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Basic Science

Basic Science. Mesenteric Ischemia Visceral Artery Aneurysms 3/1/2006. What is the most common cause of acute mesenteric ischemia? A. Embolism to SMA B. Embolism to the celiac artery C. Thrombosis of SMA D. Low flow E. Acute nonocclusive mesenteric insufficiency

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Basic Science

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  1. Basic Science Mesenteric Ischemia Visceral Artery Aneurysms 3/1/2006

  2. What is the most common cause of acute mesenteric ischemia? A. Embolism to SMA B. Embolism to the celiac artery C. Thrombosis of SMA D. Low flow E. Acute nonocclusive mesenteric insufficiency F. Mesenteric venous occlusion

  3. What is the most common cause of acute mesenteric ischemia? A. Embolism to SMA B. Embolism to the celiac artery C. Thrombosis of SMA D. Low flow E. Acute nonocclusive mesenteric insufficiency F. Mesenteric venous occlusion

  4. Which of these statements about acute mesenteric artery occlusion are true • A. Most common cause of acute mesenteric artery occlusion is thrombosis • B. Most common vessel involved in embolic acute mesenteric ischemia (AMI) is the SMA • C. Most common location of embolic occlusion within the vessel is at or within 2-3 cm of the origin • D. Patients usually present with peritonitis on exam • E. After resuscitation, an arteriogram is necessary to identify the site of occlusion in a patient with a peritoneal abdomen due to suspected AMI

  5. Which of these statements about acute mesenteric artery occlusion are true • A. (FALSE) Most common cause of acute mesenteric artery occlusion is thrombosis (EMBOLUS) • B. (TRUE) Most common vessel involved in embolic acute mesenteric ischemia (AMI) is the SMA • C. (FALSE) Most common location of embolic occlusion within the vessel is at or within 2-3 cm of the origin (6-8 cm) • D. (FALSE) Patients usually present with peritonitis on exam (pain out of proportion to exam) • E. (FALSE) After resuscitation, an arteriogram is necessary to identify the site of occlusion in a patient with a peritoneal abdomen due to suspected AMI (MAY DELAY OPERATIVE THERAPY)

  6. Most cases of embolic acute mesenteric ischemia (AMI) are of cardiac origin. A. True B. False

  7. Most cases of embolic acute mesenteric ischemia (AMI) are of cardiac origin. A. True - The clots causing embolic AMI are overwhelmingly of cardiac origin, from atrial fibrillation, mural thrombi following myocardial infarction, or valvular vegetations. B. False

  8. Which of these statements about chronic mesenteric ischemia are true • A. Chronic mesenteric ischemia is almost exclusively a problem in the older age group • B. Because of abundant collaterals between the three main mesenteric arteries, in most cases all three must be severely compromised before symptoms arise • C. The most commonly affected arteries in symptomatic CMI is the SMA and IMA • Long-term patency of bypass grafts to the celiac or SMA exceeds 90% • E. Malabsorption is a significant problem leading to weight loss

  9. Which of these statements about chronic mesenteric ischemia are true • A. (TRUE) Chronic mesenteric ischemia is almost exclusively a problem in the older age group (ATHEROSCLEROSIS) • B. (FALSE) Because of abundant collaterals between the three main mesenteric arteries, in most cases all three must be severely compromised before symptoms arise (USUALLY 2, SOMETIMES 3, OCCASIONALLY 1) • C. (FALSE) The most commonly affected arteries in symptomatic CMI is the SMA and IMA (CELIAC/SMA) • D. (TRUE) Long-term patency of bypass grafts to the celiac or SMA exceeds 90% • E. (FALSE) Malabsorption is a significant problem leading to weight loss (“FOOD FEAR” ABSTINENCE)

  10. Which of the following is a typical CT finding in patients with chronic mesenteric ischemia? A. Clot in SMA B. Clot in SMV C. Atherosclerotic plaque involving the mesenteric arteries. D. Atherosclerotic plaque involving the mesenteric veins.

