Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia

Article Outline

• Abstract
• Methods
  • Statistical analysis
• Results
  • Technical success
  • Clinical success
• Discussion
• Author contributions
• References
• Copyright

Purpose

Open revascularization in patients with chronic mesenteric ischemia (CMI) is considered the gold standard. Percutaneous transluminal angioplasty and stenting (PTAS) is often reserved for patients not suitable for open revascularization. In our institute, endovascular revascularization is the first-choice treatment. The purpose of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive patients with CMI at a single tertiary vascular referral center.

Methods

A retrospective review was performed of all consecutive patients with CMI who underwent PTAS from July 2001 to July 2008. Only symptomatic patients treated for atherosclerotic CMI were included. Patency was evaluated using computed tomography angiography (CTA). Kaplan-Meier curves were used to calculate patency rates of the treated mesenteric arteries.

Results

Sixty mesenteric arteries (30 celiac trunks, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Major morbidity was 4%. After dissection of the superior mesenteric artery (n = 1) and brachial artery (n = 1), respectively, both patients underwent endarterectomy and patch plasty. In three arteries, the lesion could not be crossed endovascularly and they were deemed immediate intention-to-treat failures. The initial technical success rate was 93%. No 30-day mortality was observed. Median follow-up was 25 months. During follow-up, 2 patients died from intestinal ischemia. Complete symptom relief was achieved in 78% of patients. Primary 1- and 2-year patency rates were 86% ± 5% and 60% ± 9%, respectively; primary-assisted patency rates were 88% ± 5% and 79% ± 7%, respectively. During follow-up, 6 patients underwent open revascularization due to failure of PTAS.

Conclusion

The initial technical success rate of PTAS as first-choice treatment of CMI is >90%. The 2-year primary patency rate dropped to 60%, but symptomatic in-stent stenoses could often be treated successfully with renewed endovascular techniques. Including one conversion, 14% of patients needed open revascularization during follow-up.

Chronic mesenteric ischemia (CMI) is an uncommon disease. The symptoms may be nonspecific and vary from the classical triad of postprandial abdominal pain, weight loss, and upper abdominal bruit to nonspecific abdominal pain and intermittent diarrhea. Open surgical treatment with bypass or endarterectomy has been the standard for many years.¹, ², ³, ⁴ Although the long-term outcome after open revascularization is both anatomically and functionally adequate, it is associated with substantial morbidity and mortality.⁴, ⁵

An alternative treatment for patients with CMI is percutaneous transluminal angioplasty and stenting (PTAS). Several reports have compared endovascular with open surgical revascularization in patients with CMI.², ³, ⁶, ⁷, ⁸ They document decreased morbidity and mortality rates and acceptable functional outcome after PTAS, but this therapy was reserved for patients not suitable for open revascularization.

The goal of this study was to report the technical and clinical success rates after endovascular revascularization as the first-choice treatment in a series of 51 consecutive and unselected patients with CMI at a single tertiary vascular referral center.

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Methods 

A retrospective review was performed on all consecutive patients with CMI from July 2001 to July 2008. All patients were treated with PTAS. Patients were identified from a vascular intervention database. Patients presenting with long-standing symptoms suggestive of CMI (postprandial abdominal pain, weight loss, and abdominal bruit) and visceral obstructive disease on vascular imaging were discussed in the multidisciplinary workgroup consisting of interventional radiologists, gastroenterologists, and vascular surgeons. Visceral obstructive disease was identified with Doppler ultrasound (DUS) scan imaging, magnetic resonance angiography (MRA), or computed tomography angiography (CTA). DUS criteria for stenosis were adapted from the criteria described by Zwolak et al.⁹ Other diagnoses were excluded by abdominal CT and gastroscopy or colonoscopy, or both, on indication. Since 2007, we have also performed gastric and jejunal exercise tonometry on indication.¹⁰, ¹¹ In patients with high suspicion for CMI, the diagnosis was obtained by digital subtraction angiography (DSA) with the option of immediate treatment. Only symptomatic patients treated for atherosclerotic CMI (significant stenosis or occlusion of at least two of three mesenteric arteries or single-vessel disease without collateral circulation) were included. Patients with acute mesenteric ischemia, acute exacerbation of CMI, thromboembolic visceral disease, or aortic dissection were excluded. All patients underwent first-time procedures. Hospital records were reviewed for demographics, symptoms, lesion characteristics, details of treatment, and outcome.

