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Radiologic Management of Mesenteric Ischemia

Variant: 1   Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
Procedure Appropriateness Category
Systemic anticoagulation Usually Appropriate
Angiography and aspiration embolectomy Usually Appropriate
Transcatheter thrombolysis Usually Appropriate
Surgical embolectomy May Be Appropriate

Variant: 2   Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
Procedure Appropriateness Category
Angiography and endovascular intervention including possible thrombolysis, angioplasty, or stent placement Usually Appropriate
Systemic anticoagulation Usually Appropriate
Surgical endarterectomy or bypass May Be Appropriate

Variant: 3   Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
Procedure Appropriateness Category
Angiography with infusion of vasodilator Usually Appropriate
Systemic anticoagulation Usually Appropriate
Systemic infusion of prostaglandin E1 May Be Appropriate
Angiography with percutaneous transluminal angioplasty Usually Not Appropriate

Variant: 4   Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
Procedure Appropriateness Category
Surgical revascularization Usually Appropriate
Systemic anticoagulation Usually Appropriate
Angiography and aspiration embolectomy May Be Appropriate
Transcatheter thrombolysis Usually Not Appropriate

Variant: 5   Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
Procedure Appropriateness Category
Surgery with median arcuate ligament release Usually Appropriate
Mesenteric angiography in lateral projection during both inspiration and expiration Usually Appropriate
Supportive measures only May Be Appropriate
Percutaneous transluminal angioplasty with stent placement May Be Appropriate
Systemic anticoagulation Usually Not Appropriate

Variant: 6   History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
Procedure Appropriateness Category
Angiography with possible percutaneous transluminal angioplasty and stent placement Usually Appropriate
Surgical bypass or endarterectomy May Be Appropriate
Systemic anticoagulation May Be Appropriate

Variant: 7   Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
Procedure Appropriateness Category
Systemic anticoagulation Usually Appropriate
Transhepatic superior mesenteric vein catheterization and pharmacomechanical thrombolysis Usually Appropriate
Transjugular superior mesenteric vein catheterization and pharmacomechanical thrombolysis and TIPS May Be Appropriate
SMA angiography followed by thrombolytic infusion May Be Appropriate
Surgical thrombectomy Usually Not Appropriate

Panel Members
Alexander Lam, MDa; Yoon-Jin Kim, MDb; Nicholas Fidelman, MDc; Mikhail C.S.S. Higgins, MD, MPHd; Brooks D. Cash, MDe; Resmi Charalel, f; Marcelo S. Guimaraes, MDg; Sharon W. Kwan, MD, MSh; Parag J. Patel, MDi; Sara Plett, MDj; Salvatore T. Scali, MDk; Kevin S. Stadtlander, MDl; Michael Stoner, MDm; Ricky T. Tong, MD, PhDn; Baljendra S. Kapoor, MDo.
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
A. Angiography and aspiration embolectomy
Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
B. Surgical embolectomy
Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
C. Systemic anticoagulation
Variant 1: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows filling defect in proximal SMA consistent with embolus. No intramural or extra-luminal air. Initial therapy.
D. Transcatheter thrombolysis
Variant 2: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
Variant 2: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
A. Angiography and endovascular intervention including possible thrombolysis, angioplasty, or stent placement
Variant 2: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
B. Surgical endarterectomy or bypass
Variant 2: Recent onset abdominal pain, no peritoneal signs, and known atrial fibrillation. CTA shows calcified atherosclerotic plaque involving the aorta and its major branches, as well as proximal short-segment occlusion of the proximal SMA. No intramural or extra-luminal air. Initial therapy.
C. Systemic anticoagulation
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
A. Angiography with infusion of vasodilator
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
B. Angiography with percutaneous transluminal angioplasty
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
C. Systemic anticoagulation
Variant 3: Patient with cardiac disease causing low cardiac output who developed abdominal pain but without peritoneal signs. CTA shows patent origins and proximal portions of celiac artery, SMA, and IMA, with diffuse irregular narrowing of SMA branches. Initial therapy.
D. Systemic infusion of prostaglandin E1
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
A. Angiography and aspiration embolectomy
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
B. Surgical revascularization
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
C. Systemic anticoagulation
Variant 4: Recent onset abdominal pain, peritoneal signs, and known atrial fibrillation. CTA shows filling defect in the proximal SMA consistent with embolus and evidence of bowel infarction. Initial therapy.
D. Transcatheter thrombolysis
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
A. Mesenteric angiography in lateral projection during both inspiration and expiration
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
B. Percutaneous transluminal angioplasty with stent placement
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
C. Supportive measures only
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
D. Surgery with median arcuate ligament release
Variant 5: Abdominal pain after meals and CTA showing widely patent origins of SMA and IMA, with compression of the celiac origin by the median arcuate ligament. Initial therapy.
E. Systemic anticoagulation
Variant 6: History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
Variant 6: History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
A. Angiography with possible percutaneous transluminal angioplasty and stent placement
Variant 6: History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
B. Surgical bypass or endarterectomy
Variant 6: History of abdominal pain after meals for the past few months and weight loss. CTA shows aortic atherosclerotic disease and suggests SMA-origin stenosis with occlusion of celiac origin and an occluded IMA. Initial therapy.
C. Systemic anticoagulation
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
A. SMA angiography followed by thrombolytic infusion
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
B. Surgical thrombectomy
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
C. Systemic anticoagulation
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
D. Transhepatic superior mesenteric vein catheterization and pharmacomechanical thrombolysis
Variant 7: Previously healthy with worsening diffuse abdominal pain for 2 weeks. CTA shows occlusion of the superior mesenteric vein and its major tributaries. Bowel appears normal. Serum lactate level is normal. Initial therapy.
E. Transjugular superior mesenteric vein catheterization and pharmacomechanical thrombolysis and TIPS
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
References
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.