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Sorour AA, Dehaini H, Alnahhal KI, Khalifeh A, Rowse JW, Quatromoni JG, Caputo FJ, Lyden SP, Kirksey L. Natural history of superior mesenteric artery in-stent restenosis. J Vasc Surg 2024; 79:818-825.e2. [PMID: 38128845 DOI: 10.1016/j.jvs.2023.11.035] [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: 09/28/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence. METHODS Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350. RESULTS The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups. CONCLUSIONS The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.
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Affiliation(s)
- Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH; Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.
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Sulzer TAL, Macedo TA, Strissel N, Hesley GK, Lekah A, Tallarita T, Dias-Neto M, Huang Y, Tenorio ER, Vacirca A, Mesnard T, Baghbani-Oskouei A, Savadi S, de Bruin JL, Verhagen HJM, Mendes B, Oderich GS. Changes in renal-mesenteric duplex ultrasound velocities after fenestrated and branched endovascular aortic aneurysm repair. J Vasc Surg 2023; 78:1162-1169.e2. [PMID: 37453587 DOI: 10.1016/j.jvs.2023.06.106] [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: 05/04/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Stenting of renal and mesenteric vessels may result in changes in velocity measurements due to arterial compliance, potentially giving rise to confusion about the presence of stenosis during follow-up. The aim of our study was to compare preoperative and postoperative changes in peak systolic velocity (PSV, cm/s) after placement of the celiac axis (CA), superior mesenteric artery (SMA) and renal artery (RAs) bridging stent grafts during fenestrated-branched endovascular aortic repair (FB-EVAR) for treatment of complex abdominal aortic aneurysms (AAA) and thoracoabdominal aortic aneurysms. METHODS Patients were enrolled in a prospective, nonrandomized single-center study to evaluate FB-EVAR for treatment of complex AAA and thoracoabdominal aortic aneurysms between 2013 and 2020. Duplex ultrasound examination of renal-mesenteric vessels were obtained prospectively preoperatively and at 6 to 8 weeks after the procedure. Duplex ultrasound examination was performed by a single vascular laboratory team using a predefined protocol including PSV measurements obtained with <60° angles. All renal-mesenteric vessels incorporated by bridging stent grafts using fenestrations or directional branches were analyzed. Target vessels with significant stenosis in the preoperative exam were excluded from the analysis. The end point was variations in PSV poststent placement at the origin, proximal, and mid segments of the target vessels for fenestrations and branches. RESULTS There were 419 patients (292 male; mean age, 74 ± 8 years) treated by FB-EVAR with 1411 renal-mesenteric targeted vessels, including 260 CAs, 409 SMAs, and 742 RAs. No significant variances in the mean PSVs of all segments of the CA, SMA, and RAs at 6 to 8 weeks after surgery were found as compared with the preoperative values (CA, 135 cm/s vs 141 cm/s [P = .06]; SMA, 128 cm/s vs 125 cm/s [P = .62]; RAs, 90 cm/s vs 83 cm/s [P = .65]). Compared with baseline preoperative values, the PSV of the targeted vessels showed no significant differences in the origin and proximal segment of all vessels. However, the PSV increased significantly in the mid segment of all target vessels after stent placement. CONCLUSIONS Stent placement in nonstenotic renal and mesenteric vessels during FB-EVAR is not associated with a significant increase in PSVs at the origin and proximal segments of the target vessels. Although there is a modest but significant increase in velocity measurements in the mid segment of the stented vessel, this difference is not clinically significant. Furthermore, PSVs in stented renal and mesenteric arteries were well below the threshold for significant stenosis in native vessels. These values provide a baseline or benchmark for expected PSVs after renal-mesenteric stenting during FB-EVAR.