Arterial access was obtained by a transfemoral (80%) or transbrachial approach (8%), or both (12%). All patients underwent systemic heparinization with 5000 IE. After placement of a 6F catheter sheath and introduction of a diagnostic catheter, an anteroposterior and lateral abdominal aortography was taken. The mesenteric arteries were cannulated with a reversed curved or angled catheter, and the outflow bed was evaluated for collateral circulation. A stenosis of >70% on DSA or a mean pressure gradient of at least 10 mm Hg across the lesion was considered hemodynamically significant.¹², ¹³ Pressure gradients were only measured in doubtful hemodynamically significant lesions prior to treatment or in persistent stenosis after treatment. Sufficient collateral circulation was defined as rapid filling of the diseased visceral artery by the gastroduodenal or pancreaticoduodenal arteries, the marginal artery of Drummond or the arc of Riolan. In case of small collaterals without rapid filling of the diseased visceral artery, collateral circulation was considered insufficient. At this point, the diagnosis of CMI was assessed or rejected. The treatment was focused on the superior mesenteric artery (SMA). In patients with long SMA occlusions and a significant celiac artery (CA) or inferior mesenteric artery (IMA) stenosis, one of the latter vessels were treated, and collateral circulation to the SMA was assessed. After the stenosis was crossed or recanalization of the occlusion was achieved with a 0.035-inch wire, PTAS was performed. All stents were slightly oversized by approximately 10% based on proposed normal diameter. The stenosis was predilated if necessary. No embolic protection devices were used.

Technical success was defined as a residual diameter reduction <30% after PTAS of the obstruction or a pressure gradient <5 mm Hg across the lesion.¹⁴ A technical failure was defined as an occlusion or stenosis that could not be crossed or dilated, or a residual stenosis of ≥30%. In patients with single-vessel disease without sufficient collateral circulation, this artery was treated. In case of insufficient collateral circulation from the treated artery or an intention-to-treat failure, a second artery was treated by PTAS. A complication was defined as any unintentional event resulting from the treatment that led to adjustment of medical treatment or irreversible damage.

Clinical success was defined as technical success in at least one artery with sufficient collateral circulation and the resolution of symptoms and weight gain at least 3 months after the procedure, or both.¹⁴ PTAS was considered the first-choice treatment in all patients. If the endovascular treatment failed, a visceral bypass was considered. All patients were prescribed aspirin (100 mg daily) after the procedure. In addition, clopidogrel was prescribed for 1 month after stent placement in all patients.¹⁵

Regular follow-up consisted of anamnesis and physical examination after 3 months and yearly thereafter. If the patient had complete symptom relief, no additional imaging was performed. In December 2008, all patients were interviewed and invited for a physical examination and CTA.

Statistical analysis 

Measured values are reported as mean ± 1 SD or median (range), as appropriate. Technical success and patency rates were based on a per-artery analysis. Clinical success was based on a per-patient analysis. Kaplan-Meier curves were used to estimate patency and success rates. They were presented as percent ± SEM.¹⁴, ¹⁶ Pearson's χ² test was used to determine differences between groups. Significance was established at P < .05. Analysis was performed using SPSS 15.0 software (SPSS Inc, Chicago, Ill).