  11. Which of the following is a typical CT finding in patients with chronic mesenteric ischemia? A. Clot in SMA B. Clot in SMV C. Atherosclerotic plaque involving the mesenteric arteries. D. Atherosclerotic plaque involving the mesenteric veins.

  12. Which of these statements about acute nonocclusive mesenteric insufficiency are true • A. Normally associated with profound illness such as sepsis, cardiovascular collapse, vasopressor use • B. Arteriographic findings include sequential focal vasospasm (“beading”), “pruned tree” appearance of distal vasculature, and presence of large vessel occlusion • C. Management includes fluid resuscitation, withdrawal of vasoconstrictors, antibiotics, and selective infusion of papaverine into the SMA. • D. Successful operative treatment of patients with clinical deterioration or peritonitis includes bypass grafting of the SMA and/or celiac artery

  13. Which of these statements about acute nonocclusive mesenteric insufficiency are true • A. (TRUE) Normally associated with profound illness such as sepsis, cardiovascular collapse, vasopressor use (LOW-FLOW, MESENTERIC VASOCONSTRICTION) • B. (FALSE) Arteriographic findings include sequential focal vasospasm (“beading”), “pruned tree” appearance of distal vasculature, and presence of large vessel occlusion (ABSENCE OF OCCLUSION) • C. (TRUE) Management includes fluid resuscitation, withdrawal of vasoconstrictors, antibiotics, and selective infusion of papaverine into the SMA. • D. (FALSE) Successful operative treatment of patients with clinical deterioration or peritonitis includes bypass grafting of the SMA and/or celiac artery (NO OCCLUSION – RESECT GANGRENOUS BOWEL ONLY)

  14. Which of these statements about mesenteric venous occlusion are true • A. Commonly found in patients with portal hypertension, pancreatitis, systemic low-flow states • B. CT and arteriography may demonstrate thickened bowel walls and lack of prompt filling of the portal system • C. Management includes hemodynamic support, anticoagulation, and fibrinolytic therapy • D. Operative management for patients with peritonitis include resection of necrotic bowel and surgical thrombectomy • E. In general, overall prognosis is good

  15. Which of these statements about mesenteric venous occlusion are true • A. (TRUE) Commonly found in patients with portal hypertension, pancreatitis, systemic low-flow states • B. (TRUE) CT and arteriography may demonstrate thickened bowel walls and lack of prompt filling of the portal system • C. (FALSE) Management includes hemodynamic support, anticoagulation, and fibrinolytic therapy (LYSIS - HIGH RISK OF BLEEDING WITH CONGESTED MUCOSA) • D. (FALSE) Operative management for patients with peritonitis include resection of necrotic bowel and surgical thrombectomy (THROMBECTOMY RARELY SUCCESSFUL) • E. (TRUE) In general, overall prognosis is good (FORMS VENOUS COLLATERALS, +/- RECANALIZATION)

  16. A young healthy patient without any obvious signs, symptoms, or risk factors of atherosclerosis presents with chronic history of postprandial pain, numerous evaluations by physicians, and dependency on pain medication. How will you evaluate this patient and what might you find?

  17. A young healthy patient without any obvious signs, symptoms, or risk factors of atherosclerosis presents with chronic history of postprandial pain, numerous evaluations by physicians, and dependency on pain medication. How will you evaluate this patient and what might you find? • MRI/MRA or arteriography, celiac artery compression from the median arcuate ligament of the diaphragm

  18. What is the treatment of celiac artery compression from the median arcuate ligament of the diaphragm?

  19. What is the treatment of celiac artery compression from the median arcuate ligament of the diaphragm • surgical release of median arcuate ligament, +/- patch angioplasty/short bypass if stenosed from fibrosis, +/- celiac nerve block (cause of pain not always clear)

  20. Which of the following forms of acute mesenteric ischemia (AMI) typically has no indication for surgery other than resection of gangrenous bowel when present? A. Embolic AMI B. Thrombotic AMI C. Nonocclusive mesenteric ischemia (NOMI) D. Mesenteric venous thrombosis (MVT) E. Arterial occlusive AMI

