Skip to Main Content




A 74-year-old hypertensive male presents with a four-hour history of acute-onset severe diffuse abdominal pain. Two weeks prior he was hospitalized with a large anterior wall MI complicated by intermittent atrial fibrillation. Due to a history of frequent falls, he was not anticoagulated. Physical examination is remarkable for an uncomfortable individual with an irregularly irregular heart rhythm and a minimally tender abdomen without peritoneal signs. Laboratory assessment is remarkable for a leukocytosis of 14,000 and mild metabolic acidosis. Electrocardiography indicates atrial fibrillation with a rapid ventricular response between 120 and 140 beats/minute. CT scan of the abdomen illustrates a distended small bowel and a questionable filling defect within the superior mesenteric artery (SMA). Mesenteric arteriography displays a "mercury meniscus sign" within the SMA 4 cm from the aorta. A diagnosis of cardioembolic acute mesenteric ischemia is made and the patient is immediately taken to the operating suite.




  • Incidence: 3 to 5 per 100,000.

  • Sixth to seventh decade of life; more often women.

  • Etiology: thromboembolism 50%, thrombosis 20%, nonocclusive mesenteric ischemia (NOMI) 20%, others 10%.1

  • Clinical presentation depends on adequacy of visceral perfusion by the three mesenteric arteries: celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) (Figure 45-1). There are usually collateralizations among the mesenteric arteries that compensate for flow if there are stenoses or occlusions, hence the common adage; two of the three mesenteric arteries need to be involved before symptoms arise. However, single mesenteric artery occlusion can be symptomatic in the absence of adequate collateralization, such as in acute thromboembolism.


Normal mesenteric artery anatomy, their branches and natural collateralization. Celiac artery (CA), superior mesenteric artery (SMA), inferior mesenteric artery (IMA), common hepatic artery (CHA), splenic artery (SA), gastroduodenal artery (GDA), superior pancreaticoduodenal artery (SPDA), inferior pancreaticoduodenal artery (IPDA), left gastric artery (LGA), right gastric artery (RGA), right gastroepiploic artery (RGEP), left gastroepiploic artery (LGEP), jejunal arteries (JAs), middle colic artery (MCA), right colic artery (RCA), ileocolic artery (ICA), marginal artery of Drummond (MAD)—between left branch of MCA and ascending branch of left colic artery (LCA), sigmoidal artery (SgA), superior rectal artery (SRA).

Graphic Jump Location





  • Thromboembolism to the SMA is common due to its obtuse angle and path, diverging gently away from the aorta and its flow.

  • Embolus source: cardiac arrhythmias (atrial or ventricular), atherosclerotic aorta, proximal thoracic aneurysms. Proximal small intestines may be uninvolved if embolus occludes the SMA a few centimeters beyond its origin, sparing proximal jejunal branches. Transverse colon may be spared if occlusion is beyond the middle colic branch of the SMA.




  • Patients are generally older and usually women.

  • Evidence of atherosclerotic disease in other vascular beds (coronary, lower extremities) is usually present.

  • More than ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessCardiology Full Site: One-Year Subscription

Connect to the full suite of AccessCardiology content and resources including textbooks such as Hurst's the Heart and Cardiology Clinical Questions, a unique library of multimedia, including heart imaging, an integrated drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessCardiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.