A comparison of open and endovascular revascularization for chronic mesenteric ischemia in a clinical decision model

Long-term value in open and endovascular repair of chronic mesenteric ischemia

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.

Survival, Reintervention, and Value of Open and Endovascular Repair for Chronic Mesenteric Ischemia

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.

Cost-Effectiveness Analysis of Open Versus Endovascular Revascularization for Chronic Mesenteric Ischemia

BACKGROUND

Recent studies have shown a trend supporting endovascular revascularization (ER) in the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared the cost effectiveness of ER and open revascularization (OR) for this indication. The purpose of this study is to conduct a cost-effectiveness analysis comparing open versus ER for CMI.

METHODS

We built a Markov model with Monte Carlo microsimulation using transition probabilities and utilities from existing literature for CMI patients undergoing OR versus ER. Costs were derived from the hospital perspective using the 2020 Medicare Physician Fee Schedule. The model randomized 20,000 patients to either OR or ER and allowed for 1 subsequent reintervention with 3 other intervening health states: alive, alive with complications, and dead. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness.

RESULTS

OR cost $4,532 for 1.03 QALYs while ER cost $5,092 for 1.21 QALYs, leading to an ICER of $3,037 per QALY gained in the ER arm. This ICER was less than our willingness to pay threshold of $100,000. Sensitivity analysis demonstrated that our model was most sensitive to costs, mortality, and patency rates after OR and ER. Probabilistic sensitivity analysis demonstrated ER would be considered cost effective 99% of iterations.

CONCLUSIONS

This study found that while 5-year costs for ER were greater than OR, ER afforded greater QALYs than OR. Although ER is associated with lower long-term patency and higher rates of reintervention, it appears to be more cost effective than OR for the treatment of CMI.

Development of a Novel Scoring Model to Estimate the Severity Grade of Mesenteric Artery Stenosis

Objective: This study aimed to derive a new scoring model from estimating the severity grade of mesenteric artery stenosis. We sought to analyze the relationship between the new scoring model and the development, treatment, and mortality of chronic mesenteric ischemia (CMI). Methods: This retrospective study included 242 patients (128 (53%) women and 114 (47%) men) with suspected CMI from January 2011 to December 2020. A weighted sum six-point score (CSI-score; the celiac artery is abbreviated by “C”, superior mesenteric artery by “S”, and inferior mesenteric artery by “I”) based on the number of affected vessels and the extent and grade of the stenosis or occlusion of the involved visceral arteries was derived by maximizing the area under the ROC curve. The calculated CSI-score ranged from 0 to 22. The patients were divided according to the best cut-off point into low-score (CSI-score < 8) and high-score (CSI-score ≥ 8) groups. Results: The area under the receiver operating characteristic curve (AUC) of the CSI-score was 0.86 (95% CI, 0.82−0.91). The best cut-off point of “8” represented the highest value of Youden’s index (0.58) with a sensitivity of 87% and specificity of 72%. The cohort was divided according to the cut-off point into a low-score group (n = 100 patients, 41%) and high-score group (n = 142 patients, 59%) and according to the clinical presentation into a CMI group (n = 109 patients, 45%) and non-CMI group (n = 133 patients, 55%). The median CSI-score for all patients was 10 (range: 0 -22). High-scoring patients showed statistically significant higher rates of coronary artery disease (54% vs. 36%, p = 0.007), chronic renal insufficiency (50% vs. 30%, p = 0.002), and peripheral arterial disease (57% vs. 16%, p < 0.001). A total of 109 (45%) patients underwent invasive treatment of the visceral arteries and were more often in the high-score group (69% vs. 11%, p < 0.001). Of those, 79 (72%) patients underwent primary endovascular treatment, and 44 (40%) patients underwent primary open surgery or open conversion after endovascular treatment. Sixteen (7%) patients died during the follow-up, with a statistically significant difference between high- and low-scoring patients (9% vs. 0%, p = 0.008). The score stratification showed that the percentage of patients treated with endovascular and open surgical methods, the recurrence of the stenosis or failure of the endovascular treatment, the need for a bypass procedure, and the mortality rates significantly increased in the subgroups. The CSI-score demonstrated an excellent ability to discriminate between patients who needed treatment and those who did not, with an AUC of 0.87 (95% CI, 0.82−0.91). Additionally, the CSI-score’s ability to predict the patients’ mortality was moderate, with an AUC of 0.73 (95% CI, 0.62−0.83). Conclusions: The new scoring model can estimate the severity grade of the stenosis of the mesenteric arteries. Our study showed a strong association of the score with the presence of chronic mesenteric ischemia, the need for treatment, the need for open surgery, and mortality.

