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Intestinal angina
Intestinal ITS
SURGICAL
Angina SIGNIFICANCE
WILLIAM P. MIKKELSEN, M.D., Los Angeles, Calijornia From tbe Department of Surgery, University of Soutbern California School of Medicine, Los Angeles, California.
known medica measures infIyence the unreIenting progression of the disease. In the same way that angina pectoris is a manifestation of intermittent myocardia1 ischemia, so too is this syndrome of abdomina1 pain a manifestation of intermittent intestina1 ischemia. Whereas the increased oxygen demand in the former is produced by physical exertion, in the Iatter it is produced by the increased intestina1 work induced by ingestion of food. In both situations the etiologic factor is the faiIure of diseased arteries to provide for this increased demand. Pal’s crisis, intestinal cIaudication and abdominal angina are synonyms that have been used to IabeI this syndrome. By definition angina signifies suffocation, whereas cIaudication means Iimping or lame. The ischemic organ responsibIe for the pain is the intestine rather than a11 of the abdominal viscera. It would thus appear that from a semantic viewpoint the term intestinal wouId most cIoseIy identify this angina syndrome. OnIy a few of the reports on mesenteric arteria1 occIusion have taken cognizance of intestina1 angina [&rr]. Its frequency as a prodrome to complete arterial mesenteric occIusion is therefore IargeIy unknown. However, a report in which this reIationship was emphasized is that of Dunphy [rz]. He reviewed the case records of tweIve patients with fata mesenteric arterial occIusion and noted that in seven there was a history of abdomina1 pain which preceded the fatal episode by weeks to years. Of the four patients reported on by Benjamin [r?] and McCIenahan and Fisher [r4], two had had intestinaI angina, one for five years and the other for two years, preceding the final acute episode. It is reasonabIe to assume that this prodrome has frequentIy been present but has
ONSIDERABLE attention has been directed by surgeons toward acute mesenteric vascuIar occIusion [r-7]. The clinica features and the pathoIogic changes which occur in the gangrenous bowe1 wall and smaIIer mesenteric vesseIs have been we11 documented. Much attention has been focused on whether the primary occIusive process has been arterior or venous. Recent reports continue to stress the gravity of the disease and record a persistence of high mortaIity rates. Even those patients who survive extensive bowe1 resection have usually been problems in management. In contrast to the acute phase, IittIe information is avaiIabIe concerning the prodroma1 features that mav be encountered in mesenteric vascular occlusion due to arterial obstruction. This prodrome, more frequent than is generaIIy appreciated, is consistently characterized by postciba1, generalized, cramping abdominal pain that may extend to the back. The pain occurs a short time after meals and persists for one to three hours. Minima1 at first, the pain steadiIy increases in severity as the weeks or months pass. Association of meaIs with this pain soon leads to a reluctance on the part of Ioss and underthe patient to eat. Weight nutrition inevitably foIIow. PhvsicaI examination, even in the presence of pain, is rather unreveaIing except for evidence of weight loss and occasiona miId abdominaI distention. AbdominaI tenderness and findings of peritonea1 irritation do not occur unti1 Iater. Laboratory studies and x-ray examination of the gastrointestina1 tract are uniformIy negative. Sedatives, oxygen, antichobnergic and vasodilating drugs produce no significant ameIioration of pain. Further, no
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American
Journal
of Surgery,
Volume
94, August,
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262
IntestinaI
Angina rysms has, in Iike manner, shown that the rich collateral permits Iigation of the inferior mesenteric artery at its origin. Instances of non-fatal occlusion of the superior mesenteric artery are also recorded [I 6,171. However, simultaneous occlusion of the superior mesenteric artery and one of the other two major aortic branches nou1c1, in all IikeIihood, offer a serious threat to survival. Of the case reports on fata mesenteric arteria1 occIusion preceded by intestina1 angina, only two [rS,rg] were found that present sufficient necropsy information concerning the status of a11 three of the aortic branches to the abdominal viscera. In both of these cases the celiac asis was found to be compIeteIy occIuded by atherosclerosis and a recent thrombus was found at the markedJy narrowed origin of the superior mesenteric artery. The two cases to be presented herein demonstrated a similar process. This suggests that obIiteration of the coIIatera1 flow from the ceIiac axis is necessary before narrowing of the orifice of the superior mesenteric artery will be productive of intestina angina. The two case reports that foIIow clearly depict the clinica features of intestina1 angina, a prodrome to acute compIete mesenteric occIusion. In the one case in which aortography was done, a positive, objective diagnosis couId be made. Of equa1 significance has been the recognition that this syndrome is potentially curable by surgery.
been overlooked, particularly when the iI patient is seen only during the acute phase of compIete arterial 0ccIusion. Certain pathologic fIndings encountered in the arteries, themselves, in mesenteric arterial occlusion have perhaps not been fuIIy appreciated. The smaller arteries are frequentl! found to be collapsed and bloodless. The occIuded segment usually is Iocated at or near the origin of the superior mesenteric artery. Extension of thrombosis into the branches of this artery does not necessarily occur. Studies reveal that with the exception of rareIy encountered cases of viscera1 angiitis, the wall of the superior mesenteric artery distaI to its first few centimeters is free of disease. Carucci’s [ 151 observations are of particuIar significance. He faiIed to find a singIe instance of atherosclerosis of the superior mesenteric artery dista1 to its first 2 cm. in a study of fifty necropsies performed upon patients over the age of fifty years. In a11 these patients there was extensive atheroscIerosis of other arteries, principalI?; the aorta, coronary or renaI vesseIs. Thirty-three of fifty cases, however, did revea1 minima1 to moderate narrowing of the ostium or the first z cm. of the superior mesenteric artery due to atherosclerosis. AtheroscIerosis of the larger arteries seems to be primarily a disease of their bifurcations. At necropsy many aortas appear reasonabIy free of disease except for atheroscIerotic narrowing at or near the ostia of their branches. Progressive narrowing at these sites leads finalIy to compIete occlusion of the ostium. Survival of the anatomic part suppIied by this occIuded artery is then dependent on the adequacy of the collateral suppIy. This is equaIIy as true for the abdomina1 viscera as for the upper and lower extremities. Distinct coIIatera1 anastomoses exist among the three major aortic branches supplying the gastrointestina1 tract. Whereas anatomic variations exist, the major avenue of communication from the celiac axis to the superior mesenteric artery is the loop formed by the superior and inferior pancreaticoduodenal arteries. Connecting the superior and inferior mesenteric arteries is the marginal artery of Drummond. Lesser coIIateraIs among these three vessels probabIy exist. Recently, arterial Iigations performed upon patients with cirrhosis have demonstrated that occlusion of the origin of the celiac axis is we11 tolerated. Excisiona surgery of abdominal aortic aneu-
CASE
REPORTS
CASE I. H. D., a forty-seven year old white man, entered St. Vincent’s HospitaI on October 19, 1953, for elective cholecystectomy. His compIaints were cramping abdominal pain of five months’ duration and weight Ioss for two months. The pain was Iocated across the upper abdomen and aIso invoIved the back. It developed haIf an hour after meaIs, continued for two to three hours and then subsided. The greater the amount of food ingested, the greater wouId be the pain. There was no seIective fat intoIerance and no vomiting. Physical examination was essentiaIIy negative. ChoIecystography reveaIed no concentration of dye within the gaIIbIadder. An upper gastrointestina1 x-ray study failed to reveal abnormalities. On October zIst cholecystectomy and exploration of the common bile duct were performed. The gaIIbIadder contained eight stones. Choledochostomy was negative. The patient’s postoperative course seemed satisfactory unti1 the fourth day 263
MikkeIsen
FIG. I. CASE I. Photograph of necropsy findings, demonstrating ostia1 narrowing and thrombosis of superior mesenteric artery. The waII of the artery distal to the ostium appears essentially normal.
