Abdominal angina is defined as the postprandial pain that occurs in individuals who have mesenteric vascular occlusive disease that has advanced to the point where blood flow cannot increase enough to meet visceral demands.[1] This mechanism is similar to that of the angina pectoris that occurs in individuals with coronary artery disease or the intermittent claudication that accompanies peripheral vascular disease.
Schnitzler first described the clinical picture of postprandial pain in 1901. However, the true description of postprandial abdominal angina is attributed to Baccelli or Goodman (1918). In 1957, Mikkelsen proposed surgical treatment of occlusive mesenteric vascular disease. Shaw and Maynard reported the first transarterial thromboendarterectomy of the superior mesenteric artery (SMA) in 1958. With the advancements in imaging technology, the degree of stenosis in mesenteric arteries can be defined accurately and treated accordingly.
Patients should be counseled to stop smoking. No effective medical therapy for abdominal angina exists. Mesenteric revascularization relieves the symptoms of abdominal angina. The classic operation for relieving the symptoms of abdominal angina includes removal of the obstructing lesion, bypass of the obstructed portion of the blood vessel, or both. The less invasive nature of modern endovascular surgery makes it an ideal alternative to bypass surgery for patients with multiple comorbidities. Percutaneous approaches via the brachial or radial artery in the upper limb have been described.
Intestinal ischemia results from the imbalance of oxygen supply to and oxygen consumption by the gastrointestinal (GI) tract. Diminished blood flow results from narrowing of the mesenteric vessels. The most common cause of abdominal angina is atherosclerotic vascular disease. It commonly involves the ostia of the mesenteric vessels.[2]
The three arteries supplying the gut are the celiac artery, the SMA, and the inferior mesenteric artery (IMA; see the image below). There are collaterals between the celiac artery and the SMA (pancreaticoduodenal arcades) and between the SMA and the IMA (meandering mesenteric artery). In cases of severe ostial narrowing, internal iliac arteries also serve as important sources of collateral hindgut and midgut perfusion in the presence of IMA occlusion.
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Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is ter....
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Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
SMA occlusion almost invariably is observed in patients with symptomatic occlusive mesenteric ischemia.
Within a few minutes of eating, there is increased blood flow in the celiac and superior mesenteric vessels in normal individuals. Patients with abdominal angina are unable to sufficiently increase flow in the mesenteric vessels. This leads to fear associated with eating and significant weight loss.
The syndrome is extremely rare, and the true incidence is unknown.
The mean age of affected individuals is slightly older than 60 years. Median arcuate ligament syndrome (Dunbar syndrome[3] ) has been reported in young individuals. In contrast to the usual male predilection of atherosclerotic vascular disease, females outnumber males by approximately 3 to 1 in most series. No data are available regarding relative incidence figures among different races.
Surgical management is the criterion standard for treatment of this disease.[4] Despite advances in surgery, the mortality associated with acute mesenteric ischemia is in the range of 60-95%.
Reocclusion is more prevalent in males than in females.
Several series have demonstrated that 86-96% of patients remain asymptomatic at 5 and 10 years, with similar graft patency rates.
Research suggests that after successful endovascular treatment, symptom relief is immediately achieved in 85% of patients. An overall morbidity of 30.8% has been reported. The most common complication has been reported to be access site hematoma/pseudoaneurysm/thrombosis (15.4%), followed by bowel infarction (4.6%).[5]
A retrospective review by Sundermeyer et al (N = 27) found endovascular SMA treatment to be suitable and safe for patients with chronic mesenteric ischemia, though the authors noted that long-term results were limited.[6]
Cai et al carried out a meta-analysis comparing the clinical outcomes of endovascular revascularization for chronic mesenteric ischemia with those of open revascularization.[7] The two approaches were similar with regard to 30-day mortality and 3-year cumulative survival rate. The endovascular approach was associated with a lower rate of in-hospital complications but a higher rate of recurrence within the 3 years following revascularization.
The classic description of abdominal angina is abdominal pain that is out of proportion with physical examination findings. The classic feature is abdominal pain that occurs a few minutes after eating and slowly subsides over next few hours.[8] Gradually, most patients develop fear of eating and lose significant weight. A history of peripheral vascular disease and significant smoking is common.
Physical examination reveals stigmata of weight loss. The abdomen typically is scaphoid and soft, even during an episode of pain.