Successful endovascular treatment of severe chronic mesenteric ischemia facilitated by intraoperative positioning system image guidance

We report our initial experience using the intraoperative positioning system (IOPS), a novel endovascular navigation system that does not require contrast or radiation, in the treatment of chronic mesenteric ischemia (CMI). We used IOPS to help treat three of four consecutive patients with CMI. Technical problems prevented successful use in one patient. For the patients for whom IOPS was used effectively, catheterization of the mesenteric artery was accomplished more quickly than for the patient for whom IOPS was not effective. Our experience has shown that IOPS can be safely and effectively used for CMI and can reduce the contrast load and radiation dose.

Transcollateral Recanalization of an Occluded Superior Mesenteric Artery

OBJECTIVE

To report the technique of transcollateral retrograde recanalization of a superior mesenteric artery flush occlusion.

METHODS

The technique of a patient undergoing transcollateral retrograde recanalization for acute symptomatic superior mesenteric artery flush occlusion was reviewed and presented. Other adjunctive methods to facilitate the endovascular treatment of the superior mesenteric artery total occlusion lesion were also compared and discussed.

RESULTS

The patient was a 47-year-old woman, acute onset of symptomatic chronic mesenteric ischemia with flush occlusion of the superior mesenteric artery which was unable to be revascularized in a routine operation. A collateral was found to connect celiac artery and superior mesenteric artery (gastroduodenal arch). The guidewire was retrograde crossed the occluded lesion via this collateral and recaptured by the catheter from the same single brachial sheath followed by balloon angioplasty and stent implantation. The patient recovered well and the symptoms completely disappeared after the procedure.

CONCLUSION

The technique of retrograde recanalization through collateral pathway is an applicable alternative option for patients with superior mesenteric artery flush occlusion who have failed attempts by conventional antegrade approaches.

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery

BACKGROUND

Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis.

METHODS

The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus.

RESULTS

Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion.

CONCLUSIONS

These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.

European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia

Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.

Renal and Mesenteric Artery Intervention

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.

How to manage chronic mesenteric ischemia? A deliberated strategy

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.

The Impact of Revascularisation on Quality of Life in Chronic Mesenteric Ischemia

BACKGROUND

Chronic mesenteric ischemia (CMI) is characterized by long-standing abdominal symptoms due to insufficient mesenteric circulation. Data on the effect of revascularisation on quality of life (QoL) for CMI are scarce. This study is the first to evaluate the impact of revascularisation on quality of life.

METHODS

Seventy-nine patients with CMI or acute-on-chronic mesenteric ischemia (AoCMI) underwent an intervention of one or more mesenteric arteries between January 2010 and July 2012. QoL before and after intervention was measured with the EuroQol-5D. Preintervention questionnaires were of standard care. Postintervention data were obtained by resending a questionnaire to the patients between February and May 2013. To investigate the clinical relevance of our findings, the minimal clinically important difference (MCID) was used. Since there is no established MCID for CMI, we used the literature reference MCID of inflammatory bowel syndrome (IBS) of 0.074.