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Results 

Technical success 

A total of 69 patients with suspected CMI underwent DSA. PTAS was not performed in 18 patients. In 6 patients, compression of the celiac artery by the arcuate ligament was observed. In the other patients, either a significant stenosis was not assessed, or abundant collateral circulation to the diseased artery was observed. Sixty mesenteric arteries (30 celiac, 24 superior mesenteric, and 6 inferior mesenteric arteries) were treated in 51 patients (26 men). Mean age was 64 ± 11 years. In 14 of the 51 patients, complete occlusion of the SMA was observed. In 11 of 14 patients, a stenosis in the celiac trunk was successfully treated by PTAS, and the SMA was left untreated. In 2 patients, the IMA was treated successfully. In the remaining patient, both the celiac trunk and SMA were occluded, and recanalization of both arteries was only successful for the SMA. All other treated vessels contained a hemodynamically significant stenosis (>70%). All patients underwent PTAS using short balloon-expandable stents with a median length of 14 mm (8-24 mm). Median stent diameter placed in the celiac trunk was 6 mm (5-7 mm); in the SMA, 6 mm (4.5-7 mm); and in the IMA, 5 mm (4-6 mm). In 3 patients, the obstruction (1 occlusion, 2 stenoses) in the celiac trunk could not be crossed endovascularly, and they were deemed immediate intention-to-treat failures. In all of the patients with an initial failure, a second mesenteric artery was successfully treated by PTAS during the same procedure. A fourth intention-to-treat failure was registered after dissection of the SMA occurred that could not be restored endovascularly. This patient underwent endarterectomy and patch plasty of the dissected artery. The initial technical success rate was 93% (56 of 60 arteries).

In addition to the dissection of the SMA, resulting in the only initial conversion, another major complication was observed in a second patient. Dissection at the access site developed, and this patient underwent endarterectomy and patch plasty of the brachial artery. In 3 other patients, a hematoma was observed at the transfemoral access site without need for surgical intervention. This resulted in a major complication rate of 4% (2 of 51 procedures). The 30-day mortality rate was 0%.

Median follow-up was 25 months. In 39 of 51 patients (76%), anatomic follow-up was obtained. Primary 1-year and 2-year patency rates were 86% ± 5% and 60% ± 9%, respectively, and assisted primary patency rates were 88% ± 5% and 79% ± 7% (Fig 1).

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• Fig 1. 

  Kaplan-Meier primary (interrupted line) and assisted primary patency (continuous line) rates of 60 mesenteric arteries treated by percutaneous transluminal angioplasty.

Clinical success 

Patients presented predominantly with postprandial pain and weight loss (Table I). Successful PTAS of a second mesenteric artery in patients with an intention-to-treat failure eventually resulted in clinical success in these patients. Technical failure of PTAS resulted in clinical failure in 1 patient who required conversion after dissection of the SMA. Ten other patients did not have complete symptom relief after 3 months, resulting in an initial clinical success rate of 78% ± 6% (Fig 2). In 6 patients, two visceral arteries were treated successfully, resulting in initial clinical success (after 3 months) in all patients. After successful treatment of only one visceral artery, initial clinical success was observed in 34 of 45 patients (P = .171).

Table I. Comorbidity and presenting symptoms in 51 patients with chronic mesenteric ischemia

CAD, Coronary artery disease; COPD, chronic obstructive pulmonary disease.

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• Fig 2. 

  Clinical success in 51 patients treated for chronic mesenteric ischemia (CMI) by percutaneous transluminal angioplasty and stenting (PTAS).

Twenty patients suffered from two-vessel disease and 24 from three-vessel disease. Seven patients suffered from single-vessel disease in the absence of collateral circulation to the diseased artery on DSA (Table II). In 5 of 7 patients, the celiac trunk was treated, and the SMA was treated in 2 patients. Four of 7 patients presented with typical postprandial pain in combination with weight loss. After PTAS, 3 of 7 patients were asymptomatic, and 1 had only partial improvement. In 3 patients, persistent complaints were observed. In 2 patients, symptom relief was obtained by treatment of Helicobacter pylori (n = 1) and Clostridium difficile infection (n = 1), respectively. In the remaining patient, PTAS treatment of the CA was technically successful, but her nausea and vomiting complaints did not improve. The patient died of pneumonia 4 months later. After PTAS in patients suffering from two-vessel disease, 5 of 20 patients did not have complete symptom relief. Three patients had only partial improvement. One patient underwent an SMA bypass, and another patient underwent an endarterectomy of SMA due to dissection. After PTAS in patients suffering from three-vessel disease, 2 patients did not have complete symptom relief. One patient had partial improvement, and the other patient underwent an SMA bypass (Fig 2). The difference in symptom relief after PTAS in patients with single- and multi-vessel disease was statistical significant (P = .014).

