Acute Mesenteric Ischemia: Endovascular Management

Initial Assessment and Treatment Strategy

For patients with acute mesenteric ischemia who lack peritoneal signs, an endovascular‑first approach (aspiration embolectomy, catheter‑directed thrombolysis, or PTA/stenting) is recommended by the American College of Radiology. 1

Endovascular treatment reduces bowel resection rates, renal and respiratory failure, short‑bowel syndrome, and mortality compared with primary surgery in acute arterial occlusive disease (American College of Radiology). 4
Aspiration embolectomy achieves technical success up to 94 % for embolic occlusions (American College of Radiology). 1
Catheter‑directed thrombolysis is indicated when a significant distal thrombus burden is present (American College of Radiology). 2
Percutaneous transluminal angioplasty with or without stenting is the preferred endovascular option for thrombotic occlusions associated with atherosclerotic disease (American College of Radiology). 4
Catheter‑directed intra‑arterial vasodilator infusion can be used to treat vasospasm accompanying acute arterial occlusion (American College of Radiology). 4
Despite an endovascular‑first strategy, ≈ 70 % of patients still require subsequent surgical bowel resection or diversion (American College of Radiology). 1

The presence of overt peritonitis, pneumoperitoneum, intramural air on CT, or clinical signs of bowel infarction mandates immediate urgent laparotomy (American College of Radiology). 4

Intra‑arterial vasodilator infusion (papaverine, nitroglycerin, or glucagon) is recommended to improve mesenteric perfusion (American College of Radiology). 4
High‑dose intravenous prostaglandin E1 may be equally effective as intra‑arterial vasodilator therapy for NOMI (American College of Radiology). 4

Continuous unfractionated heparin infusion is the primary treatment for mesenteric venous thrombosis (American College of Radiology). 4
Surgical intervention is reserved only if bowel infarction develops (American College of Radiology). 4

Endovascular revascularization with percutaneous transluminal angioplasty and stent placement is the first‑line therapy for chronic mesenteric ischemia (American College of Radiology). 4