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Habib SG, Semaan DB, Andraska EA, Madigan MC, Al-Khoury GE, Chaer RA, Eslami MH. A decade's experience with retrograde open mesenteric stenting for acute mesenteric ischemia. J Vasc Surg 2024:S0741-5214(24)01111-X. [PMID: 38750941 DOI: 10.1016/j.jvs.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach among patients presenting with AMI. METHODS We reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary end points were in-hospital, 30-day, and 1-year mortality. Kaplan-Meier estimate for 1-year mortality and primary patency loss were generated. Secondary end points included postoperative 30-day complications. RESULTS Between 2011 and 2022, ROMS was attempted on a total of 42 patients. The median age was 70 ± 15 years and the majority of patients were female. Pain out of proportion to the physical examination was the most common presenting symptom (n = 18, 42.9%) followed by peritonitis (n = 14, 33.4%). All patients underwent preoperative intravenous contrast computed tomography imaging. In situ thrombosis was identified as the etiology of AMI in 36 patients (85.7%). Technical success was achieved in 40 patients (95.2%). Conventional, non-hybrid operating rooms were used for the majority of cases. Revascularization of all 40 patients involved angioplasty and stenting of superior mesenteric artery. A single stent was placed in 35 patients (87.5%) and the reminder had more than one stent. Eighty percent of patients required bowel resection. A second-look laparotomy was required in 34 patients (85.0%). The mean operative time, including both the general surgery and vascular surgery portions of the index procedure, was 192 ± 57 minutes. Sepsis was the most common complication observed within 30 days, occurring in 8 patients (20.0%). In terms of mortality, 13 patients (32.5%) died during their index hospitalization, and 9 died (22.5%) within 30 days. On Kaplan-Meier analysis, the 1-year overall patient survival rate was 58.6%, and the primary patency rate for stents was 51.4%. CONCLUSIONS ROMS has an excellent technical success rate in management of AMI with lower than traditionally reported mortality rates for AMI. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality an alternative approach for treatment of AMI.
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Affiliation(s)
- Salim G Habib
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Dana B Semaan
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Elizabeth A Andraska
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Michael C Madigan
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Georges E Al-Khoury
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Rabih A Chaer
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Charleston Area Medical Center, Charleston, WV.
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Li W, Liu M, Jin L, Feng H, Chen X, Zhang Z. Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery. J Cardiothorac Surg 2024; 19:235. [PMID: 38627835 PMCID: PMC11020894 DOI: 10.1186/s13019-024-02745-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment. METHODS The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group. RESULTS Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency. CONCLUSIONS Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.
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Affiliation(s)
- Wenrui Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Mingyuan Liu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Lei Jin
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Zhiwen Zhang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Pengermä P, Venesmaa S, Karjalainen J, Ukkonen M, Saari P, Kärkkäinen JM. Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia. J Vasc Surg 2023; 78:1524-1530. [PMID: 37586616 DOI: 10.1016/j.jvs.2023.08.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE To evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients' discharge to home vs nursing facility a decade after an episode of AMI. METHODS The retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR-). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI. RESULTS The mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR- group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR- group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR- patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up. CONCLUSIONS In this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.
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Affiliation(s)
- Pasi Pengermä
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Sari Venesmaa
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | | | - Mika Ukkonen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Petri Saari
- Department of Radiology, Kuopio University Hospital, Kuopio, Finland
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Fuglseth H, Søreide K, Vetrhus M. Acute mesenteric ischaemia. Br J Surg 2023; 110:1030-1034. [PMID: 36748996 PMCID: PMC10416693 DOI: 10.1093/bjs/znad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Affiliation(s)
- Hanne Fuglseth
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Morten Vetrhus
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
- Department of Surgery, Vascular Surgery Unit, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Abstract
PURPOSE OF REVIEW To summarize the recent evidence on acute mesenteric ischaemia (AMI). RECENT FINDINGS The overall incidence of AMI is below 10/100 000 person years but increases exponentially with age. The overall mortality of AMI remains high, exceeding 50%, despite continuing progress and increasing availability of imaging and endovascular interventions. However, patients with (early) revascularization have significantly better outcomes. The majority of patients surviving the acute event are still alive at 1 year, but evidence on quality of life is scarce.Clinical suspicion of AMI is the key to timely diagnosis, with biphasic computed tomography-angiography the diagnostic method of choice. Currently, no biomarker has sufficient specificity to diagnose AMI. SUMMARY Improved awareness and knowledge of AMI are needed to raise the suspicion of AMI in relevant patients and thereby to achieve better outcomes.
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Li W, Cao S, Zhang Z, Zhu R, Chen X, Liu B, Feng H. Outcome Comparison of Endovascular and Open Surgery for the Treatment of Acute Superior Mesenteric Artery Embolism: A Retrospective Study. Front Surg 2022; 9:833464. [PMID: 35360433 PMCID: PMC8963895 DOI: 10.3389/fsurg.2022.833464] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/31/2022] [Indexed: 01/16/2023] Open
Abstract
Background Few centers have adopted endovascular revascularization for the treatment of superior mesenteric artery embolism (SMAE). We sought to evaluate the efficacy of endovascular therapy for the treatment of SMAE and identify post-treatment prognostic factors. Methods The clinical data of 41 patients with acute SMA embolism between 2013 and 2021 were retrospectively reviewed. Patients with mesenteric artery thrombosis, mesenteric venous thrombosis, and who had only conservative treatment were excluded. Results Forty-one consecutive patients were identified with SMAE (median age, [range] 35–86 years). Endovascular therapy was initiated in 14 patients with no clinical evidence of bowel necrosis, with mainly mechanical thrombectomy, and technical success was achieved in 93%. Endovascular therapy had advantages in duration surgery time, blood loss, bowel rest time, ICU time, and ventilator use. There was no difference in bowel necrosis, length of necrotic bowel resected, or in-hospital mortality between the two groups. An initial white blood cell (WBC) count >15 × 103/dl and neutrophil count >13 × 103/dl were associated with an increased risk of bowel necrosis, and an initial WBC count, renal function, American Society of Anesthesiologists (ASA >3) and necrotic bowel >2 m were associated with increased mortality. Conclusions Endovascular treatment has altered the management of SMAE, and it may be adopted in selected patients who are not at risk for bowel necrosis. Avoidance of bowel necrosis patients and close monitoring for bowel necrosis are important.