  21. Which of the following forms of acute mesenteric ischemia (AMI) typically has no indication for surgery other than resection of gangrenous bowel when present? A. Embolic AMI B. Thrombotic AMI C. Nonocclusive mesenteric ischemia (NOMI) - NOMI has no vascular occlusion, so revascularization is not indicated. MVT typically does not need thrombectomy, but this operation may be indicated in certain patients with localized clots diagnosed promptly. Revascularization and embolectomy are surgical options for thrombotic and embolic AMI. D. Mesenteric venous thrombosis (MVT) E. Arterial occlusive AMI

  22. Which of the following types of acute mesenteric ischemia (AMI) is more frequently found in young patients? A. Embolic AMI B. Thrombotic AMI C. Nonocclusive mesenteric ischemia (NOMI) D. Mesenteric venous thrombosis (MVT) E. Arterial occlusive AMI

  23. Which of the following types of acute mesenteric ischemia (AMI) is more frequently found in young patients? A. Embolic AMI B. Thrombotic AMI C. Nonocclusive mesenteric ischemia (NOMI) D. Mesenteric venous thrombosis (MVT) - Because hypercoagulability is the main risk factor, MVT occurs in patients of a much younger age range compared to the typical patients with AMI. Some cases of embolic AMI are found in relatively young people with atrial fibrillation, but they are the exception, not the rule. E. Arterial occlusive AMI

  24. Angiographically infused papaverine is indicated for all types of acute mesenteric ischemia (AMI). A. True B. False

  25. Angiographically infused papaverine is indicated for all types of acute mesenteric ischemia (AMI). A. True B. False - While it has no effect on the course of mesenteric venous thrombosis (MVT), papaverine infused through the angiogram catheter at the affected vessel is useful for all arterial forms of AMI. It relieves reactive vasospasm in occluded arterial vessels, and it is the only treatment for nonocclusive mesenteric ischemia other than resection of gangrenous bowel.

  26. Heparin is indicated in all types of acute mesenteric ischemia (AMI). A. True B. False

  27. Heparin is indicated in all types of acute mesenteric ischemia (AMI). A. True B. False - Heparin is indicated in post-revascularization arterial occlusion cases and in mesenteric venous thrombosis (MVT). Heparin is not useful in nonocclusive mesenteric ischemia.

  28. Angiographically infused thrombolytics are indicated in all cases of embolic acute mesenteric ischemia (AMI). A. True B. False

  29. Angiographically infused thrombolytics are indicated in all cases of embolic acute mesenteric ischemia (AMI). A. True B. False - Thrombolytics are noted to cause potentially fatal bleeding. Their use is tempered by multiple contraindications. Thrombolytics should be considered only in patients with no signs of peritonitis or other evidence of bowel necrosis.

  30. Which of these statements about visceral artery aneurysms are true • A. The arteries most commonly involved in descending order are splenic, SMA, hepatic, other arterial • B. Splenic artery aneurysms occur most commonly in women with a F:M ratio of 4:1 • C. Hepatic artery aneurysms occur most commonly in women with a F:M ratio of 2:1 • D. One out of four patients with visceral artery aneurysms present as emergencies with a mortality rate of 10-35% • E. Most patients without prohibitive risks factors should undergo elective repair

  31. Which of these statements about visceral artery aneurysms are true • A. (FALSE) The arteries most commonly involved in descending order are splenic (60%), SMA (5.5%), hepatic (20%), other arterial (EACH <5%) • B. (TRUE) Splenic artery aneurysms occur most commonly in women with a F:M ratio of 4:1 • C. (FALSE) Hepatic artery aneurysms occur most commonly in women with a F:M ratio of 2:1 (MOST COMMON IN MEN M:F 2:1) • D. (TRUE) One out of four patients with visceral artery aneurysms present as emergencies with a mortality rate of 10-35% • E. (TRUE) Most patients without prohibitive risks factors should undergo elective repair

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