RESULTS

Fifty-five (69.6%) of 79 patients returned their questionnaire and 23 (29.1%) were completely filled out. There was a significant increase of the median EQ-index score from 0.70 to 0.81 (p=0.02) and a significant reduction of symptoms in the domains usual activities (34.4%) and pain/discomfort (32.3%). There was a significant improvement of 17% in overall current health condition (VAS) (p=0.001). The MCID between baseline and postoperative EQ-5D index score was 0.162, indicating a clinically relevant improvement of quality of life after revascularisation.

CONCLUSION

Quality of life of CMI patients is improved after mesenteric artery revascularisation.

The use of an upper extremity hemodialysis access site for stenting of the superior mesenteric artery for chronic mesenteric ischemia

We report the use of an upper extremity hemodialysis access site to facilitate endovascular treatment of the superior mesenteric artery in the setting of chronic mesenteric ischemia. A 64-year-old woman with end-stage renal disease on hemodialysis presented with worsening symptoms associated with chronic mesenteric ischemia. Her left upper extremity interposition graft within the fistula access site was selected to avoid a hostile aortoiliac system and in consideration of the potential benefits it provided over transfemoral, transbrachial, and transradial sites. The procedure was technically successful without complication. Hemodialysis access sites, such as the interposition graft within the fistula of this patient, are a potential route of upper extremity access for mesenteric interventions in patients with end-stage renal disease on hemodialysis.

Improved mortality in treatment of patients with endovascular interventions for chronic mesenteric ischemia

OBJECTIVE

Chronic mesenteric ischemia (CMI) continues to be a devastating diagnosis. There is a national trend toward increased use of endovascular procedures with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed CMI patients' length of hospitalization and health care cost.

METHODS

We identified all patients admitted for CMI from the National Inpatient Sample (NIS) from 2000 to 2014. Our primary end points included length of hospital stay (LOS) and cost of hospitalization (COH). Our secondary end points included mortality assessment of the CMI hospitalization.

RESULTS

There were 15,475 patients admitted for CMI. The mean age of patients was 71 years, and 4022 (26.0%) were male. There were 10,920 (70.6%) patients treated endovascularly (ENDO) and 4555 (29.4%) patients treated in an open fashion (OPEN). Although a higher proportion of patients in the ENDO (43.3%) group vs OPEN (33.1%) had a Charlson Comorbidity Index score of ≥2 (P < .0001), they had a lower mortality rate (2.4% vs 8.7%; P < .0001), lower mean LOS (6.3 vs 14.0 days; P < .0001), and lower COH ($21,686 vs $42,974; P < .0001). After adjusting for clinical and hospital factors, OPEN continued to demonstrate higher mortality than ENDO (odds ratio, 7.2; 95% confidence interval, 4.9-10.6; P < .0001), longer LOS (mean, +9.7 days; P < .0001), and higher COH (mean, +$25,834; P < .0001).

CONCLUSIONS

The rate of ENDO continues to rise nationally in the treatment of CMI patients. After adjusting for clinical and hospital factors, patients in the ENDO group tend to have lower in-hospital mortality of 2.4% and lower LOS by 10 days, and they incur a cost saving of >$25,000 compared with patients in the OPEN group. ENDO should be considered first line of therapy for patients with CMI.

Mesenteric Ischemia

Mesenteric ischemia is an uncommon disease most often seen in the elderly. This disease results from blood flow in the mesenteric circulation that inadequately meets metabolic needs of the visceral organs and, if untreated, eventually leads to necrosis of the bowel wall. Mesenteric ischemia is divided into 2 types: acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Delayed diagnosis of CMI can lead to AMI. AMI is associated with extremely high mortalities. Early diagnosis via computed tomography angiography and prompt revascularization via endovascular therapy are recommended for symptomatic patients who have not developed bowel ischemia and necrosis.