when abdomina1 distention, jaundice and fever become marked. On October 29th abdominal exploration reveaIed areas of softening in the Iiver, a biopsy of which was interpreted as “infarction of the Iiver.” The patient faiIed to improve and remained in a state of continuous mild shock with deepening jaundice. A smaI1 bowel fistuIa deveIoped. On November 4th a third operation was performed which reveaIed extensive gangrene of the smaI1 bowe1 with numerous sites of perforation. A segment of iIeum was resected. FoIIowing this operation the patient remained comatose, jaundiced and febriIe. MuItipIe intestina1 fistulas developed. He died on November 13th. Necropsy reveaIed extensive gangrene extending from the stomach to the spIenic ffexure of the coIon. MultipIe infarcts were present in the Iiver and spIeen. The aorta reveaIed moderateIy severe atherosclerosis of the abdomina1 segment. The orifice of the ceIiac axis was compIeteIy obIiterated. The ostium of the superior mesenteric artery was narrowed by atheroscIerosis and a recent thrombus compIeteIy occIuded this vessel for a distance of 4 to 5 cm. (Fig. I.) DistaI to the area of narrowing the superior mesenteric artery appeared free of atheromatous disease.
FIG. 2. CASE II. Aortogram demonstrating occlusion of the Ieft common iIiac artery.
compIete
and both common, interna and externa1 iIiac vesseIs was performed. His postoperative course was uneventfu1 and he was discharged on August 16th. FoIIowing surgery, cIaudication of the left Iower extremity disappeared and sexua1 potency returned. Readmission on January 15, 1956, was required for the evaIuation of cramping, generalized abdomina1 pain of two months’ duration. The pain was postciba1, coming on about fifteen minutes after eating and disappearing in one to three hours. A heavy mea1 was folIowed by more severe and more proIonged pain. The patient voIunteered the information that pain wouId not deveIop if he did not eat. Physical examination reveaIed no abnormalities. A11 periphera1 arteria1 puIsations were normaI. A diagnosis of intestina1 angina was strongIy suspected. Therapy consisting of oxygen and vasoantichoIinergic and mucosa1 anaIgesic diIating, drugs was of no benefit. GastrointestinaI x-ray studies reveaIed no abnormalities. Aortography with the patient in an obIique position reveaIed adequate fiIIing of the superior mesenteric artery. (Fig. 3.) This finding prompted the dismissa of a diagnosis of intestina1 angina. However, more aIert interpretation of this fiIm wouId have uncovered the correct diagnosis. Later, cIose inspection of the aortogram revealed an area of marked narrowing at the origin of the superior mesenteric artery. (Fig. 4.) The patient was discharged on January 24th. The fourth admission on February 29th was for
CASE II. J. F. K., a forty-six year oId white man, was first admitted to the HospitaI of the Good Samaritan on JuIy 26, 1955, because of intermittent claudication of the Ieft thigh and Ieg, and sexua1 impotency of three years’ duration. Aortography demonstrated compIete occIusion of the Ieft common iliac artery. (Fig. 2.) He was discharged on JuIy 28th. He was readmitted on August 3rd, and on the foIlowing day endarterectomy of the distal aorta 264
IntestinaI
FIG. 3. CASE II. Aortogram taken six months after endarterectomy of the distat aorta and both common, internal and external iIiac arteries. FilIing of the superior mesenteric artery is demonstrated. abdominal pain that now was almost constant, PhysicaI examination revealed severe emaciation and miId abdominal distention. No abdominal masses were paIpabIe and peristalsis was active. MiId generaILed abdominal tenderness was present. Conservative therapy was instituted until March 5th, when shock deveIoped. The patient was prepared for surgery and during induction of anesthesia cardiac arrest occurred which responded to thirty seconds of cardiac massage. AbdominaI exploration was then performed with the findings of extensive, spotty, ischemic gangrene extending from the stomach to the sigmoid coIon. Mesenteric arterial pulsations were absent. The mesenteric veins were coIIapsed and contained no thrombi. The process was too extensive for resection. The patient died five hours postoperatively. Necropsy revealed extensive gangrene of the gastrointestina1 tract invoIving the stomach and the smaI1 and Iarge bowe1. The Iiver and spIeen were normal. Examination of the aorta discIosed miId atherosclerosis. The inner surfaces of the previously cndarterectomized segments of aorta and iliac vesseIs were smooth and their Iumens were patent. (Fig. 5.) The ceIiac axis and inferior mesenteric artery at their origins were compIetely obliterated by atheroscIerosis. The first centimeter of
Angina
FIG. 4. CASE II. Close-up view of the aortic-superior mesenteric artery junction of the aortogram in Figure 3. The India ink outline shows the markedly narrowed origin of the superior mesenteric artery.
increasing
the superior mesenteric artery lumen of Iess than I ml. (Fig.
was narrowed
6.) However,
to a
dista1
FIG. 5. CASE II. Photograph of the necropsy specimen of the abdomina1 aorta and iIiac arteries. The area of previous endarterectomy can be delineated.
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MikkeIsen
SUPERIOR
MESENTERIC
ARTERY
FIG. 6. CASE II. Cross section of the superior mesenteric artery taken from the areas indicated. AImost compIete obIiteration by atheroscIerosis of the first portion is compared to the essentiaIIy norma appearance of this artery 2 cm. distaIIy.
