Epidemiology of Mesenteric Vascular Disease: Clinical Implications

https://doi.org/10.1053/j.semvascsurg.2009.12.001Get rights and content

The overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö, Sweden was estimated at 12.9/100,000 person-years. Autopsy rate was 87%. Acute superior mesenteric artery (SMA) occlusion (embolus/thrombus ratio = 1.4), mesenteric venous thrombosis (MVT), and nonocclusive mesenteric ischemia (NOMI) were found in approximately 68%, 16%, and 16%, respectively. Acute SMA occlusion was found to be more common than ruptured abdominal aortic aneurysms. The incidence increased exponentially with age, equally distributed among men and women after adjusting for age and gender in the population. Thrombotic occlusions were located more proximally than embolic occlusions and intestinal infarction was more extensive, whereas patients with embolus had a higher frequency of acute myocardial infarction, and had cardiac thrombi in 48% and synchronous emboli in 68% of the patients. The proportion of patients with symptoms inherent with chronic mesenteric ischemia prior to onset of acute thrombotic occlusion has been reported to occur in 73%. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal NOMI. MVT is either caused by thrombophilia, direct injury, or local venous congestion or stasis. Multidetector row computed tomography with intravenous contrast enhancement and imaging in the arterial phase for suspicion of acute SMA occlusion and imaging in the venous phase for MVT has become the diagnostic method of choice. In-hospital mortality is highest for NOMI, lower for acute SMA occlusion, and lowest, around 20%, for MVT.

Section snippets

Incidence of Atherosclerosis in the Mesenteric Arteries

ATHEROSCLEROSIS OF THE mesenteric arteries is often a manifestation of a generalized atherosclerosis. The incidence increases with age and the prevalence among 65-year-old subjects in Europe and North America is approximately 20%.1 Patients who have undergone an aortobifemoral bypass due to occlusive disease of the iliac arteries have concomitant atherosclerosis of the mesenteric arteries in approximately 70%.2 In case of stenosis or occlusion of the mesenteric arteries, collateral arterial

Distribution of Etiologies among Patients with Acute Mesenteric Ischemia

Overall incidence rate of acute mesenteric ischemia between 1970 and 1982, diagnosed at either autopsy or operation, in the population of Malmö was estimated at 12.9 (95% confidence interval, 11.6-14.1)/100,000 person-years. Autopsy rate was 87%. In all, 402 patients were diagnosed; 270 (67.2%) with acute SMA occlusion, 63 (15.7%) with mesenteric venous thrombosis, 62 (15.4%) with nonocclusive mesenteric ischemia (NOMI), and 7 (1.7%) with indeterminate etiology (Fig 1).5 The epidemiological

Trends in Incidence and Discovery of Acute SMA Occlusion

Almost none of the published case series on acute SMA occlusion are population-based. Most patients in these series are diagnosed at operation and the autopsy frequency is unknown (Table 1). The most thorough epidemiological study has been conducted on the population of Malmö: Overall incidence of acute SMA occlusion in Malmö between 1970 and 1982 was estimated at 8.6/100,000 person-years,6 and this estimate has not been demonstrated to increase since then, even though the proportion of elderly

Trends in Mortality of Acute SMA Occlusion

Overall cause-specific mortality was 6.0/1000 deaths in 1970 to 1982 and the in-hospital mortality rate was 93%.6 These mortality estimates have decreased since then as have the autopsy rates to 24%. From 2004 to end of study, in-hospital mortality rate was 58%. The subset of patients undergoing a multidetector row CT with intravenous contrast enhancement had a lowered in-hospital mortality rate of 36% (P = .002).5

Acute Thrombotic versus Embolic Occlusion of the SMA

In an autopsy study consisting of 213 patients with acute SMA occlusion, the embolus/thrombus ratio was 1.4.7 Thrombotic occlusions were located more proximally than embolic occlusions, intestinal infarction was more extensive and thrombotic occlusions were associated with old brain infarction, aortic wall thrombosis, and disseminated cancer. Thrombosis or severe atherosclerotic changes of the celiac trunk were present in 33% of those with thrombosis in the SMA. The proportion of patients with

NOMI

NOMI, with or without stenosis of the mesenteric arteries, may be very difficult to distinguish from thromboembolic occlusion of the SMA without mesenteric angiography or autopsy because these conditions have common risk factors. In an autopsy series where the cause of death was intestinal infarction, patients with an open but stenotic SMA (n = 25) were found to be older than those without a stenosis (n = 37), and they had more often a concomitant stenosis of the celiac trunk.10 Synchronous

Incidence

Estimated overall incidences of mesenteric venous thrombosis (MVT) in Malmö 1970 to 198211 and 2000 to 200612 were similar, 2.7/100,000 person-years in 2000 to 2006, with equal incidences in both genders. The highest incidence in both men (12.0/100,000 person-years) and women (10.8/100,000 person-years) was in the age category 70 to 79 years. The mode of establishing the diagnosis of MVT changed over time, during recent years a diagnosis with CT became more prevalent. Between 2000 and 2003, the

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