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Lehane D, Geiger J, Kedwai B, Zottola Z, Newhall K, Mix D, Doyle A, Stoner M. Long-term value in open and endovascular repair of chronic mesenteric ischemia. J Vasc Surg 2024; 79:55-61. [PMID: 37709177 DOI: 10.1016/j.jvs.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. METHODS Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. RESULTS From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively. CONCLUSIONS Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.
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Affiliation(s)
- Daniel Lehane
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Joshua Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Baqir Kedwai
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Zachary Zottola
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karina Newhall
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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2
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Lehane DJ, Geiger JT, Zottola ZR, Newhall KA, Mix DS, Doyle AJ, Stoner MC. Survival, Reintervention, and Value of Open and Endovascular Repair for Chronic Mesenteric Ischemia. Ann Vasc Surg 2023; 97:203-210. [PMID: 37659648 DOI: 10.1016/j.avsg.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND There are limited analyses of survival and postoperative outcomes in chronic mesenteric ischemia (CMI) using data from large cohorts. Current guidelines recommend open repair (OR) for younger, healthier patients when long-term benefits outweigh increased perioperative risks or for poor endovascular repair (ER) candidates. This study investigates whether long-term survival, reintervention, and value differ between these treatment modalities. METHODS A retrospective cohort analysis was performed on data extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payer database containing demographics, diagnoses, treatments, and charges. Patients were selected for CMI and subsequent ER or OR using International Classification of Diseases, Ninth Revision codes. Patients with peripheral arterial disease were excluded to account for ambiguity in the International Classification of Diseases, Ninth Revision procedure code for angioplasty of noncoronary vessels, which includes angioplasty of upper and lower extremity vessels. Kaplan-Meier analysis was used to compare 1-year and 5-year survival and reintervention between treatment modalities using a propensity-matched cohort. Cox proportional hazards testing was performed to find factors associated with 1-year and 5-year survival and reintervention. Analysis of procedural value was performed using linear regression. RESULTS From 2000 to 2014, 744 patients met inclusion criteria. Of these, 209 (28.1%) underwent OR and 535 (71.9%) ER. No difference between propensity-matched groups was found in 1-year (P = 0.46) or 5-year (P = 0.91) survival. Congestive heart failure (hazard ratio [HR]: 2.8, 95% confidence interval [CI]: 1.7-4.4; P < 0.01), cancer (HR: 2.8, 95% CI: 1.3-5.8; P < 0.01), and dysrhythmia (HR: 1.8, 95% CI: 1.1-2.8; P = 0.02) correlated with 1-year mortality. Cancer (HR: 2.9, 95% CI: 1.6-5.5; P < 0.01), congestive heart failure (HR: 2.2, 95% CI: 1.5-3.2; P < 0.01), chronic pulmonary disease (HR: 1.4, 95% CI: 1.0-2.0; P = 0.04), and age (HR: 1.03, 95% CI: 1.01-1.05; P < 0.01) correlated with 5-year mortality. Treatment modality was not associated with reintervention at 1 year on Kaplan-Meier analysis (P = 0.29). However, ER showed increased instances of reintervention at 5 years (P < 0.01). Additionally, ER was associated with an increased 5-year value (0.7 ± 0.9 vs. 0.5 ± 0.5 life years/charges at index admission [$10k], P < 0.01; b coefficient: 0.2, 95% CI: 0.1-0.4, P < 0.01). CONCLUSIONS This is the largest retrospective propensity-matched single-study cohort to analyze long-term survival outcomes after intervention for CMI. Long-term mortality was independent of treatment modality and rather was associated with patient comorbidities. Therefore, treatment selection should depend on anatomic considerations and long-term value. ER should be considered over OR in patients with amenable anatomy based on the superior procedural value.
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Affiliation(s)
- Daniel J Lehane
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Joshua T Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Zachary R Zottola
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Karina A Newhall
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran S Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam J Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Michael C Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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Nana P, Koelemay MJW, Leone N, Brodis A, van den Berg JC, de Bruin JL, Geelkerken RH, Spanos K. A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia. Eur J Vasc Endovasc Surg 2023; 66:632-643. [PMID: 37451604 DOI: 10.1016/j.ejvs.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/21/2023] [Accepted: 07/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Mark J W Koelemay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Jos C van den Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands; Dutch Expert Centre for Gastrointestinal Ischaemia, Enschede, the Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Konstantinos Spanos
- Vascular Surgery Department, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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4
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Sunohara D, Miura T, Nomoto F, Itagaki T, Komatsu T, Mochidome T, Kasai T, Ikeda U. Effectiveness of endovascular therapy using stents in a patient with celiac artery compression syndrome due to the median arcuate ligament: A case report. J Cardiol Cases 2023; 28:128-131. [PMID: 37671263 PMCID: PMC10477046 DOI: 10.1016/j.jccase.2023.05.005] [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: 11/16/2022] [Revised: 04/23/2023] [Accepted: 04/28/2023] [Indexed: 09/07/2023] Open
Abstract
Celiac artery compression syndrome (CACS) is a disease caused by celiac artery compression by the median arcuate ligament (MAL), resulting in intestinal ischemic symptoms. However, a clear method for the invasive treatment of CACS has not yet been established because of limited treatment indications. In particular, only a few reports of endovascular therapy (EVT) using stents as the initial invasive treatment are available. Here, we report a case where EVT was performed using a stent in the celiac artery, resulting in good outcomes. A 59-year-old male patient presented to our hospital with postprandial abdominal pain and was diagnosed with MAL-induced CACS since the abdominal contrast computed tomography examination showed stenosis of a celiac artery origin. He was aware of the abdominal pain symptoms; therefore, we decided to treat CACS with EVT as an invasive treatment. A bare metal stent was placed in the celiac artery, whose lumen was well dilated using intravascular ultrasound. Consequently, he no longer felt abdominal pain and had good stent patency after 15 months. Minimally invasive EVT may be considered the first-line treatment for CACS. Learning objective The efficacy of endovascular therapy (EVT) using stents for the invasive treatment of celiac artery compression syndrome (CACS) resulting from the compression of the median arcuate ligament has not yet been established. Specifically, the efficacy of EVT using stents for CACS is unknown. We can safely perform EVT with stent placement using intravascular ultrasound for maintaining long-term patency. Therefore, minimally invasive EVT may be considered the first-line treatment for CACS.