RE-IMPu~NTATION
to this area of narrowing
OF
There
was no thrombus
the artery
was normal.
in this vesse1.
SUPERIOR MESENTERIC COMMENTS
HOMOGRAFT
The cIassic symptoms and findings encounttered in intestina1 angina are exempIified by these two case reports. The correct diagnosis was compIeteIy overIooked in the first case, and although strongIy suspected in the second case, was abandoned when the aortogram was incorrectIy interpreted. It was not unti1 the necropsy findings prompted a “second Iook” at the aortogram that the Iesion was deIineated. The important contributions of these cases have been that the character of the pain in this syndrome is aImost suficient by itseIf to permit a diagnosis to be made and that fiIIing of the
BRIDGING
AORTA9 SUPERIOR MESEWWUC FIG. 7. Diagrams of potential surgical procedures designed to circumvent the area of narrowing at the origin of the superior mesenteric artery.
266
IntestinaI superior mesenteric artery when seen on aortography does not eliminate it. Perhaps in other cases, as in the second case herein, a narrowed orifice of the superior mesenteric artery wilI be consistently visuahzed and ahow a positive diagnosis to be made on objective grounds. The process in each of these patients was one of steadily increasing pain and unreIenting progression of disease to the tina stage of intestina gangrene. Conservative or expectant therapeutic measures were of no benefit in preventing a continuing diminution of intestina1 blood ff ow. Inspection of the necropsy specimens indicates that surgica1 correction is technicalIS feasible. Restoration of adequate intestina1 bIood flow is permitted by the rather Iarge caliber of the superior mesenteric artery, the diameter of which averages 9 mm. [20]. It will be recahed that this vesse1 immediateIy dista1 to its origin is usuaIIy normaI. Because of the anatomic location of the origin of the superior mesenteric artery, endarterectomy by present avaiIabIe methods wouId be diffkuIt. More Iikely procedures to circumvent the area of obstruction wouId appear to be transection with reimpIantation of the superior mesenteric artery into the aorta, or bridging this vesse1 and the aorta by means of a short bypass homograft. (Fig. 7.) Cadaver dissection has demonstrated that either of these two procedures are technicaIIy feasibIe by mobilization superiorIy of the third and fourth portions of the duodenum, pancreas and the Ieft renaI vein. ApproximateIy 3 to 4 cm. of the superior mesenteric artery proxima1 to its first branch are thus exposed. The aorta lies in close proximity directIy posteriorly.
Angina presented. In one patient an objective diagnosis could be made by means of aortography. Of noteworthy significance has been the observation that whereas medical measures were of no benefit in preventing the unreIenting progression of this disease, the potential for surgica1 correction does exist. The potentia1 surgical technics are indicated. REFERENCES I.
2.
3. 4.
5. 6. 7.
8.
9. IO. II. 12.
‘3. 14. ‘5. 16.
SUMMARY
The term intestina1 angina most cIoseIy identifies the syndrome that may, for a period of months to years, precede complete mesenteric arteria1 occIusion. This syndrome is characterized by postciba1, cramping abdomina1 pain and is produced by intestina1 ischemia. The frequency with which this syndrome occurs and its pathophysioIogy are discussed. Evidence is presented suggesting that compIete occJusion of the ceJiac axis must be present before narrowing of the ostium of the superior mesenteric artery wiI1 be productive of intestina angina. Two typica case reports are
17. 18. 19. 20.
LAL-FMAN, H. and SCHEINBERG, S. Arterial and venous mesenteric occIusion. Am. J. Surg., 58: 84, 1942. MUSGROVE, J. E. and SEYBOLD, W. D. Mesenteric vascutar occlusion. S. Clin. North America, 3o: 1063, 1950. MOORE, T. Mesenteric vascular occIusion. Brit. J. Surg., 28: 347, 1941. DUNPHY, J. E. and ZOLLINGER, R. Mesenteric vascuIar occlusion. New England J. Med., 21 I : 708, 1934. FICARRA, B. J. Mesenteric vascuIar occIusion. Am. J. Surg., 66: 168, 1944. HERTZLER, A. E. SurgicaI Pathology of the Peritoneum. PhiIadeIphia, 1935. J. B.%ppincott. CONNER. L. A. A discussion of the roIe of arterial thrombosis in the visceral diseases of middle-life, based upon anaIogies drawn from coronary thrombosis. Am. J.-M. SC., 185: 13, 1933. KLEIN. E. Embolism and thrombosis of the suoerior mesenteric artery. Surg., Gynec. Z? Ohs;, 33: 385, 1921. DUNPHY, J. E. and WHITFIELD, R. D. Mesenteric vascular disease. Am. J. Surg., 47: 632, 1940. GREENBERG. G. Peritonitis foIIowina abdominal angina. .G. Rec., rgo: 129, 1939. BERMAN, L. G. and Russo, F. R. Abdominal angina. New England J. Med., 242: 61 I, 1950. DUNPHY, J. E. Abdominal oain of vascular origin. Am. Jl M. SC., 192: 109,~1936. BEXJAMIN, D. Mesenteric thrombosis. Am. J. Surg., 76: 338, 1948. MCCLENAHAN, J. E. and FISHER, B. Mesenteric thrombosis. Surgery, 23: 778, 1948. CARUCCI, J. J. hlesenteric vascuIar occlusion. Am. J. Surg., 80: 47, 1953. MOORE. T. Mesenteric vascuIar occlusion. Brit. J. .%rg., 28: 347, 1941. JOHNSON, C. C. and BAG~ENSTOSS,A. H. Mesenteric vascuIar occIusion. Proc. Staff Meet., Mayo Clin., 24: 649, 1949. Case records. New Eneland J. Med.. 240: 262. 1949. BERMAN, J. K. and THORNTON, H. C. OccIusive vascuIar disease of the abdomen. J. Indiana M. A., 33: 138, 1940. EISENBERG, A. A. and SCHLINK, H. A. Mesenteric vascular occlusion. Surg., Gynec. CT Obst., 27: 66, 1918. DISCUSSION
JXI; A. CANNON (Los Angeles, Calif.): For rather obvious reasons I do not have any sIides
that would illustrate any point of discussion, and 267
MikkeIsen Dr. MikkeIsen was kind enough to Iet me refer to two of his to open this discussion, which I would Iike to do in order to attempt to illustrate a point regarding aortograms. If you wiII remember, in his presentation (Fig. z), Dr. MikkeIsen mentioned that there was hIIing of the ceIiac axis and of the spIenic artery in the origina aortogram. Because the patient is in a true anteroposterior position, we cannot say too much about the inferior and superior mesenteric arteries except that there is some fiIIing there. Then when in order to show this superior mesentery the repeat aortogram was taken with the patient in a properIy obIique position, we find very poor fihing of the ceIiac axis, as emphasized by poor fiIIing in the hepatic arteries. However, I beIieve if we look very cIoseIy, even on Figure 3 it is possibIe for us to see the definite narrowing in the superior mesenteric artery just beIow its origin from the aorta. The point I wish to make is that Dr. MikkeIsen made the definite diagnosis on clinica grounds with regard to the cause of this patient’s troubIe, and he made it at a time when an operation would have had a chance to cure the patient. He even had the operation pIanned. He then did the