In one series, approximately 10% of patients had positive test results for guaiac. Abdominal bruit is present in 60-90% of patients, but this is a common finding in many elderly persons who are not affected by this syndrome.
Signs of peripheral vascular disease, particularly aortoiliac occlusive disease, may be present.
No laboratory tests are diagnostic. Usually, nutritional parameters are suggestive of malnutrition. If malignancy or gastric ulcer disease is suspected, consider obtaining appropriate laboratory and other diagnostic studies.
Mesenteric angiography is the classic criterion standard diagnostic study. Because the vessels emerge from the anterior wall of the aorta, the ostia are visualized only on a lateral view (see the first image below). A prominent meandering mesenteric artery (see the second image below) is another clue.
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Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anter....
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Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesent....
Duplex ultrasonography (US) is emerging as a useful screening modality in this setting. It currently is most useful in cases where the diagnosis is suspected.[9, 10, 3]
Indices that are studied include the following:
Peak systolic flow - This is increased if a stenosis is present
Normal vasodilatory response in response to eating - This is lost, especially in the superior mesenteric artery (SMA)
Computed tomography (CT) angiography (CTA) of the aorta and mesenteric arteries is considered an alternative to mesenteric angiography by most authorities.
The use of magnetic resonance direct thrombus imaging (MRDTI) to distinguish between old and new thrombus in the abdominal oarta has been described.[11]
Patients should be counseled to stop smoking. No effective medical therapy for abdominal angina exists. There is no role for screening asymptomatic patients. There is also no role for treating asymptomatic mesenteric artery disease.[12, 13]
Mesenteric revascularization relieves the symptoms of abdominal angina. The classic operation for relieving the symptoms of abdominal angina includes removal of the obstructing lesion, bypass of the obstructed portion of the blood vessel, or both. Because atherosclerosis involves systemic circulation, generally all three blood vessels (celiac artery, superior mesenteric artery [SMA], and inferior mesenteric artery [IMA]) are involved. Relieving the symptoms of abdominal angina requires revascularization of at least two of the three vessels.
With the advent of modern endovascular surgery, many new techniques have emerged as possible alternatives to bypass surgery. Its less invasive nature makes endovascular surgery ideal for patients with multiple comorbidities, who may be at high risk for complications from open surgery.
When endovascular surgery for mesenteric revascularization is performed, the patient is placed on a fluoroscopy table, and the procedure can be performed under conscious sedation. The groins are prepared bilaterally and draped in standard surgical fashion, the femoral pulse is palpated, and a needle is inserted into the artery. A guide wire is inserted through the needle with the Seldinger technique, and its position is checked with fluoroscopy. Selective catheterization of the mesenteric arteries is performed. An appropriate catheter is introduced through the sheath, and angiography is performed.[14]
Percutaneous approaches via the brachial or radial artery in the upper limb have been described.[15]
Endovascular surgery
First, aortography is performed, and the origins of the celiac artery, the SMA, and the IMA are visualized. The left anterior oblique view is best for visualizing the origins of the celiac artery and the SMA. Once a narrowed artery is identified, a guide wire is passed through the catheters, and an attempt is made to pass the wire across the narrowed portion of the artery under direct fluoroscopy. Once the wire is passed across the stenotic area, the artery's narrowed portion can be dilated with a dilator, and a balloon angioplasty is performed.
If residual stenosis after the angioplasty is more than 50% of the expected arterial lumen, it is advisable to place a stent[16] across the narrowed portion of the blood vessel. A retrospective review by Oderich et al showed that mesenteric lesions treated with covered stents are associated with lesser incidence of restenosis, recurrence, and repeated interventions.[17]
Potential complications of endovascular mesenteric revascularization procedures are dissection of mesenteric arteries, rupture of mesenteric arteries, embolization of atherosclerotic plaques, groin hematoma, and acute limb ischemia.
Open surgery
Lesions that are not amenable to endovascular management are dealt with by means of an open surgical procedure. The patient is placed under general anesthesia, the abdomen is prepared and draped, and a midline incision is made from xiphoid to pubic tubercle. Skin, subcutaneous tissue, and anterior rectus fascia are divided, and the peritoneal cavity is then entered.