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Affiliation(s)
- Daisuke Sunohara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | - Takashi Miura
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
- Department of Internal Medicine and Cardiology, Miura Heart Clinic, Nagano, Japan
| | - Fumika Nomoto
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | | | | | | | - Toshio Kasai
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
| | - Uichi Ikeda
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Cardiology, Nagano Municipal Hospital, Nagano, Japan
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Malik DA, Thomas T, Zafar M, Naqvi SA, Kaur S, Liaquat RR, Akan D. A Case of Chronic Mesenteric Ischemia Due to Celiac and Mesenteric Artery Thrombosis. Cureus 2023; 15:e44270. [PMID: 37772229 PMCID: PMC10529475 DOI: 10.7759/cureus.44270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Chronic mesenteric ischemia (CMI) is uncommon and accounts for approximately 5% of cases. CMI presents with non-specific symptoms, making it difficult to diagnose, and requires complex management involving interprofessional teams. We present the case of a 66-year-old female who presented with postprandial abdominal pain, vomiting, sitophobia, and weight loss. Investigations showed raised inflammatory markers, and plain film X-ray and endoscopy showed no significant findings. CT angiogram showed celiac and mesenteric artery thrombosis. The patient proceeded to have endovascular revascularization. With this case, we highlight the importance of considering CMI in an elderly patient with a history of microvascular disease or risk factors presenting with postprandial abdominal pain and weight loss. Early diagnosis and timely intervention are imperative for a good prognosis.
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Affiliation(s)
- Dua A Malik
- Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Teena Thomas
- Internal Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Mansoor Zafar
- Gastroenterology, General Internal Medicine, Hammersmith Hospital & Charing Cross Hospital, Imperial College London Healthcare NHS Trust, London, GBR
| | - Syed Ashhar Naqvi
- Emergency Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Sukhman Kaur
- Surgery, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Rao Rizwan Liaquat
- Emergency Medicine, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
| | - Deniz Akan
- Radiology, Conquest Hospital, East Sussex Healthcare NHS Trust, St. Leonards-on-Sea, GBR
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6
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Chou EL, Chaffin M, Simonson B, Pirruccello JP, Akkad AD, Nekoui M, Cardenas CLL, Bedi KC, Nash C, Juric D, Stone JR, Isselbacher EM, Margulies KB, Klattenhoff C, Ellinor PT, Lindsay ME. Aortic Cellular Diversity and Quantitative Genome-Wide Association Study Trait Prioritization Through Single-Nuclear RNA Sequencing of the Aneurysmal Human Aorta. Arterioscler Thromb Vasc Biol 2022; 42:1355-1374. [PMID: 36172868 PMCID: PMC9613617 DOI: 10.1161/atvbaha.122.317953] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 09/16/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mural cells in ascending aortic aneurysms undergo phenotypic changes that promote extracellular matrix destruction and structural weakening. To explore this biology, we analyzed the transcriptional features of thoracic aortic tissue. METHODS Single-nuclear RNA sequencing was performed on 13 samples from human donors, 6 with thoracic aortic aneurysm, and 7 without aneurysm. Individual transcriptomes were then clustered based on transcriptional profiles. Clusters were used for between-disease differential gene expression analyses, subcluster analysis, and analyzed for intersection with genetic aortic trait data. RESULTS We sequenced 71 689 nuclei from human thoracic aortas and identified 14 clusters, aligning with 11 cell types, predominantly vascular smooth muscle cells (VSMCs) consistent with aortic histology. With unbiased methodology, we found 7 vascular smooth muscle cell and 6 fibroblast subclusters. Differentially expressed genes analysis revealed a vascular smooth muscle cell group accounting for the majority of differential gene expression. Fibroblast populations in aneurysm exhibit distinct behavior with almost complete disappearance of quiescent fibroblasts. Differentially expressed genes were used to prioritize genes at aortic diameter and distensibility genome-wide association study loci highlighting the genes JUN, LTBP4 (latent transforming growth factor beta-binding protein 1), and IL34 (interleukin 34) in fibroblasts, ENTPD1, PDLIM5 (PDZ and LIM domain 5), ACTN4 (alpha-actinin-4), and GLRX in vascular smooth muscle cells, as well as LRP1 in macrophage populations. CONCLUSIONS Using nuclear RNA sequencing, we describe the cellular diversity of healthy and aneurysmal human ascending aorta. Sporadic aortic aneurysm is characterized by differential gene expression within known cellular classes rather than by the appearance of novel cellular forms. Single-nuclear RNA sequencing of aortic tissue can be used to prioritize genes at aortic trait loci.
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Affiliation(s)
- Elizabeth L. Chou
- Division of Vascular and Endovascular Surgery,
Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
| | - Mark Chaffin
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - Bridget Simonson
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - James P. Pirruccello
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - Amer-Denis Akkad
- Precision Cardiology Laboratory, Bayer US LLC, Cambridge,
MA, USA 02142
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - Christian Lacks Lino Cardenas
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
| | - Kenneth C. Bedi
- Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA 19104
| | - Craig Nash
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
| | - Dejan Juric
- Cancer Center, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - James R. Stone
- Department of Pathology, Massachusetts General
Hospital, Boston, Massachusetts, USA
| | - Eric M. Isselbacher
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital,
Boston, Massachusetts, USA
| | - Kenneth B. Margulies
- Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA 19104
| | - Carla Klattenhoff
- Precision Cardiology Laboratory, Bayer US LLC, Cambridge,
MA, USA 02142
| | - Patrick T. Ellinor
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Precision Cardiology Laboratory, The Broad Institute,
Cambridge, MA, USA 02142
- Demoulas Center for Cardiac Arrhythmias, Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - Mark E. Lindsay
- Cardiology Division, Massachusetts General Hospital,
Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute,
Cambridge, Massachusetts, USA
- Thoracic Aortic Center, Massachusetts General Hospital,
Boston, Massachusetts, USA
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Sultan SA, Acharya Y, Mustafa M, Hynes N. Two Decades of Experience With Chronic Mesenteric Ischaemia and Median Arcuate Ligament Syndrome in a Tertiary Referral Centre: A Parallel Longitudinal Comparative Study. Cureus 2021; 13:e20726. [PMID: 35047313 PMCID: PMC8759710 DOI: 10.7759/cureus.20726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background Chronic mesenteric ischaemia (CMI) and median arcuate ligament syndrome (MALS) have similar clinical presentations with surgical intervention as the mainstay of treatment. However, surgical response varies and is unpredictable. Therefore, we aim to evaluate the technical and clinical success rates of selective revascularisation in older patients with CMI and younger patients with MALS undergoing arcuate ligament decompression with celiac sympathectomy. Methods We conducted a retrospective single-centre longitudinal comparative study of all the patients who underwent surgery for symptoms of CMI and MALS from December 2002 to 2020 at our tertiary referral vascular centre. Our primary outcome was symptom-free survival post-intervention. The secondary outcomes were perioperative mortality, technical success, and all-cause mortality at 17 years. Results We operated on 28 patients; 17 patients with CMI (revascularisations with bypass) and 11 with MALS (decompression and celiac sympathectomy). All (100%) patients had technical success. There was no perioperative mortality. All the MALS patients had symptom-free survival following the procedure throughout follow-up. In contrast, three patients with CMI complained of recurring abdominal pain even after one year of the surgery. However, there was no further weight loss and none of them required any intervention. Conclusion Stratified management of CMI with revascularisation and open surgical decompression with celiac sympathectomy in MALS are effective treatments with favourable long-term outcomes.