Successful Use of Orbital Atherectomy as an Adjunct in Treating Extensively Calcified Mesenteric Artery Lesions

BACKGROUND

To describe the use of orbital technique of atherectomy as an adjunct to successful angioplasty and stent placement of the superior mesenteric artery (SMA).

CASE REPORT

The technique is demonstrated in a 68-year-old man with critical SMA stenosis. The SMA was cannulated with 0.014-in wire, but the lesion was highly stenotic and densely calcified and prevented the passage of even the smallest 1.5-mm balloon. Orbital atherectomy was thus performed with a 1.25-mm CSI crown. Balloon angioplasty was then possible with a 4 mm × 2 cm balloon followed by placement of a 7 mm × 22 mm balloon-mounted stent.

CONCLUSIONS

The use of atherectomy as an adjunct to angioplasty and stenting in extensive, calcified SMA lesions supports the value of this technique to avoid a much larger and morbid open procedure.

Intravascular Ultrasound-Guided Mesenteric Stenting in Patients with Advanced Chronic Kidney Disease

Endovascular treatment of chronic mesenteric ischemia in patients with impaired renal function or allergy to contrast media is a challenging procedure because angiography requires iodinated contrast media for accurate diagnosis and interventional procedures. Superior mesenteric artery stenting without contrast angiography is described in an 81-year-old woman with cardiovascular disease and chronic kidney disease (CKD) stage 5. Balloon angioplasty and stent placement were performed successfully using intravascular ultrasound, pressure wire, surface ultrasound, and fluoroscopy. Intervention without contrast media has wide applicability to patients with advanced CKD and/or those with allergy to iodinated contrast media.

Endovascular Simulation Leads to Efficiency and Competence in Thoracic Endovascular Aortic Repair Procedures

OBJECTIVE

Endovascular interventions such as thoracic endovascular aortic repair (TEVAR) have largely replaced invasive open procedures, and have been demonstrated to be effective in treating patients. Our study used endovascular simulation to assess the effect of TEVAR rehearsal on surgical trainees at different levels in training.

DESIGN

Participants were oriented on an endovascular simulator and subsequently a simulated TEVAR was performed during 4 separate sessions over a 1-month period. Metrics included total procedure/fluoroscopy time and volume of contrast used. Likert scale qualitative analysis evaluated participant׳s skills involving major procedural steps. Analysis of data across cohorts included 1-way analysis of variance, Kruskal-Wallis, and paired t-tests.

SETTING

All data were collected at University Hospitals-Case Medical Center, Cleveland, OH.

PARTICIPANTS

In all, 12 trainees in 3 cohorts (student, surgery resident postgraduate year [PGY] 1-3, surgery resident/fellow PGY 4-7, n = 4 each) were recruited.

RESULTS

All trainees reduced total procedure time (mean = 537 ± 148 vs 269 ± 66s, first session vs fourth, P < 0.05, CI: 195-341) and fluoroscopy time (mean = 201 ± 74 vs 110 ± 37s, P < 0.05, CI: 51-132) with TEVAR case progression. The student cohort decreased procedure time from 551 ± 84s to 313 ± 65s (P < 0.05, CI: 189-287) whereas PGYs 1 to 3 decreased procedure time from 591 ± 149s to 264 ± 29s (P < 0.05, CI: 113-541). Use of contrast decreased over time, but the difference was not significant. Participants acquired proficiency after a few runs in most steps of the procedure. The average qualitative score for all groups combined improved significantly (P < 0.03). PGY 4 to 7 trainees had higher technical scores but this was not statistically significant. The initial gap in junior vs senior trainee performance narrowed after a few practice sessions in all aspects evaluated.

CONCLUSIONS

TEVAR rehearsal on an endovascular simulator can reduce overall procedure and fluoroscopy time, independent of trainee skill level or experience, as well as improve subjective measures of technical success. Further studies are needed to compare simulator performance to outcomes in live cases.

