(Radiographics. 2002;22:879-880.)
© RSNA, 2002
Invited Commentary
Douglas M. Coldwell, PhD, MD
Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Commentary
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In the preceding article
, Cognet et al (1) describe the pathophysiologic basis, imaging findings, and differential diagnosis of CMI and the results of PTA treatment with and without stent placement. The authors make the excellent point that the diagnosis of CMI is usually made as one of exclusion with a myriad of other possibilities considered before the final diagnosis of CMI is made. Unfortunately, this usually leads to delays, with an adverse impact on patient survival. The physiologic basis of CMI is uncertain, and stenosis of multiple mesenteric arteries is not correlated with the ultimate diagnosis of CMI. It has long been lore that at least two of the three mesentericarteries must be stenotic before the symptoms of abdominal angina or chronic abdominal pain are present. Such correlation of the arteriographic findings and the clinical symptoms is not present; a number of patients with two or three vessels involved had no symptoms, whereas some had symptoms without the involvement of two arteries.
This article underscores the lack of imaging methods available to diagnose the presence of CMI. The respiratory degradation of MR angiography of the mesenteric arteries and the use of nephrotoxic contrast agents in CT angiography impede the use of noninvasive methods. Duplex US is more sensitive, but the operator dependence of this technique makes it more difficult to accurately reproduce results in these arteries. The lack of imaging methods to investigate the fine vessels at the periphery of the mesenteric vessels also hampers the ease of diagnosis.
Surgical results were compared with PTA results in the treatment of CMI. Surgery has long been the primary treatment, with the symptom-free 3-year survival rate ranging between 76% and 100%, whereas the PTA results are over the shorter term, with a mean follow-up of 26 months and a primary assisted clinical success rate of 71%–100% with a mean of 90%. These results are very similar and argue for recognition that percutaneous methods are as effective as surgery. Equally compelling is the expected finding that both the procedural mortality and procedural morbidity are less with endovascular methods, 1.6% and 7.8% versus 9% and about 28% for surgical methods, respectively. Also of interest is that the percutaneous methods have increased in effectiveness over the past 10 years, but the surgical complications and the postoperative morbidity have been essentially unchanged.
Recent articles in the vascular surgery literature continue to reiterate the dominance of mesenteric arterial reconstruction over percutaneous methods (2,3). Most authorities would agree that surgical methods are necessary for the treatment of acute mesenteric ischemia, since the mortality is so high. However, the exclusive use of surgical revascularization for the treatment of CMI is not as convincing. Although there are extended follow-up data for the surgical methods and not for percutaneous methods, the usefulness of endovascular methods is undeniable, since the procedure can easily be repeated without the surgical morbidity and the primary assisted patency of the treated mesenteric arteries is very high. Matsumoto et al (4) have shown the equivalence of the percutaneous method with surgery, demonstrating a 5-year survival rate of 76% compared with a surgical rate of 79% in a similar patient population (2).
Although CMI is a difficult entity to diagnose reliably, it is effectively treated with percutaneous endovascular methods without the need for surgical revision in most cases. Cognet et al (1) have presented a persuasive argument that supports these conclusions.
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References
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- Cognet F, Ben Salem D, Dranssart M, et al. Chronic mesenteric ischemia: imaging and percutaneous treatment. RadioGraphics 2002; 22:863-880.[Abstract/Free Full Text]
- Cho JS, Carr JA, Jacobsen G, et al. Long-term outcome after mesenteric artery reconstruction: a 37-year experience. J Vasc Surg 2002; 35:453-460.[CrossRef][Medline]
- Park WM, Gloviczki P, Cherry KJ, Jr, et al. Contemporary management of acute mesenteric ischemia: factors associated with survival. J Vasc Surg 2002; 35:445-452.[CrossRef][Medline]
- Matsumoto AH, Angle JF, Spinosa DJ, et al. Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and long-term follow-up. J Am Coll Surg 2002; 194(1 suppl):S22-S31.[CrossRef][Medline]
Related Article
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Chronic Mesenteric Ischemia: Imaging and Percutaneous Treatment
- François Cognet, Douraied Ben Salem, Marie Dranssart, Jean-Pierre Cercueil, Michel Weiller, Etienne Tatou, Louis Boyer, and Denis Krausé
RadioGraphics 2002 22: 863-879.
[Abstract]
[Full Text]
[PDF]
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