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Affiliation(s)
- Sherif A Sultan
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL.,Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
| | - Yogesh Acharya
- Vascular and Endovascular Surgery, Western Vascular Institute, Galway University Hospital, National University of Ireland, Galway, IRL
| | | | - Niamh Hynes
- Vascular and Endovascular Surgery, CORRIB-CÚRAM-Vascular Group, National University of Ireland, Galway, IRL
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8
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Barnes JA, Columbo JA, Ponukumati AS, Zwolak RM, Olive FT, Goodney PP, Powell RJ, Zacharias N. Long-Term Outcomes of Mesenteric Stenting and Analysis of In-Stent Restenosis Duplex Velocity Criteria. Ann Vasc Surg 2020; 68:226-233. [DOI: 10.1016/j.avsg.2020.04.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/22/2020] [Accepted: 04/23/2020] [Indexed: 12/01/2022]
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9
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Xu C, Tolaymat B, Taylor M, Aicher BO, Flentje AO, Sahajwani S, Endicott KM, Nagarsheth KH. Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era. Ann Vasc Surg 2020; 70:386-392. [PMID: 32634563 DOI: 10.1016/j.avsg.2020.06.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. METHODS/RESULTS Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1 centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. CONCLUSIONS SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.
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Affiliation(s)
- Cynthia Xu
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Besher Tolaymat
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Maryclare Taylor
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Brittany O Aicher
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Alison O Flentje
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sunny Sahajwani
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Kendal M Endicott
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Khanjan H Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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10
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Abstract
Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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11
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Shao T, Kang N, DeAmorim H, Rey J, Bornak A. Staged Treatment for an Unusual Case of Median Arcuate Ligament Syndrome Caused by Compression of the Celiac and Superior Mesenteric Arteries. Ann Vasc Surg 2020; 66:672.e5-672.e7. [PMID: 32027988 DOI: 10.1016/j.avsg.2020.01.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 01/04/2020] [Accepted: 01/16/2020] [Indexed: 11/17/2022]
Abstract
We report the unusual presentation of a patient with median arcuate ligament syndrome (MALS) and compression of both the celiac artery and the superior mesenteric artery (SMA). He underwent a staged treatment. First, a laparoscopic release of the median arcuate ligament was performed. In the second stage, due to persistent postprandial pain, the SMA was stented, resulting in complete symptom relief. Recognizing this rare anatomical presentation is very important to avoiding MALS misdiagnosis and providing the appropriate staged treatment.
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Affiliation(s)
- Tony Shao
- Division of Vascular and Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL
| | - Naixin Kang
- Division of Vascular and Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL
| | - Hilene DeAmorim
- Division of Vascular and Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL
| | - Jorge Rey
- Division of Vascular and Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL.
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12
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Allain C, Besch G, Guelle N, Rinckenbach S, Salomon du Mont L. Prevalence and Impact of Malnutrition in Patients Surgically Treated for Chronic Mesenteric Ischemia. Ann Vasc Surg 2019; 58:24-31. [DOI: 10.1016/j.avsg.2019.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 11/24/2022]
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13
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Superior mesenteric artery stenting using embolic protection device for treatment of acute or chronic mesenteric ischemia. J Vasc Surg 2018; 68:1071-1078. [DOI: 10.1016/j.jvs.2017.12.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/22/2017] [Indexed: 01/21/2023]
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14
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Björck M, Koelemay M, Acosta S, Bastos Goncalves F, Kölbel T, Kolkman JJ, Lees T, Lefevre JH, Menyhei G, Oderich G, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Sanddal Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Geelkerken B, Gloviczki P, Huber T, Naylor R. Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 53:460-510. [PMID: 28359440 DOI: 10.1016/j.ejvs.2017.01.010] [Citation(s) in RCA: 343] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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15
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Huynh C, Schwartz R. Symptomatic Delayed Aortic Dissection After Superior Mesenteric Artery Stenting for Chronic Mesenteric Ischemia. Vasc Endovascular Surg 2017; 51:377-379. [DOI: 10.1177/1538574417702775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Cindy Huynh
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robert Schwartz
- OhioHealth Comprehensive Heart and Vascular Center, OhioHealth Mansfield Hospital, Mansfield, OH, USA
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16
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Blauw JTM, Bulut T, Oderich GS, Geelkerken BRH. Mesenteric vascular treatment 2016: from open surgical repair to endovascular revascularization. Best Pract Res Clin Gastroenterol 2017; 31:75-84. [PMID: 28395791 DOI: 10.1016/j.bpg.2017.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 01/31/2023]
Abstract
The rise of endovascular techniques has improved the outcome of mesenteric ischemia. Key principle in reduction of morbidity and mortality is "revascularization first, resection later". We believe that mesenteric ischemia is a clinical challenge demanding 24/7 multidisciplinary team availability. This article describes the current insights into treatment of mesenteric ischemia.
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Affiliation(s)
- Juliëtte T M Blauw
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, The Netherlands; Department of Surgery, Isala Clinics, Zwolle, The Netherlands.
| | - Tomas Bulut
- Department of Radiology, Medical Spectrum Twente, Enschede, The Netherlands.
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Bob R H Geelkerken
- Department of Vascular Surgery, Medical Spectrum Twente, Enschede, The Netherlands; Experimental Centre for Technical Medicine, University of Twente, Enschede, The Netherlands.