aortogram and was not abIe to interpret the aortogram in a confirmatory fashion, and unfortunateIy neither was the roentgenoIogist. It seems obvious that obIiterative arterioscIerosis is becoming increasingIy a surgical disease. I think we wil1 agree that operation on the termina1 aorta and its dista1 branches is now an accepted part of our surgica1 armamentarium. Obstructive lesions of the interna carotid and renaI arteries due to arterioscIerosis are being attacked ,with increasing frequency. There is no doubt that Dr. MikkeIsen’s provocative paper will help lead the way to successfu1 attacks on lesions in the superior mesenteric and celiac arteries in the future. Dr. MikkeIsen has obviousIy proved that earIy recognition is possibIe, and actuaIIy that is the onIy necessary requirement in this situation. We do not even have to have the aortogram. I am aIso confident that seIected cases of coronary atheroscIerosis may become amenabIe to surgical attack in the near future. AII these Iesions are simiIar. They attack arteria1 bifurcations, are segmenta1, and earIy invoIve reIativeIy Iarge arteries where the dista1 tree, at Ieast initiaIly, is patent. When a thrombus occurs, it is aIways a secondary manifestation. An observation which is perhaps worth remembering and emphasizing is that any operation for arterioscIerosis must be considered pahiative. It is going to be paIIiative unti1 a method of preventing the reIentIess progression of the probIem in a generaIized fashion is somehow arrived at. At present it is very obvious that there is no medicine which is effective in the treatment of arteriosclerosis. Dr. Beck has mentioned many times that you simply
cannot treat a patient with coronary artery disease with an eIectrocardiogram. I have felt, from my own experience with a fair number of peopIe with obstructive arteriosclerosis, that diet would seem to be increasingIy important in the etioIogy of this condition. There are many exampIes which can Iead one to this conclusion, and in genera1 these exampIes come around to the point that populations which are underfed, or at Ieast populations which have a low intake of fat, do not tend to show arterioscIerosis. During the war in Europe the incidence of arteriosclerosis or atheroscIerotic disease went down with the caIoric and fat intake, and it has gone up again with the rise of caIoric and fat intake. Consequently I fee1 obIigated to say something to a postoperative patient in this regard. I teIl him in an adamant way that I think it is of extreme importance for him to reduce down to the low side of his thinnest aduIt weight. I aIso teI1 him to avoid fat and excess caIories from then on. If you question these patients with regard to their weight when they were twenty years old, invariabIy you wiI1 find that they have gained 20 to 30 pounds. I think you wiI1 agree that a11 of us have undoubtedIy seen thin, wispy ninety year oId people. We have to stop to think a minute to remember very many obese ninety year oIdsters. WILLARD E. GOODWIN (Los AngeIes, CaIif.): We, as urologists, use arteriography a great dea1. I should like to add some remarks about technic which may be heIpfu1 in studying suspected cases of this disease. About half the arteriograms we take are done by the transfemora1 method, i.e., needIe puncture of the femoral artery, foIIowed by passage of a poIyethyIene tube through the needIe to any desired Ievel in the aorta.* This aIIows the arteriogram to be made with the patient Iying on his back or in an obIique position. As weI1, the intra-aortic injection may be pIaced at any level the operator desires. If you wished to study such a patient arteriographically, this transfemora1 technic couId be empIoyed in order to find the right IeveI. MuItipIe smaI1 injections at different Ievels can be made without fear of muItipIe aortic punctures as in the transIumbar technic. ALFRED A. STRAUSS (PaIm Springs, Calif.): I am very much interested in Dr. MikkeIsen’s articIe on intestina1 angina. We have had two cases with similar symptoms in which the patient had three attacks within a period of five years. The most striking thing about the patient was the sudden onset of pain with marked IocaI tenderness in the *WALTER, R. C. and GOODWIN,W. E. Aortography and retroperitonea1 oxygen in urologic diagnosis: a comparison of transIumbar and percutaneous femoraI methods of aortography.. J. urol., 70: 52&53j’, 1953.
268
IntestinaI Ieft upper quadrant of the abdomen, with a certain amount of restlessness and anxiety. The tentative diagnosis was voIvuIus or mesenteric thrombosis. The indication was quite cIear to perform an exploratory operation. About 12 inches of small bowe1 were thickened, edematous, red and meatlike in appearance. The bIood suppIy above and beIow the lesion seemed quite definite, so a resection and end-to-end anastomosis were performed. The patient made an uneventful recovery. After this operation the patient was warned that if he had a similar attack he must not wait but go immediateIy to the hospita1 or he wouId be apt to lose his life. About fourteen months later, while driving from or to his o&e, he again had a severe attack in his abdomen and immediately drove to the hospita1. Again the symptoms were simiIar with the same clinica findings. This time about 18 inches of bowel had to be resected. The patient made an uneventfu1 recovery. About three years Iater the patient again had a similar attack and again went to the hospita1. This time about 12 inches of bowe1 were resected about 4 feet above the ileocecal vaIve. The patient made an uneventful recovery. This patient has been carefully studied as to
269
Angina heart and other sources which might cause this condition. In studying the bIood vessels of the dissected portion, it seemed that the vessels were somewhat narrowed and had, on cross section, an increased amount of connective tissue as compared with norma blood vesseIs of the mesenteric vessels. The second case was very much like the first one. Between the Iirst and second operations there was a period of three years. The pathologic findings were about the same. The first patient’s last operation was performed three years ago and he seems well; it has been a year and a haIf since the second patient’s operation. The arteriogram taken on both patients found no cause for this condition. I think the description given by Dr. Mikkelsen of this cIinicaI condition is very interesting because very few men so far have found by arteriogram the real cause of this condition. WILLIAM P. MIKKELSEN (closing): I wish to thank Drs. Cannon, Goodwin and Strauss for their comments. Dr. Goodwin’s approach to arteriography is we11 taken. Perhaps the best comment I can make about it is that if ever I am fortunate enough to see one of these patients again, I believe that I shaI1 forego aortography.