Table II. Initial clinical success after PTAS in patients suffering from single-vessel and multivessel disease

PTAS, Percutaneous transluminal angioplasty and stenting.

During a median follow-up of 25 months, symptoms relapsed in 13 of the 40 patients with initial complete symptom relief. Relapse of symptoms was observed only in patients with multi-vessel disease. In 12 of 13 patients with symptom relapse, CTA showed restenosis of the treated mesenteric artery. Five patients underwent successful percutaneous transluminal angioplasty (PTA) of an in-stent stenosis. The other 8 patients had mild symptoms and were monitored without renewed intervention. In another 6 patients, significant restenosis was identified in the treated mesenteric artery without symptom relapse. Two patients died during follow-up of intestinal ischemia. Both patients had withdrawn from follow-up and presented with acute mesenteric ischemia. Twelve patients died of causes not related to the CMI, of which 6 were cardiovascular deaths. During follow-up, recurrence of symptoms after treatment of two visceral arteries was similar to treatment of one visceral artery (P = .962). The primary 1-year and 2-year clinical success rates were 70% ± 7% and 56% ± 8%, respectively, and assisted primary clinical success rates were 72% ± 6% and 68% ± 7% (Fig 3).

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• Fig 3. 

  Kaplan-Meier primary (interrupted line) and assisted primary clinical success (continuous line) rates in 51 patients with chronic mesenteric ischemia treated by percutaneous transluminal angioplasty.

PTAS failed during follow-up in 6 patients, and they underwent open revascularization. The first 2 patients underwent successful PTAS of a stenosed celiac trunk, and the occluded SMA was left untreated. When symptoms did not resolve after 1 month, a common iliac artery SMA bypass was performed, as mentioned above. The third patient underwent PTAS of a stenosed celiac trunk. The occluded SMA and stenosed IMA were left untreated. A DSA showed scant collateral circulation. Although symptoms resolved, a common iliac artery SMA bypass was performed. The fourth patient underwent PTAS of the celiac trunk, but the occluded SMA was left untreated. After 2 years, successful PTA of an in-stent stenosis in the celiac trunk was performed. Postprandial pain and weight loss returned 9 months later, and open revascularization was performed using an antegrade bifurcated bypass to the hepatic artery and SMA. The fifth patient underwent successful PTAS of a stenosed SMA, but endovascular treatment of the stenosis in the celiac trunk failed. The occluded IMA was left untreated. Restenosis of the SMA occurred after 25 months and was treated by PTA. Although technically successful, postprandial pain and weight loss did not resolve, and open revascularization was performed using an antegrade bifurcated bypass to the hepatic artery and SMA. The sixth patient underwent recanalization and stent placement of a totally occluded SMA, but recanalization of the totally occluded celiac trunk failed. Four years after PTAS, the patient presented with acute mesenteric ischemia due to occlusion of the recanalized SMA. Open revascularization consisting of a retrograde SMA bypass was performed; unfortunately, the patient died the first day after surgery. All bypasses were anastomosed distally from the stent, and this was not associated with technical difficulties.

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Discussion 

Endovascular treatment as first-choice treatment for patients with CMI appears to be a safe therapy with initial technical and clinical success rates similar to open revascularization.¹, ², ¹⁷ During midterm follow-up, substantial recurrence of symptoms has been observed. In the current series, we have treated unselected patients endovascularly, also including young and fit patients. Therefore, the results of this series might be better for comparison with the findings after open revascularization, since PTAS has often been reserved for patients unfit for open revascularization.

Open revascularization is associated with substantial morbidity and mortality. Reported morbidity ranges from 12% to 33%.¹⁷, ¹⁸ Two major complications (4%) were observed in our series, and no patients died as a result of PTAS. In a series from a nationwide database in the United States, more than 5500 patients were treated for CMI. The mortality rate of 3.7% after PTAS was significantly lower than the 13% after bypass.⁴ In the largest recent series from specialized centers, the mortality rate after open revascularization ranges from 2% to 15%.¹, ², ³, ⁶, ⁷

The initial technical success rate in our series was 93%. Seven patients (14%) eventually underwent open revascularization after PTAS failure. In only 1 patient did PTAS have to be converted immediately to endarterectomy due to dissection of the treated artery. Three other patients underwent open revascularization within 3 months after PTAS. During follow-up, 3 more patients underwent open revascularization after late failure of PTAS.