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17
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Goldman MP, Reeve TE, Craven TE, Edwards MS, Corriere MA, Hurie JB, Garg N, Velazquez-Ramirez G. Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions. Ann Vasc Surg 2017; 38:29-35. [DOI: 10.1016/j.avsg.2016.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/08/2016] [Accepted: 08/18/2016] [Indexed: 11/30/2022]
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18
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Columbo JA, Kang R, Goodney PP. Endovascular-First for Chronic Mesenteric Ischemia and the Importance of Long-Term Surveillance. Angiology 2016; 68:841-842. [PMID: 27856668 DOI: 10.1177/0003319716679342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ravinder Kang
- 2 Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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19
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Rosen RJ, Jain A, Drury J. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Amit Jain
- Lenox Hill Heart and Vascular Institute; New York NY USA
| | - Jennifer Drury
- Lenox Hill Heart and Vascular Institute; New York NY USA
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20
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Rajaratnam K, Paraskevas KI, Ramli AH, Shehata A, Jackson R, Clarke MJ. Celiac and Superior/Inferior Mesenteric Angioplasty and Stenting for Chronic Mesenteric Ischemia: A Single-Center Experience. Angiology 2016; 68:571-574. [DOI: 10.1177/0003319716662424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angioplasty and stenting emerged as the less invasive treatment options compared to open surgical revascularization for the management of patients with chronic mesenteric ischemia (CMI). However, endovascular techniques may not achieve symptomatic relief in many patients with CMI. We report our results from the endovascular management of patients with CMI. Data were reviewed from 45 patients undergoing celiac and/or mesenteric angioplasty and stenting for CMI, from October 2006 to January 2016. Angioplasty and stenting of celiac and/or mesenteric arteries were successful in relieving symptoms completely in 29 of 45 and partially in 6 of 45 patients. Only 10 of 45 patients mentioned no improvement, while symptom recurrence occurred in another 3 of 45 patients between 3 and 36 months postprocedurally due to stent occlusion. Angioplasty and stenting of celiac and/or mesenteric arteries provide symptomatic relief in a considerable percentage of patients with CMI. If symptoms fail to improve, an open surgical revascularization procedure should be considered.
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Affiliation(s)
- Kanapathi Rajaratnam
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Kosmas I. Paraskevas
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ahmad Hariz Ramli
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Amro Shehata
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ralph Jackson
- Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michael J. Clarke
- Department of Vascular Surgery, Northern Vascular Center, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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21
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Chronic mesenteric ischemia outcome analysis and predictors of endovascular failure. J Vasc Surg 2016; 63:1582-7. [DOI: 10.1016/j.jvs.2016.02.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/10/2016] [Indexed: 11/17/2022]
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22
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Isquemia mesentérica crónica. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Shah AS, Schwartz LB, Moawad J, Gewertz BL. Technique profile: mesenteric reconstructions for occlusive disease. Expert Rev Cardiovasc Ther 2015; 13:1445-58. [DOI: 10.1586/14779072.2015.1094376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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24
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Saedon M, Saratzis A, Karim A, Goodyear S. Endovascular Versus Surgical Revascularization for the Management of Chronic Mesenteric Ischemia. Vasc Endovascular Surg 2015; 49:37-44. [PMID: 25964291 DOI: 10.1177/1538574415585127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization (SR) or endovascular revascularization (ER). Materials and Methods: Systematic review of 12 studies comparing ER and SR in CMI. Primary end point was perioperative (30 days) survival. A secondary composite end point consisted of perioperative mortality, nonfatal cardiac events, nonfatal stroke, and nonfatal bowel ischemia. Further end points included late survival, primary patency, and symptom improvement. Results: The cumulative odds ratio (OR) for perioperative mortality was 0.78 (95% confidence interval [CI]: 0.40-1.50, P = .45) and 0.56 (95% CI: 0.28-1.11, P = .10) for the composite end point. The cumulative OR for survival after the 30th day was 0.83 (95% CI: 0.47-1.46), P = .51. Late primary patency was reported in 8 studies, with a cumulative OR of 3.57 (95% CI: 1.83-6.97, P = .0002)—favoring SR. Conclusion: In the first meta-analysis to compare ER and SR in CMI, there were no differences in mortality and morbidity. Patency rates were better following SR.
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Affiliation(s)
- Mahmud Saedon
- Division of Metabolic and Vascular Health, University of Warwick, Coventry, United Kingdom
- West Midlands Vascular Society, West Midlands, United Kingdom
| | - Athanasios Saratzis
- West Midlands Vascular Society, West Midlands, United Kingdom
- Warwickshire Vascular and Endovascular Unit, University Hospital Coventry & Warwickshire, Coventry, United Kingdom
| | - Ahmed Karim
- West Midlands Vascular Society, West Midlands, United Kingdom
- Warwickshire Vascular and Endovascular Unit, University Hospital Coventry & Warwickshire, Coventry, United Kingdom
| | - Steve Goodyear
- West Midlands Vascular Society, West Midlands, United Kingdom
- Warwickshire Vascular and Endovascular Unit, University Hospital Coventry & Warwickshire, Coventry, United Kingdom
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25
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Grilli CJ, Fedele CR, Tahir OM, Wrigley CW, Garcia MJ, Kimbiris G, Agriantonis DJ, Leung DA. Recanalization of Chronic Total Occlusions of the Superior Mesenteric Artery in Patients with Chronic Mesenteric Ischemia: Technical and Clinical Outcomes. J Vasc Interv Radiol 2014; 25:1515-22. [DOI: 10.1016/j.jvir.2014.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/21/2014] [Accepted: 07/03/2014] [Indexed: 12/30/2022] Open
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26
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Oderich GS, Bower TC, Sullivan TM, Bjarnason H, Cha S, Gloviczki P. Open versus endovascular revascularization for chronic mesenteric ischemia: risk-stratified outcomes. J Vasc Surg 2014; 49:1472-9.e3. [PMID: 19497510 DOI: 10.1016/j.jvs.2009.02.006] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 02/06/2007] [Accepted: 02/03/2009] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Outcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification. METHODS The data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting. RESULTS The ER patients were significantly older (71 +/- 15 vs 65 +/- 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 +/- 0.5 vs 1.8 +/- 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group (P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 +/- 8 vs 3 +/- 5 days; P < .001). At 5 years, OR had improved (P < .05) recurrence-free survival (89% +/- 4% vs 51% +/- 9%), and primary (88% +/- 3% vs 41% +/- 9%) and secondary patency rates (97% +/- 2% vs 88% +/- 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved (P < .05) recurrence-free survival (91% +/- 3% vs 56% +/- 8% at 5 years) and better primary and secondary patency rates (93% +/- 2% and 98% +/- 1% vs 52% +/- 8% and 93% +/- 4% at 3 years). CONCLUSION OR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.
