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Single vessel abdominal arterial disease

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The long-standing discussion concerning the mere existence of single vessel abdominal artery disease can be closed: chronic gastrointestinal ischaemia (CGI) due to single vessel abdominal artery stenosis exists, can be treated successfully and in a safe manner. The most common causes of single vessel CGI are the coeliac artery compression syndrome (CACS) in younger patients, and atherosclerotic disease in elderly patients. The clinical symptoms of single vessel CGI patients are postprandial and exercise-related pain, weight loss, and an abdominal bruit. The current diagnostic approach in patients suspected of single vessel CGI is gastrointestinal tonometry combined with radiological visualisation of the abdominal arteries to define possible arterial stenosis. Especially in single vessel abdominal artery stenosis, gastrointestinal tonometry plays a pivotal role in establishing the diagnosis CGI. First-choice treatment of single vessel CGI remains surgical revascularisation, especially in CACS. In elderly or selected patients endovascular stent placement therapy is an acceptable option.

Introduction

Three aortic branches provide the arterial blood supply to the gastrointestinal tract: the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). The CA supplies stomach, liver, part of the pancreas and proximal part of the duodenum. The SMA supplies the distal part of the duodenum, the entire small bowel and the proximal colon. The IMA is relatively small and supplies the distal colon. It is generally assumed that in single vessel abdominal arterial disease the abundant collateral circulation of the arterial mesenteric tract prevents clinically relevant gastrointestinal ischaemia. This might be illustrated by the fact that single vessel abdominal arterial stenosis is frequently found in the general population (up to 18%), but the clinical diagnosis chronic gastrointestinal ischaemia (CGI) is rarely made [1], *[2]. The aetiology of the majority of stenoses of the abdominal arteries can be divided into concentric and eccentric diseases; see Table 1. In the younger patient the coeliac artery compression syndrome (CACS) is the most common cause of abdominal arterial stenosis. Atherosclerotic disease is the major cause of abdominal arterial stenosis in the elderly patient. Non-concentric intra-arterial disease causes significant stenoses (i.e. arterial thrombosis or dissection) in a minority of cases.

Until recently, controversy existed about the mere existence of single vessel CGI. It was generally thought that CGI is caused by significant stenosis involving at least two of the three main mesenteric arteries. Consequently it was thought that due to the supposedly abundant collateral circulation, single vessel abdominal arterial stenosis (caused by either atherosclerosis or compression by the median arcuate ligament) would not give clinically relevant gastrointestinal ischaemia.

Section snippets

Epidemiology

Data about the prevalence of, mostly, asymptomatic abdominal arterial stenosis are available from autopsy studies [3], [4] These data show that solitary narrowing of the CA and SMA is frequently found, respectively in 44% and 37% of subjects, and CA stenoses were significant (>50–70%) in 21% of subjects [5]. A more recent autopsy study showed that in 29% of cases stenosis of either CA or SMA was found, with the CA as the most common affected site. The latter study also showed a strong

Clinical presentation

The clinical symptoms of CGI caused by single vessel abdominal arterial disease (either due to atherosclerosis or to CACS) are comparable to the symptoms of multivessel abdominal arterial disease patients [10]. Postprandial pain, weight loss, exercise-related pain and an abdominal bruit are presenting symptoms found in respectively 84%, 74%, 44% and 26% of patients with single vessel CGI (Table 2) *[10], *[11]. The postprandial symptoms occur typically within 15–30 min after the meal and last

Abdominal arterial atherosclerosis

In the largest prospective cohort-study in patients with CGI, the CA was the most common affected vessel, compared to the SMA, accounting for respectively 92% and 8% of all single vessel stenosis [10]. Other studies report that the SMA was more affected in single vessel atherosclerotic disease than CA stenosis, but these studies were all small and retrospective in design *[13], [14].

The aforementioned cohort study and several case reports have described CGI resulting from solitary CA or SMA

Abdominal arterial stenosis

Non-invasive diagnostic methods to screen for arterial abdominal stenosis are abdominal duplex ultrasound scanning, [57] computed tomography angiography (CTA) and magnetic resonance angiography (MRA) (Table 3). Angiography of the mesenteric arteries is still considered to be the ‘gold standard’ for diagnosing and staging of arterial abdominal stenosis. The advantages of digital subtraction angiography (DSA) are the high sensitivity (and specificity) for stenoses in the origin of the abdominal

Treatment

In general, treatment of single vessel abdominal arterial disease involves fewer complications and very low mortality as compared to multivessel disease. The primary goal of treatment in patients with single vessel disease is relief of symptoms. This is in contrast with patients with multivessel abdominal arterial disease; these patients are at increased risk for complicated disease (i.e. high morbidity and mortality). In the latter group, treatment primarily aims to prevent progression of

Accidental findings of single vessel abdominal arterial stenosis

The increased availability of non-invasive diagnostics, such as CTA and MRA, has resulted in an increase of detection of unexpected vascular pathologic changes. Isolated CA and SMA stenosis without accompanying symptoms of CGI are occasionally observed. In the past, evaluation of the vascular abdominal anatomy was performed using conventional angiography in patients who are candidates for transplantation or subjects who are possible candidates for living related donor procedures. In the current

Summary

The discussion as to whether single vessel abdominal arterial disease can cause CGI is finished. In the past years, different larger cohort studies have shown that this disease entity exists, can be diagnosed correctly and treated with clinical success at long-term follow up.

The most important CA stenosis aetiology is extrinsic compression due to the median arcuate ligament (i.e. CACS). Atherosclerosis is the second most common cause of single vessel mesenteric disease. In both asymptomatic and

Conflict of interest

None of the authors have a conflict of interest regarding this article.

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