What are the guideline sources, guidelines and references for Chronic mesenteric ischemia ?
Guideline sources The following summarized guidelines for the evaluation and management of chronic mesenteric ischemia are prepared by our editorial team based on guidelines from the Society for Vascular Surgery (SVS 2021), the European Association for Gastroenterology, Endoscopy and Nutrition (EAGEN/CIRSE/NVMDL/HSGO/UEG/DMIS/ESGAR 2020), the European Society of Cardiology (ESC/ESVS 2018), the American College of Radiology (ACR 2018), the European Society for Vascular Surgery (ESVS 2017), and the European Society for Trauma and Emergency Surgery (ESTES 2016). 1 2 3 4 5 6 Guidelines https://web.pathway.md/diseases/recLUyrZ00BDDENSB 1/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway 1. Screening and diagnosis Diagnosis: As per SVS 2021 guidelines, make a diagnosis of chronic mesenteric ischemia in patients with the appropriate clinical scenario and the presence of significant stenoses (> 70%) within the celiac axis and superior mesenteric artery. Consider making the diagnosis in patients involving only one of these arteries. B As per UEG 2020 guidelines, suspect the diagnosis of chronic mesenteric ischemia in patients with unexplained postprandial abdominal pain, weight loss (> 5% body weight), adapted eating pattern (to avoid abdominal complaints) or diarrhea. B Show 7 more As per ESVS 2017 guidelines: Regard the diagnosis of chronic mesenteric ischemia as less likely in the absence of multi- vessel stenosis or occlusion. Obtain careful investigation for alternative causes. B View chronic mesenteric ischemia as the cause of the symptoms in patients with otherwise unexplained abdominal symptoms and occlusive disease of 2-3 mesenteric arteries. B Differential diagnosis: As per SVS 2021 guidelines, obtain an expedited workup to exclude gastrointestinal malignancies and other potential causes in patients with abdominal pain, weight loss, and fear of food, including investigations such as: upper and lower gastrointestinal endoscopy abdominal CT abdominal ultrasound. B As per UEG 2020 guidelines, obtain at least the following diagnostic tests to exclude alternative diagnoses: upper gastrointestinal endoscopy lower gastrointestinal endoscopy (depending on age and symptoms, but is mandatory in patients with diarrhea) abdominal imaging (CT/MRI). B 2. Diagnostic investigations Diagnostic imaging: As per SVS 2021 guidelines, obtain mesenteric duplex ultrasound as the preferred screening test for mesenteric artery occlusive disease. B Show 2 more As per UEG 2020 guidelines, obtain CT angiography ( 1 mm acquisition slice thickness, arterial and venous/portal venous phase) in patients with suspected chronic mesenteric ischemia. B Show 4 more https://web.pathway.md/diseases/recLUyrZ00BDDENSB 2/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway As per ACR 2018 guidelines, obtain CT angiography or MRA as initial imaging in patients with suspected acute mesenteric ischemia. B As per ESC 2018 guidelines: Obtain duplex ultrasound as first-line imaging in patients with suspected chronic mesenteric ischemia. B Consider assessing for alternative causes in patients with suspected chronic mesenteric ischemia and occlusive disease of a single mesenteric artery. C As per ESVS 2017 guidelines, obtain duplex ultrasound of the mesenteric arteries as first-line imaging in patients with suspected chronic mesenteric ischemia. B Show 2 more Laboratory testing: recognize that normal lactate, LDH, and/or WBC levels do not exclude chronic mesenteric ischemia. B 3. Diagnostic procedures Gastrointestinal endoscopy: As per SVS 2021 guidelines, perform upper and/or lower gastrointestinal endoscopy to exclude gastrointestinal malignancies and other potential causes in patients with abdominal pain, weight loss, and fear of food. B As per UEG 2020 guidelines, recognize that normal gastrointestinal endoscopy does not exclude chronic mesenteric ischemia. B 4. Medical management Setting of care: As per UEG 2020 guidelines, refer patients with symptoms and radiological features of vasculitis to an expert in the treatment of vasculitis before proceeding to endovascular revascularization. B As per ESVS 2017 guidelines, evaluate and treat patients with chronic mesenteric ischemia at specialized centers providing multidisciplinary assessment as well as both open and endovascular treatment. B Antihypertensive therapy: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension. C