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Affiliation(s)
- Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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27
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Parameshwarappa SK, Savlania A, Viswanathan S, Gadhinglajkar S, Raman KT, Unnikrishnan M. Chronic mesenteric ischemia and therapeutic paradigm of mesenteric revascularization. Indian J Gastroenterol 2014; 33:169-74. [PMID: 23996740 DOI: 10.1007/s12664-013-0377-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 07/29/2013] [Indexed: 02/04/2023]
Abstract
Chronic mesenteric ischemia is a life-threatening clinical problem resulting in death from inanition and/or bowel infarction, if left untreated, albeit low disease prevalence. Typical presentation is postprandial abdominal pain, severe weight loss, and altered bowel habit. Surgical revascularization of the superior mesenteric artery provides effective long-term treatment for chronic intestinal ischemia. Eleven patients underwent superior mesenteric artery revascularization, nine of them with open retrograde superior mesenteric artery bypass and two with angioplasty and stenting. All patients except one made a satisfactory recovery in this cohort. Major complication included one graft thrombosis leading to bowel ischemia and death. The rest all recovered weight in 3-6 months with a follow up period of 6 to 28 months. Two patients had recurrence of symptoms due to failing bypass requiring stenting for assisted primary patency. Superior mesenteric artery revascularization can be performed with minimal morbidity and mortality, providing excellent symptom relief and quality of life.
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Affiliation(s)
- Shashidhar Kallappa Parameshwarappa
- Division of Vascular Surgery, Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Medical College PO, Trivandrum, 695 011, India
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28
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Oderich GS, Erdoes LS, LeSar C, Mendes BC, Gloviczki P, Cha S, Duncan AA, Bower TC. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg 2013; 58:1316-23. [DOI: 10.1016/j.jvs.2013.05.013] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 05/07/2013] [Accepted: 05/07/2013] [Indexed: 12/12/2022]
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Shirasu T, Hosaka A, Okamoto H, Shigematsu K, Takeda Y, Miyata T, Watanabe T. Bowel necrosis following endovascular revascularization for chronic mesenteric ischemia: a case report and review of the literature. BMC Gastroenterol 2013; 13:118. [PMID: 23865626 PMCID: PMC3727947 DOI: 10.1186/1471-230x-13-118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 07/11/2013] [Indexed: 12/17/2022] Open
Abstract
Background Endovascular revascularization has recently been established as a less invasive treatment method for chronic mesenteric ischemia. However, intestinal necrosis caused by distal embolization following this procedure has not been emphasized. Case presentation The present report describes a 59-year-old man who was treated with endovascular revascularization for chronic mesenteric ischemia. After the procedure, he was diagnosed with intestinal necrosis caused by distal embolization. Despite emergent bowel resection, he died on postoperative day 109. Conclusion Although endovascular revascularization for chronic mesenteric ischemia is less invasive and may be suitable for high-risk patients, attention should be paid to avoid embolic complications that can cause intestinal infarction possibly leading to a fatal condition.
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Affiliation(s)
- Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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30
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Ouchi A, Isogai M, Harada T, Kaneoka Y, Kamei K, Maeda A. Duodenal ulcer penetration into the superior mesenteric artery after percutaneous transluminal angioplasty and stent placement for acute mesenteric ischemia: report of a case. Surg Today 2013; 44:1552-5. [PMID: 23681599 PMCID: PMC4097201 DOI: 10.1007/s00595-013-0557-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 02/03/2013] [Indexed: 01/16/2023]
Abstract
A 78-year-old male presented with the chief complaints of abdominal pain and vomiting. Contrast-enhanced computed tomography and abdominal angiography showed occlusion of the superior mesenteric artery due to thrombosis, and emergency percutaneous transluminal angioplasty and stent placement were carried out. Two months later, stent thrombosis developed, and a second stent was placed. Eight months later, he complained of general fatigue and anorexia. Gastrointestinal endoscopy revealed a duodenal ulcer at the third portion close to the superior mesenteric artery. Thirteen days after conservative management, duodenal ulcer penetration into the superior mesenteric artery with subsequent air embolism developed, and the patient died of multiple organ failure.
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Affiliation(s)
- Akira Ouchi
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan,
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Abstract
This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.