SURGICAL
Angina SIGNIFICANCE
WILLIAM P. MIKKELSEN, M.D., Los Angeles, Calijornia From tbe Department of Surgery, University of Soutbern California School of Medicine, Los Angeles, California.
known medica measures infIyence the unreIenting progression of the disease. In the same way that angina pectoris is a manifestation of intermittent myocardia1 ischemia, so too is this syndrome of abdomina1 pain a manifestation of intermittent intestina1 ischemia. Whereas the increased oxygen demand in the former is produced by physical exertion, in the Iatter it is produced by the increased intestina1 work induced by ingestion of food. In both situations the etiologic factor is the faiIure of diseased arteries to provide for this increased demand. Pal’s crisis, intestinal cIaudication and abdominal angina are synonyms that have been used to IabeI this syndrome. By definition angina signifies suffocation, whereas cIaudication means Iimping or lame. The ischemic organ responsibIe for the pain is the intestine rather than a11 of the abdominal viscera. It would thus appear that from a semantic viewpoint the term intestinal wouId most cIoseIy identify this angina syndrome. OnIy a few of the reports on mesenteric arteria1 occIusion have taken cognizance of intestina1 angina [&rr]. Its frequency as a prodrome to complete arterial mesenteric occIusion is therefore IargeIy unknown. However, a report in which this reIationship was emphasized is that of Dunphy [rz]. He reviewed the case records of tweIve patients with fata mesenteric arterial occIusion and noted that in seven there was a history of abdomina1 pain which preceded the fatal episode by weeks to years. Of the four patients reported on by Benjamin [r?] and McCIenahan and Fisher [r4], two had had intestinaI angina, one for five years and the other for two years, preceding the final acute episode. It is reasonabIe to assume that this prodrome has frequentIy been present but has
ONSIDERABLE attention has been directed by surgeons toward acute mesenteric vascuIar occIusion [r-7]. The clinica features and the pathoIogic changes which occur in the gangrenous bowe1 wall and smaIIer mesenteric vesseIs have been we11 documented. Much attention has been focused on whether the primary occIusive process has been arterior or venous. Recent reports continue to stress the gravity of the disease and record a persistence of high mortaIity rates. Even those patients who survive extensive bowe1 resection have usually been problems in management. In contrast to the acute phase, IittIe information is avaiIabIe concerning the prodroma1 features that mav be encountered in mesenteric vascular occlusion due to arterial obstruction. This prodrome, more frequent than is generaIIy appreciated, is consistently characterized by postciba1, generalized, cramping abdominal pain that may extend to the back. The pain occurs a short time after meals and persists for one to three hours. Minima1 at first, the pain steadiIy increases in severity as the weeks or months pass. Association of meaIs with this pain soon leads to a reluctance on the part of Ioss and underthe patient to eat. Weight nutrition inevitably foIIow. PhvsicaI examination, even in the presence of pain, is rather unreveaIing except for evidence of weight loss and occasiona miId abdominaI distention. AbdominaI tenderness and findings of peritonea1 irritation do not occur unti1 Iater. Laboratory studies and x-ray examination of the gastrointestina1 tract are uniformIy negative. Sedatives, oxygen, antichobnergic and vasodilating drugs produce no significant ameIioration of pain. Further, no
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American
Journal
of Surgery,
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94, August,
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262
IntestinaI
Angina rysms has, in Iike manner, shown that the rich collateral permits Iigation of the inferior mesenteric artery at its origin. Instances of non-fatal occlusion of the superior mesenteric artery are also recorded [I 6,171. However, simultaneous occlusion of the superior mesenteric artery and one of the other two major aortic branches nou1c1, in all IikeIihood, offer a serious threat to survival. Of the case reports on fata mesenteric arteria1 occIusion preceded by intestina1 angina, only two [rS,rg] were found that present sufficient necropsy information concerning the status of a11 three of the aortic branches to the abdominal viscera. In both of these cases the celiac asis was found to be compIeteIy occIuded by atherosclerosis and a recent thrombus was found at the markedJy narrowed origin of the superior mesenteric artery. The two cases to be presented herein demonstrated a similar process. This suggests that obIiteration of the coIIatera1 flow from the ceIiac axis is necessary before narrowing of the orifice of the superior mesenteric artery will be productive of intestina angina. The two case reports that foIIow clearly depict the clinica features of intestina1 angina, a prodrome to acute compIete mesenteric occIusion. In the one case in which aortography was done, a positive, objective diagnosis couId be made. Of equa1 significance has been the recognition that this syndrome is potentially curable by surgery.
been overlooked, particularly when the iI patient is seen only during the acute phase of compIete arterial 0ccIusion. Certain pathologic fIndings encountered in the arteries, themselves, in mesenteric arterial occlusion have perhaps not been fuIIy appreciated. The smaller arteries are frequentl! found to be collapsed and bloodless. The occIuded segment usually is Iocated at or near the origin of the superior mesenteric artery. Extension of thrombosis into the branches of this artery does not necessarily occur. Studies reveal that with the exception of rareIy encountered cases of viscera1 angiitis, the wall of the superior mesenteric artery distaI to its first few centimeters is free of disease. Carucci’s [ 151 observations are of particuIar significance. He faiIed to find a singIe instance of atherosclerosis of the superior mesenteric artery dista1 to its first 2 cm. in a study of fifty necropsies performed upon patients over the age of fifty years. In a11 these patients there was extensive atheroscIerosis of other arteries, principalI?; the aorta, coronary or renaI vesseIs. Thirty-three of fifty cases, however, did revea1 minima1 to moderate narrowing of the ostium or the first z cm. of the superior mesenteric artery due to atherosclerosis. AtheroscIerosis of the larger arteries seems to be primarily a disease of their bifurcations. At necropsy many aortas appear reasonabIy free of disease except for atheroscIerotic narrowing at or near the ostia of their branches. Progressive narrowing at these sites leads finalIy to compIete occlusion of the ostium. Survival of the anatomic part suppIied by this occIuded artery is then dependent on the adequacy of the collateral suppIy. This is equaIIy as true for the abdomina1 viscera as for the upper and lower extremities. Distinct coIIatera1 anastomoses exist among the three major aortic branches supplying the gastrointestina1 tract. Whereas anatomic variations exist, the major avenue of communication from the celiac axis to the superior mesenteric artery is the loop formed by the superior and inferior pancreaticoduodenal arteries. Connecting the superior and inferior mesenteric arteries is the marginal artery of Drummond. Lesser coIIateraIs among these three vessels probabIy exist. Recently, arterial Iigations performed upon patients with cirrhosis have demonstrated that occlusion of the origin of the celiac axis is we11 tolerated. Excisiona surgery of abdominal aortic aneu-
CASE
REPORTS
CASE I. H. D., a forty-seven year old white man, entered St. Vincent’s HospitaI on October 19, 1953, for elective cholecystectomy. His compIaints were cramping abdominal pain of five months’ duration and weight Ioss for two months. The pain was Iocated across the upper abdomen and aIso invoIved the back. It developed haIf an hour after meaIs, continued for two to three hours and then subsided. The greater the amount of food ingested, the greater wouId be the pain. There was no seIective fat intoIerance and no vomiting. Physical examination was essentiaIIy negative. ChoIecystography reveaIed no concentration of dye within the gaIIbIadder. An upper gastrointestina1 x-ray study failed to reveal abnormalities. On October zIst cholecystectomy and exploration of the common bile duct were performed. The gaIIbIadder contained eight stones. Choledochostomy was negative. The patient’s postoperative course seemed satisfactory unti1 the fourth day 263
MikkeIsen
FIG. I. CASE I. Photograph of necropsy findings, demonstrating ostia1 narrowing and thrombosis of superior mesenteric artery. The waII of the artery distal to the ostium appears essentially normal.