Mesenteric ischemia

PURPOSE OF REVIEW

Diagnosis of acute mesenteric ischemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischemia may be treated with urgent intestinal revascularization.

RECENT FINDINGS

The establishment of a hybrid operation room is most important to be able to perform explorative laparotomy for evaluation of the extent of mesenteric ischemia and successful intestinal revascularization. Endovascular recanalization and stenting has become an important alternative, especially in patients with both acute and chronic thrombotic superior mesenteric artery (SMA) occlusion. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. The concept of damage-control surgery is recommended after intestinal revascularization.

SUMMARY

Intestinal revascularization in patients with arterial occlusive mesenteric ischemia reduces bowel morbidity and mortality. Observational studies report that both endovascular and open vascular therapy options are effective, but endovascular technique may be preferred in these often elderly and fragile patients.

Successful endovascular treatment of severe chronic mesenteric ischemia by concurrent triple-vessel mesenteric artery revascularization

A 52-year-old man presenting with severely symptomatic chronic mesenteric ischemia had proximal occlusion of the celiac and superior mesenteric arteries and critical stenosis of the inferior mesenteric artery ostium. Concurrent percutaneous revascularization with stenting of all three mesenteric arteries was successfully achieved using techniques tailored to each lesion. Complete clinical recovery was observed at the six-month post-procedure follow-up.

Cost-effectiveness of endovascular repair, open repair, and conservative management of splenic artery aneurysms

OBJECTIVE

Open repair (OPEN) and conservative management (CONS) have been the treatments of choice for splenic artery aneurysms (SAAs) for many years. Endovascular repair (EV) has been increasingly used with good short-term results. In this study, we evaluated the cost-effectiveness of OPEN, EV, and CONS for the treatment of SAAs.

METHODS

A decision analysis model was developed using TreeAge Pro 2013 software (TreeAge Inc, Williamstown, Mass) to evaluate the cost-effectiveness of the different treatments for SAAs. A hypothetical cohort of 10,000 55-year-old female patients with SAAs was assessed in the reference-case analysis. Perioperative mortality, disease-specific mortality rates, complications, rupture risks, and reinterventions were retrieved from a recent and extensive meta-analysis. Costs were analyzed with the 2014 Medicare database. The willingness to pay was set to $60,000/quality-adjusted life years (QALYs). Outcomes evaluated were QALYs, costs from the health care perspective, and the incremental cost-effectiveness ratio (ICER). Extensive sensitivity analyses were performed and different clinical scenarios evaluated. Probabilistic sensitivity analysis was performed to include the uncertainty around the variables. A flowchart for clinical decision-making was developed.

RESULTS

For a 55-year-old female patient with a SAA, EV has the highest QALYs (11.32; 95% credibility interval [CI], 9.52-13.17), followed by OPEN (10.48; 95% CI, 8.75-12.25) and CONS (10.39; 95% CI, 8.96-11.87). The difference in effect for 55-year-old female patients between EV and OPEN is 0.84 QALY (95% CI, 0.42-1.34), comparable with 10 months in perfect health. EV is more effective and less costly than OPEN and more effective and more expensive compared with CONS, with an ICER of $17,154/QALY. Moreover, OPEN, with an ICER of $223,166/QALY, is not cost-effective compared with CONS. In elderly individuals (age >78 years), the ICER of EV vs CONS is $60,503/QALY and increases further with age, making EV no longer cost-effective. Very elderly patients (age >93 years) have higher QALYs and lower costs when treated with CONS. The EV group has the highest number of expected reinterventions, followed by CONS and OPEN, and the number of expected reinterventions decreases with age.

CONCLUSIONS

EV is the most cost-effective treatment for most patient groups with SAAs, independent of the sex and risk profile of the patient. EV is superior to OPEN, being both cost-saving and more effective in all age groups. Elderly patients should be considered for CONS, based on the high costs in relation to the very small gain in health when treated with EV. The very elderly should be treated with CONS.