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32
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Ahanchi SS, Stout CL, Dahl TJ, Carty RL, Messerschmidt CA, Panneton JM. Comparative analysis of celiac versus mesenteric artery outcomes after angioplasty and stenting. J Vasc Surg 2013; 57:1062-6. [DOI: 10.1016/j.jvs.2012.10.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/04/2012] [Accepted: 10/11/2012] [Indexed: 11/27/2022]
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33
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AbuRahma AF, Campbell JE, Stone PA, Hass SM, Mousa AY, Srivastava M, Nanjundappa A, Dean LS, Keiffer T. Perioperative and late clinical outcomes of percutaneous transluminal stentings of the celiac and superior mesenteric arteries over the past decade. J Vasc Surg 2013; 57:1052-61. [DOI: 10.1016/j.jvs.2012.10.082] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 10/08/2012] [Accepted: 10/10/2012] [Indexed: 11/15/2022]
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Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia. J Vasc Surg 2013; 57:747-55; discussion 754-5. [PMID: 23332245 DOI: 10.1016/j.jvs.2012.09.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/11/2012] [Accepted: 09/18/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate long-term patient survival and causes of death after open (OR) or endovascular (ER) mesenteric revascularization for atherosclerotic chronic mesenteric ischemia using propensity score-matched comparison and clinical risk stratification. METHODS The clinical data of 343 patients treated with mesenteric revascularization for chronic mesenteric ischemia between 1991 and 2010 were retrospectively reviewed. Clinical, anatomical, and procedure-related variables were analyzed using a multivariate model to identify independent predictors of any-cause early and late (>30 days) mortality. Cause of death was retrieved from review of the National Death Index. Patient survival was analyzed using Society for Vascular Surgery (SVS) comorbidity scores and propensity score-matched comparison based on independent predictors of any-cause mortality. RESULTS There were 187 patients treated by OR and 156 patients treated by ER. Early procedure-related mortality was 2.6% (9/343), including five OR (2.7%) and four ER (2.6%) patients. Median follow-up was 96 ± 54 months (range, 1-168 months). There were 144 late deaths, most commonly from cardiac causes in 35% (51/144), followed by cancer in 15% (21/144), pulmonary complications in 13% (19/144), and mesenteric ischemia in 11% (16/144). A further 21 patients died from various identifiable causes, and 14 patients (10%) died of unknown causes. Overall, 25 patients (7.3%) died of mesenteric-related causes, including nine early and 16 late deaths (OR, 10/187; 8.0%, and ER, 6/156; 6.4%). Multivariate analysis identified age >80, diabetes, chronic kidney disease (CKD) stage IV or V, and home oxygen therapy as independent predictors (P < .05) of any cause of death. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death (P < .05). Late patient survival at 5 years in the OR and ER groups was 75% ± 4% and 60% ± 9% for low SVS risk (<9), 52% ± 8% and 43% ± 9% for intermediate SVS risk (9-16), and 67% ± 15% and 30% ± 8% for high SVS risk (>16). Using propensity matched scores, 5-year survival was nearly identical for patients treated by OR (60%) or ER (57%; P = .7). CONCLUSIONS Long-term patient survival after mesenteric revascularization was not influenced by type of arterial reconstruction. Age >80 years, diabetes, CKD stage IV or V, and home oxygen were independent predictors of any-cause mortality. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death.
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Abstract
Atherosclerotic vascular disease involving the mesenteric arteries occurs frequently in the elderly population. Although the prevalence of ischemic bowel disease is difficult to determine, acute mesenteric ischemia (AMI) has been reported to cause in 1 in 1000 hospital admissions, whereas chronic mesenteric ischemia (CMI) is estimated to affect 1 in 100,000 individuals. Mesenteric ischemia generally manifests in its chronic form as postprandial abdominal pain resulting in significant weight loss, and in its acute form as an abrupt development of abdominal pain, lower gastrointestinal bleeding, and subsequent intestinal necrosis. This article discusses the cause, clinical manifestations, diagnosis, and management of AMI and CMI.
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Baker AC, Chew V, Li CS, Lin TC, Dawson DL, Pevec WC, Hedayati N. Application of duplex ultrasound imaging in determining in-stent stenosis during surveillance after mesenteric artery revascularization. J Vasc Surg 2012; 56:1364-71; discussion 1371. [DOI: 10.1016/j.jvs.2012.03.283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 02/16/2012] [Accepted: 03/19/2012] [Indexed: 10/27/2022]
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Pecoraro F, Rancic Z, Lachat M, Mayer D, Amann-Vesti B, Pfammatter T, Bajardi G, Veith FJ. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg 2012; 27:113-22. [PMID: 23088809 DOI: 10.1016/j.avsg.2012.05.012] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Revised: 07/06/2011] [Accepted: 05/06/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist. METHODS A systematic literature review of the last 25-years was conducted through MEDLINE, Embase, and Cochrane Review/Trials register to identify studies reporting on CMI treatment with more than 10 patients. Primary outcomes were perioperative mortality and morbidity rates. Secondary outcomes were survival rates, primary and secondary patency rates, vessels treated, CMI recurrence, follow-up (FU), technical success (TS), and in-hospital length of stay (InH-LOS). Patients were divided into endovascular treatment (ET) or open treatment (OT) groups. Subsequently, primary and secondary outcomes were analyzed by study publication year for the interval periods 1986-2000 ("A") and 2001-2010 ("B"). Differences were assessed using the t-test and the χ(2) test. RESULTS Forty-three articles with 1,795 patients were included. Perioperative mortality and morbidity rates were lower in the ET group. No difference in survival rate was observed. Primary and secondary patencies were superior in the OT group. A greater number of vessels were revascularized in the OT group. CMI recurrence was more frequent in the ET group. FU was longer in the OT group. TS was superior in the OT group and InH-LOS was shorter in the ET group. A higher number of patients were treated by ET in the period "A." No differences in mortality and morbidity were observed between period "A" and "B" in ET and OT groups. CONCLUSIONS Considering the lower periprocedural mortality and morbidity after ET, this approach should be considered as the first treatment option in most CMI patients, especially in those with severe malnutrition. Primary OT should be restricted to cases that do not qualify for ET or good surgical risk patients with long life expectancy. Considering better long-term results of OT, ET treatment should be considered as a bridge therapy to OT in some patients requiring retreatment if ET does not preclude subsequent OT.
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Affiliation(s)
- Felice Pecoraro
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland; Vascluar Surgery Unit, University Hospital P. Giaccone, Via L.Giuffrè 5, Palermo, Italy.
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Manunga JM, Oderich GS. Orbital Atherectomy as an Adjunct to Debulk Difficult Calcified Lesions Prior to Mesenteric Artery Stenting. J Endovasc Ther 2012; 19:489-94. [DOI: 10.1583/12-3900.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Oderich GS, Tallarita T, Gloviczki P, Duncan AA, Kalra M, Misra S, Cha S, Bower TC. Mesenteric artery complications during angioplasty and stent placement for atherosclerotic chronic mesenteric ischemia. J Vasc Surg 2012; 55:1063-71. [PMID: 22322121 DOI: 10.1016/j.jvs.2011.10.122] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 10/25/2011] [Accepted: 10/27/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the incidence, management, and outcomes of mesenteric artery complications (MACs) during angioplasty and stent placement (MAS) for chronic mesenteric ischemia (CMI). METHODS We retrospectively reviewed the clinical data of 156 patients treated with 173 MAS for CMI (1998-2010). MACs were defined as procedure-related mesenteric artery dissection, stent dislodgement, embolization, thrombosis, or perforation. End points were procedure-related morbidity and death. RESULTS There were 113 women and 43 men (mean age, 73 ± 14 years). Eleven patients (7%) developed 14 MACs, including distal mesenteric embolization in six, branch perforation in three, dissection in two, stent dislodgement in two, and stent thrombosis in one. Five patients required adjunctive endovascular procedures, including in two patients each, catheter-directed thrombolysis or aspiration, retrieval of dislodged stents, and placement of additional stents for dissection. Five patients (45%) required conversion to open repair: two required evacuation of mesenteric hematoma, two required mesenteric revascularization, and one required bowel resection. There were four early deaths (2.5%) due to mesenteric embolization or myocardial infarction in two patients each. Patients with MACs had higher rates of mortality (18% vs 1.5%) and morbidity (64% vs 19%; P <.05) and a longer hospital length of stay (6.3 ± 4.2 vs 1.6 ± 1.2 days) than those without MACs. Periprocedural use of antiplatelet therapy was associated with lower risk of distal embolization or vessel thrombosis (odds ratio, 0.2; 95% confidence interval, 0.06-0.90). Patients treated by a large-profile system had a trend toward more MACs (odds ratio, 1.8; 95% confidence interval, 0.7-26.5; P = .07). CONCLUSIONS MACs occurred in 7% of patients who underwent MAS for CMI and resulted in higher mortality, morbidity, and longer hospital length of stay. Use of antiplatelet therapy reduced the risk of distal embolization or vessel thrombosis. There was a trend toward more MACs in patients who underwent interventions performed with a large-profile system.