Lipid-lowering therapy: Offer statins in all patients with PADs. A Target reducing LDL-C to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B https://web.pathway.md/diseases/recLUyrZ00BDDENSB 3/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway Glycemic control: obtain strict glycemic control in patients with diabetes mellitus and PAD. B 5. Nonpharmacologic interventions Lifestyle modifications: advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B Nutritional support: As per SVS 2021 guidelines, do not offer TPN as an alternative to revascularization for patients with chronic mesenteric ischemia due to the risk of clinical deterioration, bowel infarction and catheter-related complications. D As per UEG 2020 guidelines, consider avoiding increasing oral intake, starting enteral tube feeding or TPN before revascularization in patients with chronic mesenteric ischemia. D 6. Therapeutic procedures Indications for revascularization: As per SVS 2021 guidelines, perform revascularization in patients with chronic mesenteric ischemia to reverse the presenting symptoms (weight loss, fear of food, diarrhea, postprandial pain) and improve the overall quality of life. B Show 4 more As per ESC 2018 guidelines, perform revascularization in patients with symptomatic multivessel chronic mesenteric ischemia. B Do not delay revascularization in order to improve the nutritional status. B As per ESVS 2017 guidelines, perform revascularization in patients with symptomatic chronic mesenteric ischemia caused by multi-vessel occlusive disease. B Show 2 more As per ESTES 2016 guidelines, consider performing elective revascularization in patients with proven chronic mesenteric ischemia. C Endovascular revascularization: As per SVS 2021 guidelines: Perform endovascular revascularization as the initial treatment for patients with chronic mesenteric ischemia and suitable lesions. B Consider using balloon-expandable covered intraluminal stents for the treatment of mesenteric artery occlusive disease in patients with chronic mesenteric ischemia. C As per UEG 2020 guidelines, perform percutaneous transluminal angioplasty and stenting in patients with atherosclerotic mesenteric artery lesions. B Show 3 more As per ESVS 2017 guidelines, target the superior mesenteric artery as the main vessel using either open or endovascular techniques in patients requiring revascularization for chronic https://web.pathway.md/diseases/recLUyrZ00BDDENSB 4/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway mesenteric ischemia. B Show 2 more 7. Perioperative care Evaluation before revascularization: Ensure optimization from a medical standpoint in patients undergoing revascularization for chronic mesenteric ischemia before performing an intervention but expedite their preoperative evaluation. E Obtain CT angiography to delineate the vascular anatomy before any revascularization. Consider obtaining catheter-based arteriogram as an alternative if the anatomy is not clear on CT angiography. B 8. Surgical interventions Surgical revascularization: As per SVS 2021 guidelines: Rreserve open surgical revascularization for patients with chronic mesenteric ischemia with lesions not amenable to endovascular therapy, endovascular failures, and a selected group of younger, healthier patients in which the long-term benefits may offset the increased perioperative risks. B Determine the choice of open surgical revascularization for patients with chronic mesenteric ischemia based on anatomy, comorbidities, prior interventions and provider preference. E As per UEG 2020 guidelines, consider reserving mesenteric bypass procedures for patients not suitable for endovascular revascularization. C Show 2 more As per ESVS 2017 guidelines, balance the superior long-term results of open surgery against a possible early benefit of endovascular intervention with regard to periprocedural mortality and morbidity in patients with chronic mesenteric ischemia requiring revascularization. B Show 3 more Celiac artery release: Consider performing surgical celiac artery release in patients with median arcuate ligament syndrome. C Obtain a diagnostic imaging (inspiration/expiration duplex ultrasound, CT angiography or contrast-enhanced MRA) in patients without improvements in symptoms after celiac artery release. B 9. Specific circumstances Asymptomatic patients (management): https://web.pathway.md/diseases/recLUyrZ00BDDENSB 5/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway Perform revascularization for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of all 3 mesenteric vessels only after carefully weighing the risks and benefits of treatment, given the low level of evidence. B Consider performing endovascular intervention for the prevention of acute mesenteric ischemia in asymptomatic patients with significant stenosis/occlusion of 2 mesenteric vessels requiring to undergo major abdominal surgery with potential ligation of collateral circulation. C Asymptomatic patients (follow-up): obtain close monitoring for symptoms consistent with chronic mesenteric ischemia in asymptomatic patients with severe mesenteric artery occlusive disease. Consider obtaining annual evaluation with mesenteric duplex ultrasound as a possible follow-up schedule. B 10. Patient education General counseling: educate and counsel patients undergoing revascularization for chronic mesenteric ischemia about the recurrent symptoms due to the high rate of recurrence. E 11. Preventative measures Secondary prevention: Consider assessing the cardiovascular risk profile in patients with an asymptomatic atherosclerotic stenosis of the mesenteric arteries. C Consider initiating cardiovascular secondary prevention in patients with symptomatic atherosclerotic chronic mesenteric ischemia as soon as the diagnosis is made. C 12. Follow-up and surveillance Post-revascularization antiplatelet therapy: As per UEG 2020 guidelines: Consider administering dual antiplatelet therapy for at least 1 month after endovascular mesenteric artery stenting, followed by lifelong antiplatelet monotherapy. C Consider adding one antiplatelet agent for 4 weeks after endovascular mesenteric artery stenting in patients treated with direct OACs, vitamin K antagonists or LMWH. C As per ESVS 2017 guidelines: Initiate antiplatelet therapy in patients after revascularization for chronic mesenteric ischemia. A Consider initiating dual antiplatelet therapy for 3-12 months in patients after endovascular revascularization for chronic mesenteric ischemia. C Follow-up after revascularization: As per SVS 2021 guidelines, obtain follow-up in an outpatient setting after revascularization in patients with chronic mesenteric ischemia. Consider obtaining follow-up with a possible https://web.pathway.md/diseases/recLUyrZ00BDDENSB 6/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway schedule within a month of the procedure and then biannually for the first 2 years and then annually thereafter. E Show 2 more As per ESVS 2017 guidelines: Consider obtaining repeated follow-up by clinical assessment to detect symptomatic restenosis in patients after revascularization for chronic mesenteric ischemia. C Consider obtaining repeated long-term follow-up by imaging to detect asymptomatic restenosis in patients after revascularization for chronic mesenteric ischemia. C Patients with recurrent disease (evaluation): obtain duplex ultrasound and/or CT angiography to assess in-stent stenosis in patients with recurrence of symptoms. B Patients with recurrent disease (management): offer remedial treatment for de novo lesions in patients with recurrent symptoms of chronic mesenteric ischemia. B Show 2 more 13. Quality improvement Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B References 1. M Bj rck, M Koelemay, S Acosta et al. Editor's Choice Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2017 Apr;53 4 460 510. Open 2. Luke G Terlouw, Adriaan Moelker, Jan Abrahamsen et al. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J. 2020 May;8 4 371 395. Open 3. Thomas S Huber, Martin Bj rck, Ankur Chandra et al. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. Vasc Surg. 2021 Jan;73 1S 87S 115S. Open 4. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open https://web.pathway.md/diseases/recLUyrZ00BDDENSB 7/8 6/23/23, 3:26 AM Chronic mesenteric ischemia Pathway 5. Tilsed JV, Casamassima A, Kurihara H et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42 2 253 70. Open 6. Expert Panels on Vascular Imaging and Gastrointestinal Imaging:, Michael Ginsburg, Piotr Obara et al. ACR Appropriateness Criteria Imaging of Mesenteric Ischemia. J Am Coll Radiol. 2018 Nov;15 11S S332 S340. Open 7. Expert Panel on Interventional Radiology, Alexander Lam, Yoon-Jin Kim et al. ACR Appropriateness Criteria Radiologic Management of Mesenteric Ischemia: 2022 Update. J Am Coll Radiol. 2022 Nov;19 11S S433 S444. Open https://web.pathway.md/diseases/recLUyrZ00BDDENSB 8/8