Although endarterectomy and antegrade and retrograde bypasses are associated with significant rates of morbidity and mortality, open revascularization provides durable symptom relief. After open revascularization, excellent long-term clinical success rates up to 92% after 5 years have been reported.¹, ², ⁶, ⁷ It has been considered the standard for many years. In a review of 292 patients treated by PTAS, symptom relief without reintervention was maintained in 75% of these patients.¹⁵ In our current series, symptoms with varying severity had recurred in 13 of 40 patients after a median follow-up of 25 months. The 2-year primary clinical success rate had dropped to 56%. However, the symptomatic restenoses in most patients could again be treated endovascularly, resulting in a 2-year primary-assisted clinical success rate of 68%. It appears that the results after endovascular revascularization are not as durable as after open revascularization.

A critical point in treating patients with CMI—both open and endovascularly—is adequate diagnostic studies. Imaging studies to identify the presence of mesenteric artery obstructive disease include DUS, MRA, CTA, and DSA. CMI is suspected in patients with at least two mesenteric arteries demonstrating a hemodynamically significant stenosis or occlusion. Single-vessel disease without collaterals may also lead to symptomatic CMI. Treatment of asymptomatic patients with a significant celiac trunk or SMA stenosis has not been recommended. The presence of an asymptomatic mesenteric artery stenosis is not associated with death or adverse cardiologic events, and these patients do not develop chronic intestinal ischemia or intestinal infarction.¹⁹ Only asymptomatic patients with significant three-vessel arterial disease should be considered for prophylactic mesenteric arterial revascularization.²⁰ Symptoms can be nonspecific, and typical symptoms are not always the result of mesenteric ischemia.

Failure of symptom relief after successful PTAS or open revascularization might result from an incorrect diagnosis. In our series, at least 3 patients with an incorrect diagnosis underwent PTAS. Two patients did not obtain symptom relief before eradication therapy for Helicobacter pylori and Clostridium difficile. In the third patient, a proper explanation for the nausea, vomiting, and chronic diarrhea not responding to PTAS was never found.

Gastric exercise tonometry is a functional test that can be used as an addition to anatomic imaging.¹⁰ In our series, the clinical outcome after treatment of patients with single-vessel disease was disappointing and significantly worse compared to patients with multi-vessel disease. Especially in these patients, a functional test could have additional value to identify gastrointestinal ischemia. In a series of 95 patients treated for CMI, 84% had durable and complete symptom relief after surgical revascularization or endovascular stent placement. Prior to the revascularization, 85% of patients had abnormal results on gastric exercise tonometry. Of the patients with a single-vessel stenosis, 38 of 50 were free from symptoms, compared with 32 of 35 with multiple-vessel stenoses (P = .086).² This test was used in only 3 of our patients but seems to have additional value in selected patients.

In this retrospective series, morbidity and mortality rates after endovascular revascularization as first-choice treatment in patients with CMI are low compared with reported outcomes after open revascularization. The initial technical success rate of PTAS was >90%. The 2-year primary patency and clinical success rate is only reasonable, and in-stent stenoses can often be treated successfully with repeated endovascular techniques. Although one initial conversion was observed, only 14% of patients needed open revascularization during midterm follow-up. Therefore, we believe PTAS can be the first-choice treatment in patients with CMI, while open revascularization is reserved for patients in which PTAS fails.

