Chronic mesenteric ischemia – integrating digestive simptomatology in cardiovascular pathology. Current therapeutic alternatives

Introduction: Although atherosclerosis of the celiac trunk and mesenteric arteries is relatively common in the general population, chronic mesenteric ischemia is a rare pathology, particularly due to extensive collateral vessels at this level. Thus, given the low incidence and symptomatology dominated by digestive symptoms, it is easy to understand why this diagnosis is often dela-yed in favor of investigations that target a possible neo-plasia / inflammatory bowel disease, or even overlook-ed and categorised as functional bowel disorder.

Methods: We present the case of a 61 year old patient with multiple cardiovascular risk factors (type 2 dia-betes, hypertension, dyslipidemia, obesity), diarrhea, loss of appetite, significant weight loss (9 kg over the last 4 months), and diffuse abdominal pain in the last two months, predominantly postprandial. Prior to presentation in our clinic, abdominal CT and colono-scopy were performed, both showing no abnormali-ties. On admission: hemodynamic stable patient (TA 150/80mmHg), ECG – SR 60/min, intermediate axis, poor R wave progression in the precordial derivations. Biologically – slight normocytic normochromic ane-mia, dyslipidemia. Following a suspicion of chronic mesenteric ischaemia, CT angiography was performed, which revealed superior mesenteric artery (SMA) sub-occlusive stenosis.

Results: Diagnosis was confirmed by digital subtrac-tion angiography (ostial SMA sub-occlusive stenosis followed by 50% tubular stenosis in the medio-proxi-mal segment), coronarographic findings also revealing significant bicoronary lesions (80% LAD, 85% RCA). Thus, given the confirmed diagnosis of symptomatic chronic mesenteric ischemia, it was decided to revascu-larize the SMA lesion, according to the ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. The available options, respectively the surgi-cal versus endovascular revascularization, have been discussed within the Heart Team. Taking into account the characteristics of the lesion (short, proximal, cal-cification-free stenosis) and comorbidities, endovascu-lar treatment was choose – percutaneous angioplasty with pharmacologically active stent (PROMUS) at the proximal AMS, with favorable short-term progression without recurrence of symptomatology during hospi-talization. At discharge, double anti-platelet treatment (aspirin 75mg daily, clopidogrel 75mg daily), anti-hyperlipemiant, antihypertensive and oral antidiabe-tic was recommended, together with the indication to complete coronary percutaneous revascularization in a second planned procedure.

Conclusions: Because of the low incidence in the ge-neral population and frequent presentation throu-gh non-specific digestive symptoms, the diagnosis of chronic mesenteric ischemia is often delayed. However, the benefits of early revascularization of symptomatic patients make it necessary to maintain a high clinical suspicion in such cases, especially as current minimally invasive endovascular techniques allow rapid recovery with lower periprocedural risks compared to surgical revascularization.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)