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Affiliation(s)
- Wenrui Li
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Saisai Cao
- Peking University People's Hospital, Beijing, China
| | - Zhiwen Zhang
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Renming Zhu
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xueming Chen
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bin Liu
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai Feng
- Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
- *Correspondence: Hai Feng
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Tolonen M, Lemma A, Vikatmaa P, Peltola E, Mentula P, Björkman P, Leppäniemi A, Sallinen V. The implementation of a pathway and care bundle for the management of acute occlusive arterial mesenteric ischemia reduced mortality. J Trauma Acute Care Surg 2021; 91:480-488. [PMID: 34086659 PMCID: PMC8404963 DOI: 10.1097/ta.0000000000003305] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a disease with high mortality and requires a multidisciplinary approach for effective management. A pathway and care bundle were developed and implemented with the objective to reduce mortality. The aim of this retrospective comparative study was to analyze the effects of the pathway on patient management and outcome. METHODS All consecutive patients operated in a secondary and tertiary referral center because of occlusive arterial AMI were identified between 2014 and April 2020. The pathway aimed to increase overall awareness, and hasten and improve diagnostics and management. Patients treated before implementation of the pathway (pregroup, years 2014-2017) were compared with patients treated using the pathway (postgroup, May 2018 to April 2020). Univariate and multivariate analyses were used to compare the groups. RESULTS There were 78 patients in the pregroup and 67 patients in the postgroup with comparable baseline characteristics and disease acuity. The postgroup was more often diagnosed with contrast-enhanced computed tomography (58 [74%] vs. 63 [94%], p = 0.001) and had shorter mean in-hospital delay to operating room (7 hours [interquartile range, 3.5-12.5] vs. 3 hours [interquartile range, 2-11], p = 0.023). Revascularization was done more often in the postgroup (53 [68%] vs. 56 [84%], p = 0.030) especially using endovascular treatment (26 [33%] vs. 43 [64%], p < 0.001). Thirty-day mortality was lower in the postgroup (23 [51%] vs. 17 [25%], p = 0.001). Being managed in the postgroup remained as a protective factor (odds ratio, 0.32; 95% confidence interval, 0.14-0.75; p = 0.008) for 30-day mortality in the multivariate analysis. CONCLUSION Implementing a pathway and care bundle resulted in enhanced regional and in-hospital awareness of AMI, more appropriate computed tomography imaging, shorter in-hospital delays, increased number of revascularizations, and, hence, lower mortality. LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.
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Ennab RM, Al-Omari MH, Jaradat II, Aljabali AAA. Endovascular management of acute mesenteric ischemia in a young patient with thyrotoxicosis and atrial fibrillation: A case report and review of the literature. Int J Surg Case Rep 2020; 76:190-194. [PMID: 33038846 PMCID: PMC7550828 DOI: 10.1016/j.ijscr.2020.09.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 01/16/2023] Open
Abstract
Acute mesenteric ischemia has a high mortality rate of 50%–80%. CT angiography is highly valuable in the diagnosis of acute mesenteric ischemia. Patients who present with peritonitis or hemodynamic instability should undergo open surgery. Endovascular management is increasingly being considered as the main modality of management of AMI in selected cases. Endovascular management of AMI involves aspiration thrombectomy, thrombolysis, and/or possible angioplasty and stenting.
Introduction Acute mesenteric ischemia caused by an embolism resulting from atrial fibrillation in a thyrotoxic young male patient is a rare event. Endovascular intervention is increasingly being considered as the primary modality of treatment in selected patients. Presentation of case A 41-years male known to have hyperthyroidism presented with atrial fibrillation, acute mesenteric ischemia, splenic infarction, and left renal infarction. He was successfully managed with endovascular intervention of the superior mesenteric artery. Discussion Acute mesenteric ischemia has a high mortality rate. CT angiography is the investigation of choice for diagnosis of the mesenteric vessels occlusion and assessment of bowel ischemia. The clinical presentation guides into the treatment and the choice between open surgery and endovascular intervention as the primary modality of treatment. Thyrotoxicosis is a risky comorbid condition for any procedure to be done, so proper perioperative management is essential to decrease morbidity and mortality. Conclusion Prompt diagnosis and management of acute mesenteric ischemia is essential to decrease the morbidity and mortality rates. Endovascular management can be considered as a primary modality of treatment in selected cases.
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Affiliation(s)
- Raed M Ennab
- Department of Clinical Sciences/Vascular Surgery, Faculty of Medicine, Yarmouk University, Irbid, Jordan.
| | - Mamoon H Al-Omari
- Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ihab I Jaradat
- Department of Clinical Sciences/General Surgery, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Alaa A A Aljabali
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
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