when abdomina1 distention, jaundice and fever become marked. On October 29th abdominal exploration reveaIed areas of softening in the Iiver, a biopsy of which was interpreted as “infarction of the Iiver.” The patient faiIed to improve and remained in a state of continuous mild shock with deepening jaundice. A smaI1 bowel fistuIa deveIoped. On November 4th a third operation was performed which reveaIed extensive gangrene of the smaI1 bowe1 with numerous sites of perforation. A segment of iIeum was resected. FoIIowing this operation the patient remained comatose, jaundiced and febriIe. MuItipIe intestina1 fistulas developed. He died on November 13th. Necropsy reveaIed extensive gangrene extending from the stomach to the spIenic ffexure of the coIon. MultipIe infarcts were present in the Iiver and spIeen. The aorta reveaIed moderateIy severe atherosclerosis of the abdomina1 segment. The orifice of the ceIiac axis was compIeteIy obIiterated. The ostium of the superior mesenteric artery was narrowed by atheroscIerosis and a recent thrombus compIeteIy occIuded this vessel for a distance of 4 to 5 cm. (Fig. I.) DistaI to the area of narrowing the superior mesenteric artery appeared free of atheromatous disease.
FIG. 2. CASE II. Aortogram demonstrating occlusion of the Ieft common iIiac artery.
compIete
and both common, interna and externa1 iIiac vesseIs was performed. His postoperative course was uneventfu1 and he was discharged on August 16th. FoIIowing surgery, cIaudication of the left Iower extremity disappeared and sexua1 potency returned. Readmission on January 15, 1956, was required for the evaIuation of cramping, generalized abdomina1 pain of two months’ duration. The pain was postciba1, coming on about fifteen minutes after eating and disappearing in one to three hours. A heavy mea1 was folIowed by more severe and more proIonged pain. The patient voIunteered the information that pain wouId not deveIop if he did not eat. Physical examination reveaIed no abnormalities. A11 periphera1 arteria1 puIsations were normaI. A diagnosis of intestina1 angina was strongIy suspected. Therapy consisting of oxygen and vasoantichoIinergic and mucosa1 anaIgesic diIating, drugs was of no benefit. GastrointestinaI x-ray studies reveaIed no abnormalities. Aortography with the patient in an obIique position reveaIed adequate fiIIing of the superior mesenteric artery. (Fig. 3.) This finding prompted the dismissa of a diagnosis of intestina1 angina. However, more aIert interpretation of this fiIm wouId have uncovered the correct diagnosis. Later, cIose inspection of the aortogram revealed an area of marked narrowing at the origin of the superior mesenteric artery. (Fig. 4.) The patient was discharged on January 24th. The fourth admission on February 29th was for
CASE II. J. F. K., a forty-six year oId white man, was first admitted to the HospitaI of the Good Samaritan on JuIy 26, 1955, because of intermittent claudication of the Ieft thigh and Ieg, and sexua1 impotency of three years’ duration. Aortography demonstrated compIete occIusion of the Ieft common iliac artery. (Fig. 2.) He was discharged on JuIy 28th. He was readmitted on August 3rd, and on the foIlowing day endarterectomy of the distal aorta 264
IntestinaI
FIG. 3. CASE II. Aortogram taken six months after endarterectomy of the distat aorta and both common, internal and external iIiac arteries. FilIing of the superior mesenteric artery is demonstrated. abdominal pain that now was almost constant, PhysicaI examination revealed severe emaciation and miId abdominal distention. No abdominal masses were paIpabIe and peristalsis was active. MiId generaILed abdominal tenderness was present. Conservative therapy was instituted until March 5th, when shock deveIoped. The patient was prepared for surgery and during induction of anesthesia cardiac arrest occurred which responded to thirty seconds of cardiac massage. AbdominaI exploration was then performed with the findings of extensive, spotty, ischemic gangrene extending from the stomach to the sigmoid coIon. Mesenteric arterial pulsations were absent. The mesenteric veins were coIIapsed and contained no thrombi. The process was too extensive for resection. The patient died five hours postoperatively. Necropsy revealed extensive gangrene of the gastrointestina1 tract invoIving the stomach and the smaI1 and Iarge bowe1. The Iiver and spIeen were normal. Examination of the aorta discIosed miId atherosclerosis. The inner surfaces of the previously cndarterectomized segments of aorta and iliac vesseIs were smooth and their Iumens were patent. (Fig. 5.) The ceIiac axis and inferior mesenteric artery at their origins were compIetely obliterated by atheroscIerosis. The first centimeter of
Angina
FIG. 4. CASE II. Close-up view of the aortic-superior mesenteric artery junction of the aortogram in Figure 3. The India ink outline shows the markedly narrowed origin of the superior mesenteric artery.
increasing
the superior mesenteric artery lumen of Iess than I ml. (Fig.
was narrowed
6.) However,
to a
dista1
FIG. 5. CASE II. Photograph of the necropsy specimen of the abdomina1 aorta and iIiac arteries. The area of previous endarterectomy can be delineated.
265
MikkeIsen
SUPERIOR
MESENTERIC
ARTERY
FIG. 6. CASE II. Cross section of the superior mesenteric artery taken from the areas indicated. AImost compIete obIiteration by atheroscIerosis of the first portion is compared to the essentiaIIy norma appearance of this artery 2 cm. distaIIy.
