Mesenteric Vascular Disease.

The clinical presentation of mesenteric ischemia depends on the site, grade, and cause of vascular obstruction; the degree of collateralization; and the stage of disease. Patients in the early stages of ischemia typically have abdominal pain out of context with an unimpressive abdominal examination. It is during this stage that medical and endovascular techniques can be most effective. After signs of peritonitis are present (signaling bowel infarction), surgical exploration and bowel resection are necessary. Chronic mesenteric ischemia induced by stenotic arteriosclerosis should be treated with percutaneous transluminal angioplasty and stenting (PTAS). Chronic mesenteric arterial occlusions are better handled with bypass surgery. Acute embolic or thrombotic ischemia is surgically treated after medical resuscitation. Endovascular techniques may be applicable in selected patients (usually in those with subacute symptoms), but thrombolytic therapy should be avoided if intestinal infarction is suspected. Non-occlusive mesenteric ischemia requires a rapid correction of the predisposing hypotension or sepsis followed by papaverine infusion into the superior mesenteric artery. Celiac artery compression syndrome requiring treatment is best treated with surgical release of the median arcuate ligament; PTAS should not be performed. Mesenteric venous occlusion should be treated with anticoagulation. Surgical exploration and bowel resection is necessary in patients presenting with acute signs and symptoms, reserving thrombolytic therapy for early, mildly symptomatic, thromboses in whom there is no contraindication to thrombolysis.