Synopsis
Recognise intestinal angina, apply current vessel and symptom thresholds, and select endovascular-first revascularisation without dangerous nutritional delay.
- Think of CMI in reproducible postprandial abdominal pain, food avoidance and weight loss, particularly with smoking or atherosclerosis elsewhere; the classic triad is helpful but not required.
- Current ESVS thresholds require symptoms plus vascular disease: CMI is recommended as present with more than 50% SMA stenosis and more than 50% in another mesenteric artery; it may be considered with symptoms and more than 70% isolated SMA stenosis.
- In severe CMI with severe weight loss, diarrhoea or constant pain, do not delay urgent revascularisation for nutritional improvement; when suitable anatomy requires treatment, use an endovascular-first strategy with routine stenting rather than balloon angioplasty alone and revascularise at least the SMA.
Key red flags
New constant pain replacing episodic postprandial pain, rest pain or rapidly escalating analgesic need suggests acute-on-chronic ischaemia.
Severe weight loss, persistent diarrhoea and inability to maintain intake define severe CMI in the ESVS urgent-treatment recommendation; feeding first can increase demand and delay reperfusion.
Peritonism, acidosis, shock or CT signs of bowel hypoenhancement, pneumatosis or portal gas require the acute mesenteric ischaemia pathway.
An isolated coeliac stenosis without a compatible syndrome is often incidental; unexplained pain still needs assessment for malignancy and gastrointestinal alternatives rather than reflex stenting.
Investigation priorities
First-line examination after at least four hours fasting in suspected CMI when performed by an experienced laboratory.
Preferred test to diagnose disease, exclude alternative intra-abdominal pathology and plan access, stent or bypass anatomy.
Management branches
A smoker has reproducible pain after meals, food avoidance and weight loss; fasting duplex suggests SMA and coeliac disease.
- Recognise a compatible chronic syndrome and expedite CTA, while screening for plausible gastrointestinal alternatives without delaying a severe presentation.
- On CTA, confirm more than 50% SMA stenosis plus more than 50% stenosis in another mesenteric artery; this symptom-and-multivessel combination meets the ESVS recommended diagnostic threshold.
Threshold-matching symptomatic disease requires intervention and CTA shows an endovascularly accessible SMA lesion.