RE-IMPu~NTATION
to this area of narrowing
OF
There
was no thrombus
the artery
was normal.
in this vesse1.
SUPERIOR MESENTERIC COMMENTS
HOMOGRAFT
The cIassic symptoms and findings encounttered in intestina1 angina are exempIified by these two case reports. The correct diagnosis was compIeteIy overIooked in the first case, and although strongIy suspected in the second case, was abandoned when the aortogram was incorrectIy interpreted. It was not unti1 the necropsy findings prompted a “second Iook” at the aortogram that the Iesion was deIineated. The important contributions of these cases have been that the character of the pain in this syndrome is aImost suficient by itseIf to permit a diagnosis to be made and that fiIIing of the
BRIDGING
AORTA9 SUPERIOR MESEWWUC FIG. 7. Diagrams of potential surgical procedures designed to circumvent the area of narrowing at the origin of the superior mesenteric artery.
266
IntestinaI superior mesenteric artery when seen on aortography does not eliminate it. Perhaps in other cases, as in the second case herein, a narrowed orifice of the superior mesenteric artery wilI be consistently visuahzed and ahow a positive diagnosis to be made on objective grounds. The process in each of these patients was one of steadily increasing pain and unreIenting progression of disease to the tina stage of intestina gangrene. Conservative or expectant therapeutic measures were of no benefit in preventing a continuing diminution of intestina1 blood ff ow. Inspection of the necropsy specimens indicates that surgica1 correction is technicalIS feasible. Restoration of adequate intestina1 bIood flow is permitted by the rather Iarge caliber of the superior mesenteric artery, the diameter of which averages 9 mm. [20]. It will be recahed that this vesse1 immediateIy dista1 to its origin is usuaIIy normaI. Because of the anatomic location of the origin of the superior mesenteric artery, endarterectomy by present avaiIabIe methods wouId be diffkuIt. More Iikely procedures to circumvent the area of obstruction wouId appear to be transection with reimpIantation of the superior mesenteric artery into the aorta, or bridging this vesse1 and the aorta by means of a short bypass homograft. (Fig. 7.) Cadaver dissection has demonstrated that either of these two procedures are technicaIIy feasibIe by mobilization superiorIy of the third and fourth portions of the duodenum, pancreas and the Ieft renaI vein. ApproximateIy 3 to 4 cm. of the superior mesenteric artery proxima1 to its first branch are thus exposed. The aorta lies in close proximity directIy posteriorly.
Angina presented. In one patient an objective diagnosis could be made by means of aortography. Of noteworthy significance has been the observation that whereas medical measures were of no benefit in preventing the unreIenting progression of this disease, the potential for surgica1 correction does exist. The potentia1 surgical technics are indicated. REFERENCES I.
2.
3. 4.
5. 6. 7.
8.
9. IO. II. 12.
‘3. 14. ‘5. 16.
SUMMARY
The term intestina1 angina most cIoseIy identifies the syndrome that may, for a period of months to years, precede complete mesenteric arteria1 occIusion. This syndrome is characterized by postciba1, cramping abdomina1 pain and is produced by intestina1 ischemia. The frequency with which this syndrome occurs and its pathophysioIogy are discussed. Evidence is presented suggesting that compIete occJusion of the ceJiac axis must be present before narrowing of the ostium of the superior mesenteric artery wiI1 be productive of intestina angina. Two typica case reports are
17. 18. 19. 20.
LAL-FMAN, H. and SCHEINBERG, S. Arterial and venous mesenteric occIusion. Am. J. Surg., 58: 84, 1942. MUSGROVE, J. E. and SEYBOLD, W. D. Mesenteric vascutar occlusion. S. Clin. North America, 3o: 1063, 1950. MOORE, T. Mesenteric vascular occIusion. Brit. J. Surg., 28: 347, 1941. DUNPHY, J. E. and ZOLLINGER, R. Mesenteric vascuIar occlusion. New England J. Med., 21 I : 708, 1934. FICARRA, B. J. Mesenteric vascuIar occIusion. Am. J. Surg., 66: 168, 1944. HERTZLER, A. E. SurgicaI Pathology of the Peritoneum. PhiIadeIphia, 1935. J. B.%ppincott. CONNER. L. A. A discussion of the roIe of arterial thrombosis in the visceral diseases of middle-life, based upon anaIogies drawn from coronary thrombosis. Am. J.-M. SC., 185: 13, 1933. KLEIN. E. Embolism and thrombosis of the suoerior mesenteric artery. Surg., Gynec. Z? Ohs;, 33: 385, 1921. DUNPHY, J. E. and WHITFIELD, R. D. Mesenteric vascular disease. Am. J. Surg., 47: 632, 1940. GREENBERG. G. Peritonitis foIIowina abdominal angina. .G. Rec., rgo: 129, 1939. BERMAN, L. G. and Russo, F. R. Abdominal angina. New England J. Med., 242: 61 I, 1950. DUNPHY, J. E. Abdominal oain of vascular origin. Am. Jl M. SC., 192: 109,~1936. BEXJAMIN, D. Mesenteric thrombosis. Am. J. Surg., 76: 338, 1948. MCCLENAHAN, J. E. and FISHER, B. Mesenteric thrombosis. Surgery, 23: 778, 1948. CARUCCI, J. J. hlesenteric vascuIar occlusion. Am. J. Surg., 80: 47, 1953. MOORE. T. Mesenteric vascuIar occlusion. Brit. J. .%rg., 28: 347, 1941. JOHNSON, C. C. and BAG~ENSTOSS,A. H. Mesenteric vascuIar occIusion. Proc. Staff Meet., Mayo Clin., 24: 649, 1949. Case records. New Eneland J. Med.. 240: 262. 1949. BERMAN, J. K. and THORNTON, H. C. OccIusive vascuIar disease of the abdomen. J. Indiana M. A., 33: 138, 1940. EISENBERG, A. A. and SCHLINK, H. A. Mesenteric vascular occlusion. Surg., Gynec. CT Obst., 27: 66, 1918. DISCUSSION
JXI; A. CANNON (Los Angeles, Calif.): For rather obvious reasons I do not have any sIides
that would illustrate any point of discussion, and 267
MikkeIsen Dr. MikkeIsen was kind enough to Iet me refer to two of his to open this discussion, which I would Iike to do in order to attempt to illustrate a point regarding aortograms. If you wiII remember, in his presentation (Fig. z), Dr. MikkeIsen mentioned that there was hIIing of the ceIiac axis and of the spIenic artery in the origina aortogram. Because the patient is in a true anteroposterior position, we cannot say too much about the inferior and superior mesenteric arteries except that there is some fiIIing there. Then when in order to show this superior mesentery the repeat aortogram was taken with the patient in a properIy obIique position, we find very poor fihing of the ceIiac axis, as emphasized by poor fiIIing in the hepatic arteries. However, I beIieve if we look very cIoseIy, even on Figure 3 it is possibIe for us to see the definite narrowing in the superior mesenteric artery just beIow its origin from the aorta. The point I wish to make is that Dr. MikkeIsen made the definite diagnosis on clinica grounds with regard to the cause of this patient’s troubIe, and he made it at a time when an operation would have had a chance to cure the patient. He even had the operation pIanned. He then did the