The transverse colon is reflected upwards, and the middle colic artery is identified and traced back to the origin of the SMA. Proximal and distal control of the SMA is obtained, and an arteriotomy is performed to open the artery, followed by removal of atherosclerotic plaques. The arteriotomy may be transverse or longitudinal. For transverse arteriotomies, primary closure is suitable, but for longitudinal arteriotomies, a vein patch closure is preferred to minimize residual stenosis of the artery.
Other surgical options include the following:
Antegrade bypass - A vascular conduit is used to bypass the stenosed area of the mesenteric vessel, and inflow is from the supraceliac aorta; unlike other vascular bypasses, for which native vein is the preferred conduit, antegrade bypass for mesenteric revascularization is preferentially done with prosthetic grafts (see the first three images below)
Retrograde bypass - In this bypass, inflow for the conduit comes from the distal, nondiseased portion of the aorta or common iliac arteries (see the fourth image below)
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Celiac artery is exposed at its origin in preparation for antegrade bypass.
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Superior mesenteric artery and several branches are exposed for antegrade bypass.
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Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
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Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD,....
Classic surgical operations have excellent outcomes.
Cardiac monitoring with transesophageal echocardiography (TEE) or invasive monitoring may be needed. Intraoperative examination with duplex ultrasonography (US) is performed to confirm the technical adequacy of the revascularization (see the image below). Postoperatively, most patients require monitoring in an intensive care unit (ICU).
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Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
Surgical controversies
Controversies in surgical treatment include the following:
The choice of reconstructive approach (ie, antegrade bypass vs transaortic endarterectomy vs retrograde bypass)
The role of duplex US in follow-up
The best material for bypass (ie, vein vs prosthetic graft)
The specific approach to surgical reconstruction (bypass or endarterectomy; see the image below), depends on the following:
Location and number of stenoses
Previous surgeries
Patient comorbidities
Local operative conditions
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Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endar....
Because patency rates, morbidity, and mortality are comparable for the two approaches, the authors prefer to make the decision on a case-by-case basis, applying the technique best suited to the individual patient's specific circumstances.
If a restenosis is identified on postoperative follow-up, it is treated according to the same criteria used for the original lesion.
In addition to the usual cardiac problems traditionally associated with major vascular repairs, major postoperative complications of surgical treatment include the following:
Although most of these patients are cachectic, preoperative central venous nutrition has not been shown to decrease complications and is used only selectively.
No particular dietary restrictions are associated with the surgery.
Faisal Aziz, MD, Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Anthony J Comerota, MD, FACS, FACC, FRACS, Director of Jobst Vascular Institute, Program Director of General Vascular Surgery Residency, Toledo Hospital; Director of Jobst (ProMedica) Vascular Laboratories; Adjunct Professor of Surgery, Department of Surgery, University of Michigan Medical School
Disclosure: Received honoraria from BMS for speaking and teaching; Received consulting fee from BMS for consulting; Received grant/research funds from BMS for research studies; Received honoraria from Covidien for speaking and teaching; Received consulting fee from Covidien for consulting; Received honoraria from Otsuka for speaking and teaching; Received honoraria from Sanofi/Aventis for speaking and teaching; Received consulting fee from Sanofi/Aventis for consulting; Received grant/research funds from Sa.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
David L Morris, MD, PhD, FRACS, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.
Chief Editor
John Geibel, MD, MSc, DSc, AGAF, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Marc D Basson, MD, PhD, MBA, FACS, Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences
Disclosure: Nothing to disclose.
Acknowledgements
We wish to thank Carol EH Scott-Conner, MD, PhD, and Beth Ballinger, MD, for their previous contributions to this article.
References
Mahajan K, Haseeb M. Abdominal Angina. Treasure Island, FL: StatPearls; 2020.
Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is termed meandering mesenteric artery. As seen on angiography, this is sign of chronic mesenteric ischemia.
Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.
Celiac artery is exposed at its origin in preparation for antegrade bypass.
Superior mesenteric artery and several branches are exposed for antegrade bypass.
Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.
Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is termed meandering mesenteric artery. As seen on angiography, this is sign of chronic mesenteric ischemia.
Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.
Celiac artery is exposed at its origin in preparation for antegrade bypass.
Superior mesenteric artery and several branches are exposed for antegrade bypass.
Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.
Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
Upper gastrointestinal series (barium swallow) shows ulcer.
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