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Affiliation(s)
- Gustavo S Oderich
- Division of Vascular and Endovascular Surgery and Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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Turba UC, Saad WE, Arslan B, Sabri SS, Trotter S, Angle JF, Hagspiel KD, Kern JA, Cherry KJ, Matsumoto AH. Chronic mesenteric ischaemia: 28-year experience of endovascular treatment. Eur Radiol 2012; 22:1372-84. [PMID: 22302502 DOI: 10.1007/s00330-011-2376-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 12/12/2011] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To report the outcomes associated with endovascular therapy for patients with chronic mesenteric ischemia (CMI). METHODS A retrospective review of patients who underwent endovascular therapy for CMI between April 1981 and September 2009 at a single institution was performed. Procedural details, mesenteric arteries treated, technical and clinical success rates, outcomes per patient and per vessel were assessed. RESULTS In 166 patients treatment was attempted using a variety of balloon and stent platforms during the 28-year period. The technical success rate was 97% per patient and 94% per vessel. The technical success rate of stenting (99.4%) was higher than for percutaneous transluminal angioplasty (PTA; 86%; P = 0.0001). Immediate clinical improvement was seen in 146 out of 166 (88.2%). The type of guidewire or device platform, brachial vs. femoral artery access, balloon and/or stent diameters used, and stenosis vs. occlusion had no statistical impact on mortality or the primary patency of any mesenteric artery outcomes. The outcome of the superior mesenteric artery (SMA) with PTA appears to be superior to that of stenting (P = 0.014). CONCLUSION Technical success rates are improved with the use of stents; however, PTA use in the SMA seems to offer better primary patency rates. KEY POINTS • Superior mesenteric artery (SMA) stenosis is often responsible for ischaemic symptoms. • Treatment with percutaneous transluminal angioplasty (PTA) seems superior to stenting • Although technical success rates are improved with the use of stents. • Higher mortality in the elderly and those presenting with nausea/vomiting/bloody stools.
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Affiliation(s)
- Ulku Cenk Turba
- Interventional Radiology, University of Virginia, Charlottesville, VA, USA.
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Negri S, Ferraro S, Piffaretti G, Rivolta N, Bossi M, Carrafiello G, Castelli P. An unusual case of stent migration after celiac trunk endovascular revascularization. Cardiovasc Intervent Radiol 2011; 35:950-3. [PMID: 22113207 DOI: 10.1007/s00270-011-0303-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 10/16/2011] [Indexed: 12/13/2022]
Abstract
A 61-year-old woman underwent celiac trunk stenting to treat abdominal angina. Three months later, she was readmitted for recurrent symptoms. Computed tomography control revealed the migration of the stent into the splenic artery. No sign of vessel injury or end-organ ischemia was detected. Repeat stenting of the celiac trunk was performed; the postoperative course was uneventful. 12 months later, the patient was asymptomatic with the second stent in its correct position, and she was asymptomatic for mesenteric ischemia.
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Affiliation(s)
- Silvia Negri
- Vascular Surgery, Department of Surgical Sciences, Circolo University Hospital, University of Insubria School of Medicine, Varese, Italy
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Tallarita T, Oderich GS, Macedo TA, Gloviczki P, Misra S, Duncan AA, Kalra M, Bower TC. Reinterventions for stent restenosis in patients treated for atherosclerotic mesenteric artery disease. J Vasc Surg 2011; 54:1422-1429.e1. [PMID: 21963821 DOI: 10.1016/j.jvs.2011.06.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Mesenteric artery angioplasty and stenting (MAS) has been plagued by high restenosis and reintervention rates. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR). METHODS The clinical data of 157 patients treated for chronic mesenteric ischemia with MAS of 170 vessels was entered into a prospective database (1998-2010). Fifty-seven patients (36%) developed MAISR after a mean follow-up of 29 months, defined by duplex ultrasound peak systolic velocity >330 cm/s and angiographic stenosis >60%. We reviewed the clinical data, radiologic studies, and outcomes of patients who underwent reintervention for restenosis. End points were mortality and morbidity, patient survival, symptom recurrence, reintervention, and patency rates. RESULTS There were 30 patients (25 female and five male; mean age, 69 ± 14 years) treated with reintervention for MAISR. Twenty-four patients presented with recurrent symptoms (21 chronic, three acute), and six had asymptomatic preocclusive lesions. Twenty-six patients (87%) underwent redo endovascular revascularization (rER) with stent placement in 17 (13 bare metal and four covered) or percutaneous transluminal angioplasty (PTA) in nine. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. Seven patients (27%) treated by rER developed complications, including access site problems in four patients, and distal embolization with bowel ischemia, congestive heart failure and stent thrombosis in one each. Symptom improvement was noted in 22 of the 24 symptomatic patients (92%). After a mean follow-up of 29 ± 12 months, 15 patients (50%) developed a second restenosis, and seven (23%) required other reintervention. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/9, 3/9, and 2/9 for PTA, 5/13, 8/13, and 5/13 for bare metal stents, and 1/4, 4/4, and 0/4 for open bypass. For all patients, freedom from recurrent symptoms, restenosis, and reinterventions were 70% ± 10%, 60% ± 10% and 50% ±10% at 2 years. For patients treated by rER, secondary patency rates were 72 ± 12 at the same interval. CONCLUSIONS Nearly 40% of patients developed mesenteric artery in-stent restenosis, of which half required reintervention because of symptom recurrence or progression to an asymptomatic preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%).
