There is no diagnostic method specific for the
diagnosis of AMI; thus, diagnosis is challenging.
The diagnosis is generally delayed, and the disease is
already advanced at the time of treatment.[
1-
6] Given
the low incidence and wide spectrum, there is limited
number of studies on AMI, majority of which are
retrospective.[
1-
15] In AMI, the mortality rate ranges
from 30 to 100% in different studies.[
1-
6,
16,
17] In our
study, the overall mortality rate was 60.7%.
The AOMI cases, caused by an arterial embolus or
thrombus in SMA, are the cause of intestinal ischemia
in 70 to 80% of cases. To a lesser extent, intestinal
ischemia may occur as a result of MVT or NOMI.[5,6]
In our study, there was AOMI in 67.8% of the patients,
while MVT and NOMI were observed in 14.3% and
17.9%, respectively. The mortality rate was higher in
the NOMI group (80%).
Nonocclusive mesenteric ischemia is mainly
observed in patients with acute, severe, critical illness,
such as heart failure and surgical patients.[11] Clinical
presentation is often insidious and nonspecific, leading
to delayed diagnosis.[11,18,19] The NOMI rate has been
reported as 15% among AMIs in the literature, its
incidence is unclear as diagnosis cannot be made in
critically ill patients.[11,18,20] In our study, all patients
with diagnosis of NOMI had history of major
cardiovascular surgery.
In some studies, it has been reported that comorbid
disease is one of the risk factors for mortality.[1,19,21] In
our study, atrial fibrillation and arterial hypertension
rates were significantly higher in the AOMI group
(p<0.05). There was no history of arterial hypertension
in the NOMI group. The reason for the speculative
protective effect of arterial hypertension remains to be
unknown; however, it may be associated with better
preservation of autoregulation pressure gradient in
the splanchnic region.[22] In our study, the presence
of comorbid disease showed no significant effect on
mortality.
In AMI, the poor prognosis and mortality were
associated with organ dysfunction, renal failure,
high APACHE II score, and elevated lactate
level, which was more prominent during the first
24 h. Persistent elevation in the serum lactate
level reflects continued splanchnic hypoperfusion or
multiorgan failure. Particularly in patients requiring
vasoactive agents, the role of vasoactive agents in
enhanced splanchnic vasoconstriction might have
an influence on mortality. In AMI, a serum lactate
level >2 mmol/L was associated with irreversible
intestinal ischemia.[1,23] It should be kept in mind
that normal arterial lactate level does not necessarily
exclude AMI and that high lactate concentration may
indicate delayed diagnosis.[1,23]
D-dimer is a fibrin product that is generated
by enzymatic degradation during intravascular
coagulation, and in case of elevated lactate levels, it can
be further increased in AMI and in other diseases.[24]
D-dimer level was found to be significantly higher in
the MVT group. In our study, it was found that serum
lactate and creatinine levels were significantly higher
in nonsurvivors compared to survivors (p<0.05).
It has been reported that age is a negative
prognostic criterion in AMI.[1,19,25] However, age was
not a risk factor for mortality in AMI in our study
(p>0.05).
Although anticoagulation with heparin is the key
treatment in MVT, no benefit was observed in arterial
AMI.[26] Anticoagulant therapy was initiated in all
MVT patients. It was thought that COVID-19 was
the underlying reason in two patients who developed
MVT during the pandemic. Both of these patients
died.
Only a minority of patients benefit from
revascularization.[27] In our study, mesenteric artery
embolectomy was performed in three AOMI patients.
Intestinal resection was required in the majority of
patients who underwent surgery.
Delayed diagnosis and treatment, elevated lactate
level, sepsis at the time of presentation, and colonic
involvement, in addition to the small intestine,
are poor prognostic factors for mortality. Thus,
early diagnosis and effective treatment of sepsis
may reduce the mortality rate. In AMI patients
with involvement of the small intestines and colon,
viscera revascularization techniques (embolectomy,
thrombectomy, endarterectomy, or bypass) must be
attempted before wide resection.[1,2,21,28] In our
study, colon involvement was higher in the AOMI
group.
This study has some limitations. Since the data
analysis period was long and the study was conducted
at a new institution, the changes in healthcare
providers, surgeons, and approaches might have led
to significant changes in the diagnostic procedures
and treatment options. Additionally, the number
of diagnosed NOMI patients was limited since the
diagnosis of NOMI is more challenging.
In conclusion, clinical outcomes remain poor,
with high in-hospital mortality in AMI. Younger
patients had a similar mortality risk to older
patients. Hypertension and atrial fibrillation
were more common in the AOMI group and
associated with larger intestinal ischemia. The
number of patients with NOMI might have been
underestimated as the diagnosis is more difficult in
these patients. Acute mesenteric ischemia-related
deaths were mostly associated with multiorgan
failure, renal failure, elevated lactate levels, and
colon involvement. Monitoring the arterial lactate
level appeared helpful in identifying patients with
poor prognosis. Early diagnosis, timely treatment,
and renal protection are of importance to improve
clinical prognosis.
Ethics Committee Approval: The study protocol was
approved by the Izmir Bakırçay University, Çiğli Training
and Research Hospital Ethics Committee (date: 30.03.2022,
no: 546). The study was conducted in accordance with the
principles of the Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea, design, data collection,
literature review, wrting the article: İ.K.; Control, crtitical
review, literature review: A.D.; Data collection, references
and fundings: A.Ş.; Data collection, materials; H.A.; Wrting
the article, design, crtitical review: Ş.B.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.