COMPLICATIONS:
Because of the high prevalence of atherosclerosis, one of the most common complications involves MI.
Acute renal failure in the immediate postoperative period can be prevented by keeping the patient well hydrated and administering mannitol before the aorta is cross-clamped.
Other possible complications include bleeding, infection, bowel infarction, prolonged ileus, and graft infection.
Follow-up
- Because of the high likelihood of concomitant vascular disease in the rest of the arterial tree, patients must be closely monitored.
- Any laboratory or radiologic examinations not previously performed in the hospital are performed in an outpatient setting.
- The patient should have frequent visits to monitor the prothrombin time, activated partial thromboplastin time, and international normalized ratio to assure proper anticoagulation.
Outcome and Prognosis
Because of the delay in diagnosis, mesenteric artery ischemia is typically a lethal disease, with a mortality rate of 45-65%.
When more than half the bowel is removed, mortality rates of up to 80% have been reported.
A review of 45 studies demonstrated that the prognosis for patients with acute mesenteric ischemia differs when one looks at the etiology.
Mortality rates are highest for patients with arterial thrombosis (70-87%), followed by nonocclusive mesenteric ischemia (70-80%), arterial embolism (66-71%), and venous thrombosis (44%).
Mortality rates have been improving over the last 4 decades.
Future and Controversies
Over the past 20 years, diagnosis and treatment of mesenteric ischemia has advanced only minimally.
- In a review of 57 cases, only 18% of patients were properly diagnosed with mesenteric ischemia before operation or death. Of the 57 patients in this review, 46 died.
- Some advances in diagnosis include magnetic resonance imaging and laser Doppler flowmetry. Preliminary results for these modalities are encouraging.
- Percutaneous transluminal angioplasty with stenting has proven valuable as a treatment option in selected patients. A study demonstrated that, at 6 months, patency was equivalent between stenting and open revascularization; however, freedom from symptoms was less in the stented group.
- As previously mentioned, similar results were found in a study by Kougias et al, in which the effectiveness of balloon angioplasty and/or endovascular stenting (48 patients, 58 vessels) was compared with that of open revascularization (96 patients, 157 vessels) in the treatment of chronic mesenteric ischemia.The investigators determined that members of the endovascular group had a shorter hospital stay (3 days) than did patients in the open revascularization group (12 days, P <0.03) and that the 30-day mortality rate, frequency of inhospital complications, and 3-year cumulative survival rate were the same for both groups.
- Three years after the procedures, however, cumulative freedom from recurrent symptoms was found in a higher percentage of open revascularization patients than in members of the endovascular group (66% vs 27%, P <0.02). The authors suggested that this was because the percentage of patients who underwent a 2-vessel procedure rather than a 1-vessel intervention was higher in the open group than in the endovascular one.
- Some authors recommend a trial of thrombolytic therapy if patients can be treated within 8 hours of presentation and do not have signs of bowel necrosis or peritonitis.If no evidence of improvement is noted within 4 hours, patients should undergo exploration.
- Local tissue plasminogen activator may reduce the amount of bowel requiring resection.
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