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Author contributions 

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References 

1. Park WM, Cherry KJ, Chua HK, Clark RC, Jenkins G, Harmsen WS, et al. Current results of open revascularization for chronic mesenteric ischemia: a standard for comparison. J Vasc Surg. 2002;35:853–859
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (79 KB)
   • CrossRef
2. Mensink PB, van Petersen AS, Geelkerken RH, Otte JA, Huisman AB, Kolkman JJ. Clinical significance of splanchnic artery stenosis. Br J Surg. 2006;93:1377–1382
   • View In Article
   • MEDLINE
   • CrossRef
3. Sivamurthy N, Rhodes JM, Lee D, Waldman DL, Green RM, Davies MG. Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes. J Am Coll Surg. 2006;202:859–867
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (157 KB)
   • CrossRef
4. Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pomposelli FB. Mesenteric revascularization: management and outcomes in the United States, 1988-2006. J Vasc Surg. 2009;50:341–348
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (763 KB)
   • CrossRef
5. Derrow AE, Seeger JM, Dame DA, Carter RL, Ozaki CK, Flynn TC, et al. The outcome in the United States after thoracoabdominal aortic aneurysm repair, renal artery bypass, and mesenteric revascularization. J Vasc Surg. 2001;34:54–61
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (27 KB)
   • CrossRef
6. Kasirajan K, O'Hara PJ, Gray BH, Hertzer NR, Clair DG, Greenberg RK, et al. Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting. J Vasc Surg. 2001;33:63–71
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (85 KB)
   • CrossRef
7. Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung TK, Cambria RP. Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience. J Vasc Surg. 2007;45:1162–1171
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (526 KB)
   • CrossRef
8. Zerbib P, Lebuffe G, Sergent-Baudson G, Chamatan A, Massouille D, Lions C, et al. Endovascular versus open revascularization for chronic mesenteric ischemia: a comparative study. Langenbecks Arch Surg. 2008;393:865–870
   • View In Article
   • CrossRef
9. Zwolak RM, Fillinger MF, Walsh DB, LaBombard FE, Musson A, Darling CE, et al. Mesenteric and celiac duplex scanning: a validation study. J Vasc Surg. 1998;27:1078–1087discussion 1088
   • View In Article
   • MEDLINE
   • CrossRef
10. Kolkman JJ, Groeneveld AB, van der Berg FG, Rauwerda JA, Meuwissen SG. Increased gastric PCO2 during exercise is indicative of gastric ischaemia: a tonometric study. Gut. 1999;44:163–167
    • View In Article
    • MEDLINE
    • CrossRef
11. Otte JA, Huisman AB, Geelkerken RH, Kolkman JJ. Jejunal tonometry for the diagnosis of gastrointestinal ischemia (Feasibility, normal values and comparison of jejunal with gastric tonometry exercise testing). Eur J Gastroenterol Hepatol. 2008;20:62–67
    • View In Article
    • CrossRef
12. Resch T, Lindh M, Dias N, Sonesson B, Uher P, Malina M, et al. Endovascular recanalisation in occlusive mesenteric ischemia–feasibility and early results. Eur J Vasc Endovasc Surg. 2005;29:199–203
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (92 KB)
    • CrossRef
13. Park CM, Chung JW, Kim HB, Shin SJ, Park JH. Celiac axis stenosis: incidence and etiologies in asymptomatic individuals. Korean J Radiol. 2001;2:8–13
    • View In Article
    • MEDLINE
    • CrossRef
14. Myers KA. Reporting guidelines for open and endovascular surgery: why the current recommendations should be revised. J Endovasc Surg. 1995;2:321–328
    • View In Article
    • MEDLINE
    • CrossRef
15. Kougias P, El Sayed HF, Zhou W, Lin PH. Management of chronic mesenteric ischemia (The role of endovascular therapy). J Endovasc Ther. 2007;14:395–405
    • View In Article
    • CrossRef
16. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–538
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (1996 KB)
    • CrossRef
17. Kruger AJ, Walker PJ, Foster WJ, Jenkins JS, Boyne NS, Jenkins J. Open surgery for atherosclerotic chronic mesenteric ischemia. J Vasc Surg. 2007;46:941–945
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (93 KB)
    • CrossRef
18. Mateo RB, O'Hara PJ, Hertzer NR, Mascha EJ, Beven EG, Krajewski LP. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes. J Vasc Surg. 1999;29:821–831dicussion 832
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (113 KB)
    • CrossRef
19. Wilson DB, Mostafavi K, Craven TE, Ayerdi J, Edwards MS, Hansen KJ. Clinical course of mesenteric artery stenosis in elderly Americans. Arch Intern Med. 2006;166:2095–2100
    • View In Article
    • MEDLINE
    • CrossRef
20. Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. 1998;27:840–844
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (65 KB)
    • CrossRef