aortogram and was not abIe to interpret the aortogram in a confirmatory fashion, and unfortunateIy neither was the roentgenoIogist. It seems obvious that obIiterative arterioscIerosis is becoming increasingIy a surgical disease. I think we wil1 agree that operation on the termina1 aorta and its dista1 branches is now an accepted part of our surgica1 armamentarium. Obstructive lesions of the interna carotid and renaI arteries due to arterioscIerosis are being attacked ,with increasing frequency. There is no doubt that Dr. MikkeIsen’s provocative paper will help lead the way to successfu1 attacks on lesions in the superior mesenteric and celiac arteries in the future. Dr. MikkeIsen has obviousIy proved that earIy recognition is possibIe, and actuaIIy that is the onIy necessary requirement in this situation. We do not even have to have the aortogram. I am aIso confident that seIected cases of coronary atheroscIerosis may become amenabIe to surgical attack in the near future. AII these Iesions are simiIar. They attack arteria1 bifurcations, are segmenta1, and earIy invoIve reIativeIy Iarge arteries where the dista1 tree, at Ieast initiaIly, is patent. When a thrombus occurs, it is aIways a secondary manifestation. An observation which is perhaps worth remembering and emphasizing is that any operation for arterioscIerosis must be considered pahiative. It is going to be paIIiative unti1 a method of preventing the reIentIess progression of the probIem in a generaIized fashion is somehow arrived at. At present it is very obvious that there is no medicine which is effective in the treatment of arteriosclerosis. Dr. Beck has mentioned many times that you simply
cannot treat a patient with coronary artery disease with an eIectrocardiogram. I have felt, from my own experience with a fair number of peopIe with obstructive arteriosclerosis, that diet would seem to be increasingIy important in the etioIogy of this condition. There are many exampIes which can Iead one to this conclusion, and in genera1 these exampIes come around to the point that populations which are underfed, or at Ieast populations which have a low intake of fat, do not tend to show arterioscIerosis. During the war in Europe the incidence of arteriosclerosis or atheroscIerotic disease went down with the caIoric and fat intake, and it has gone up again with the rise of caIoric and fat intake. Consequently I fee1 obIigated to say something to a postoperative patient in this regard. I teIl him in an adamant way that I think it is of extreme importance for him to reduce down to the low side of his thinnest aduIt weight. I aIso teI1 him to avoid fat and excess caIories from then on. If you question these patients with regard to their weight when they were twenty years old, invariabIy you wiI1 find that they have gained 20 to 30 pounds. I think you wiI1 agree that a11 of us have undoubtedIy seen thin, wispy ninety year oId people. We have to stop to think a minute to remember very many obese ninety year oIdsters. WILLARD E. GOODWIN (Los AngeIes, CaIif.): We, as urologists, use arteriography a great dea1. I should like to add some remarks about technic which may be heIpfu1 in studying suspected cases of this disease. About half the arteriograms we take are done by the transfemora1 method, i.e., needIe puncture of the femoral artery, foIIowed by passage of a poIyethyIene tube through the needIe to any desired Ievel in the aorta.* This aIIows the arteriogram to be made with the patient Iying on his back or in an obIique position. As weI1, the intra-aortic injection may be pIaced at any level the operator desires. If you wished to study such a patient arteriographically, this transfemora1 technic couId be empIoyed in order to find the right IeveI. MuItipIe smaI1 injections at different Ievels can be made without fear of muItipIe aortic punctures as in the transIumbar technic. ALFRED A. STRAUSS (PaIm Springs, Calif.): I am very much interested in Dr. MikkeIsen’s articIe on intestina1 angina. We have had two cases with similar symptoms in which the patient had three attacks within a period of five years. The most striking thing about the patient was the sudden onset of pain with marked IocaI tenderness in the *WALTER, R. C. and GOODWIN,W. E. Aortography and retroperitonea1 oxygen in urologic diagnosis: a comparison of transIumbar and percutaneous femoraI methods of aortography.. J. urol., 70: 52&53j’, 1953.
268
IntestinaI Ieft upper quadrant of the abdomen, with a certain amount of restlessness and anxiety. The tentative diagnosis was voIvuIus or mesenteric thrombosis. The indication was quite cIear to perform an exploratory operation. About 12 inches of small bowe1 were thickened, edematous, red and meatlike in appearance. The bIood suppIy above and beIow the lesion seemed quite definite, so a resection and end-to-end anastomosis were performed. The patient made an uneventful recovery. After this operation the patient was warned that if he had a similar attack he must not wait but go immediateIy to the hospita1 or he wouId be apt to lose his life. About fourteen months later, while driving from or to his o&e, he again had a severe attack in his abdomen and immediately drove to the hospita1. Again the symptoms were simiIar with the same clinica findings. This time about 18 inches of bowel had to be resected. The patient made an uneventfu1 recovery. About three years Iater the patient again had a similar attack and again went to the hospita1. This time about 12 inches of bowe1 were resected about 4 feet above the ileocecal vaIve. The patient made an uneventful recovery. This patient has been carefully studied as to
269
Angina heart and other sources which might cause this condition. In studying the bIood vessels of the dissected portion, it seemed that the vessels were somewhat narrowed and had, on cross section, an increased amount of connective tissue as compared with norma blood vesseIs of the mesenteric vessels. The second case was very much like the first one. Between the Iirst and second operations there was a period of three years. The pathologic findings were about the same. The first patient’s last operation was performed three years ago and he seems well; it has been a year and a haIf since the second patient’s operation. The arteriogram taken on both patients found no cause for this condition. I think the description given by Dr. Mikkelsen of this cIinicaI condition is very interesting because very few men so far have found by arteriogram the real cause of this condition. WILLIAM P. MIKKELSEN (closing): I wish to thank Drs. Cannon, Goodwin and Strauss for their comments. Dr. Goodwin’s approach to arteriography is we11 taken. Perhaps the best comment I can make about it is that if ever I am fortunate enough to see one of these patients again, I believe that I shaI1 forego aortography.