 489−490.
Kirkpatrick ID, Kroeker MA, Greenberg HM. Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology 2003;229: 91−98.
Gilfeather M, Holland GA, Siegelman ES, et al. Gadolinium-enhanced ultrafast three-dimensional spoiled gradient-echo MR imaging of the abdominal aorta and visceral and iliac vessels. Radiographics 1997;17: 423–432.
Bjorck M, Bergqvist D, Troeng T. Incidence and clinical presentation of bowel ischaemia after aortoiliac surgery − 2930 operations from a population-based registry in Sweden. Eur J Vasc Endovasc Surg 1996;12: 139−144.
Acosta S, Bjorck M. Acute thrombo-embolic occlusion of the superior mesenteric artery: a prospective study in a well defined population. Eur J Vasc Endovasc Surg 2003;26: 179−183.
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