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Affiliation(s)
- Tiziano Tallarita
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, Minn, USA
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Malgor RD, Oderich GS. Technique of Recanalization of Long-Segment Flush Superior Mesenteric Artery Occlusions. Vasc Endovascular Surg 2011; 45:733-7. [DOI: 10.1177/1538574411418011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rafael D. Malgor
- Department of Surgery, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S. Oderich
- Department of Surgery, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Abstract
Ischemic changes of the abdominal organs are crucial since they develop slowly and are therefore often diagnosed at a late stage. Due to this general aspect, mortality from this disease could not be significantly reduced over the last decade. One of the main causes of these high mortality rates is the insufficient integration of the overall clinical picture into the diagnostic work-up. Acute mesenteric ischemia should be differentiated from chronic visceral ischemia. Acute intestinal ischemia is a vascular emergency with a mortality rate of 60-80%. The incidence of chronic visceral vascular disorders accounts for approximately 1-2% of all abdominal conditions and has to be differentiated from the acute form, since intestinal ischemia has a progressive nature and usually is related to general atherosclerotic disease. Therefore, this condition is associated with an increase of arteriosclerotic-related multimorbidity in an increasingly elderly population. Due to excellent collateralization, extensive chronic occlusion processes affecting the visceral arteries can be asymptomatically treated on a long-term basis.
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Debus E, Larena-Avellaneda A, Carpenter W, Diener H, Kölbel T. Operative Therapie der chronischen mesenterialen Ischämie. Chirurg 2011; 82:871-4, 876-9. [DOI: 10.1007/s00104-011-2099-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Clinical manifestations of chronic mesenteric ischemia (CMI) can range from vague abdominal pain to debilitating states of intestinal angina resulting in significant weight loss and morbidity. Once the condition has been diagnosed, treatment usually is elective, except in rare cases of rapid progression to acute mesenteric ischemia. Medical management of CMI is mostly supportive. However, in disorders of coagulation, antiplatelet agents and warfarin may be helpful to prevent further thrombosis, and these disorders may require lifelong therapy. For decades, the mainstay of therapy for CMI has been surgery. Extensive disease often requires complete revascularization, although bypass of the superior mesenteric artery alone also has been shown to be effective. Multiple variations of surgical bypass have been advocated but require further evaluation to determine efficacy. Transaortic endarterectomy is a viable option for limited disease. Minimally invasive vascular procedures such as percutaneous endovascular angioplasty and stenting are proving to be effective for short-segment atherosclerotic stenosis, particularly near the origin of the vessels. Although endovascular therapy has less long-term durability compared with open surgical procedures, these treatments prove simpler, with shortened hospital stays and reduced morbidity. Furthermore, angiographic therapy is a feasible alternative for patients in whom surgery is deemed precarious.
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Affiliation(s)
- Jayaprakash Sreenarasimhaiah
- Jayaprakash Sreenarasimhaiah, MD University of Texas Southwestern Medical Center, Department of Medicine, Division of Digestive and Liver Diseases, 5323 Harry Hines Boulevard, MC 8887, Dallas, TX 75390, USA.
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Yaqub Y, Suarez J, Jenkins LA. LASER endovascular atherectomy with secondary stenting of technically challenging calcified celiac trunk stenosis. Catheter Cardiovasc Interv 2011; 78:301-3. [DOI: 10.1002/ccd.23063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 02/13/2011] [Accepted: 02/17/2011] [Indexed: 11/05/2022]
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Schoch DM, LeSar CJ, Joels CS, Erdoes LS, Sprouse LR, Fugate MW, Greer MS, Fisher DF, Mixon H, Hogan M, Burns RP. Management of Chronic Mesenteric Vascular Insufficiency: An Endovascular Approach. J Am Coll Surg 2011; 212:668-75; discussion 675-7. [DOI: 10.1016/j.jamcollsurg.2010.12.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 12/16/2010] [Indexed: 01/29/2023]
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Hinojosa Becerril C, Aragón-Han P. Derivación aortovisceral anterógrada por abordaje toracoabdominal. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gupta PK, Horan SM, Turaga KK, Miller WJ, Pipinos II. Chronic mesenteric ischemia: endovascular versus open revascularization. J Endovasc Ther 2010; 17:540-9. [PMID: 20681773 DOI: 10.1583/09-2935.1] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED To review 20 years of literature on chronic mesenteric ischemia (CMI), examining its complex clinical presentation and comparing open and endovascular treatment options. METHODS The PubMed and EBSCOHost electronic databases were queried to identify English-language articles published over the last 20 years. Scrutiny of the retrieved articles identified 1939 patients (mean age 65 years). Of these, 1163 patients underwent open surgery: 714 between 2000 and 2009 and 449 between 1990 and 1999. Of the 776 patients undergoing endovascular repairs, the majority (684) were performed between 2000 and 2009; 92 patients were treated between 1990 and 1999. Data were entered in an electronic database and were pooled for categorical analysis. RESULTS No major differences were seen among open surgeries or among endovascular surgeries performed when comparing the 2 time periods. On comparing open and endovascular surgeries performed between 2000 and 2009, symptom improvement was 2.4 times more likely after open compared to endovascular surgery (95% CI 1.5 to 3.6, p<0.001). Five-year primary patency and 5-year assisted primary patency were 3.8 (95% CI 2.4 to 5.8, p<0.001) and 6.4 (95% CI 1.3 to 30.1, p = 0.02) times greater in the open group. Freedom from symptoms at 5 years was 4.4 times greater for open versus endovascular (95% CI 2.8 to 7.0, p<0.001). The complication rate for open versus endovascular surgery was 3.2 times greater (95% CI 2.5 to 4.2, p<0.001). The difference in mortality was not statistically significant (p = 0.75). CONCLUSION Our data demonstrate that open revascularization surpasses endovascular procedures in long-term vessel patency and control of symptoms. Patients undergoing open procedures do, however, develop increased complications perioperatively. The preferred revascularization approach used in treating this condition should be tailored to the anatomy and physiology of each patient.
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Affiliation(s)
- Prateek K Gupta
- Department of Surgery, Creighton University, Omaha, Nebraska, USA
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