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Affiliation(s)
- Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thanila A Macedo
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
| | | | | | | | | | - Marina Dias-Neto
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bernardo Mendes
- Department of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
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3
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Kupinski AM. Mesenteric and renal arterial duplex ultrasound: A review. Vasc Med 2023; 28:463-475. [PMID: 37259501 DOI: 10.1177/1358863x231172247] [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] [Indexed: 06/02/2023]
Abstract
Duplex ultrasound examinations of the mesenteric and renal circulations are commonly used to detect disease as well as to follow up patients after open surgery or endovascular intervention. The aims of this review were to present essential elements of these duplex ultrasound examinations as well as conduct a literature review of diagnostic criteria. Documentation of appropriate images and data will aid in an accurate interpretation. Spectral Doppler waveforms from various segments of these arterial systems can contribute both direct and indirect evidence of the presence of disease. Various studies have validated the duplex ultrasound diagnostic criteria which more recently have expanded to include specific criteria for stented vessels. This review presents a summary of the fundamental exam components and diagnostic criteria utilized for mesenteric and renal duplex ultrasound.
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Affiliation(s)
- Ann Marie Kupinski
- North Country Vascular Diagnostics, Inc., Altamont, NY, USA
- Albany Medical College, Albany, NY, USA
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4
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Conway AM, Carroccio A, Rosen RJ. Acute and Chronic Mesenteric Ischemia. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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5
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Safi N, Ånonsen KV, Berge ST, Medhus AW, Sundhagen JO, Hisdal J, Kazmi SSH. Early Identification of Chronic Mesenteric Ischemia with Endoscopic Duplex Ultrasound. Vasc Health Risk Manag 2022; 18:233-243. [PMID: 35431549 PMCID: PMC9005355 DOI: 10.2147/vhrm.s358570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/21/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Due to diagnostic delay, chronic mesenteric ischemia (CMI) is underdiagnosed. We assumed that the patients suspected of CMI of the atherosclerotic origin or median arcuate ligament syndrome (MALS) could be identified earlier with endoscopic duplex ultrasound (E-DUS). Patients and Methods Fifty CMI patients with CTA-verified stenosis of either ≥50% and ≥70% of celiac artery (CA) and superior mesenteric artery (SMA) were examined with E-DUS and transabdominal duplex ultrasound (TA-DUS). Peak systolic velocities (PSV) of ≥200cm/s and ≥275cm/s for CA and SMA, respectively, were compared with CTA. Subgroup analysis was performed for the patients with (n=21) and without (n=29) prior revascularization treatment of CMI. The diagnostic ability of E-DUS and TA-DUS was tested with crosstabulation analysis. Receiver operating characteristics (ROC) curve analysis was performed, and the area under the curve (AUC) was calculated to investigate the test accuracy. Results In the patients with ≥70% stenosis, E-DUS had higher sensitivity than TA-DUS (91% vs 81% for CA and 100% vs 92% for SMA). AUC for SMA ≥70% in E-DUS was 0.75 and with TA-DUS 0.68. The sensitivity of E-DUS for CTA-verified stenosis ≥70% for CA was 100% in the patients without prior treatment. E-DUS demonstrated higher sensitivity than TA-DUS for both arteries with stenosis ≥50% and ≥70% in the treatment-naive patients. Conclusion E-DUS is equally valid as TA-DUS for the investigation of CMI patients and should be used as an initial diagnostic tool for patients suspected of CMI.
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Affiliation(s)
- Nathkai Safi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kim Vidar Ånonsen
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Simen Tveten Berge
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle Wilhelm Medhus
- Department of Gastroenterology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jon Otto Sundhagen
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Syed Sajid Hussain Kazmi
- Department of Vascular Surgery, Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Correspondence: Syed Sajid Hussain Kazmi, Tel +47 92468309, Email
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Pamulapati V, Guitart JR, Helenowski IB, Resnick S, Ho KJ. Use of computed tomographic and digital subtraction angiography to determine optimal duplex ultrasound criteria for predicting superior mesenteric artery in-stent restenosis. Vasc Med 2021; 26:566-568. [PMID: 34269145 DOI: 10.1177/1358863x211025615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vivek Pamulapati
- Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joan R Guitart
- Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Irene B Helenowski
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Scott Resnick
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Karen J Ho
- Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Green J, Ryer E, Borden N, Ali B, Garvin R, Yang A, Hashmi A, Salzler G, Elmore J. Defining Duplex Ultrasound Criteria for In-Stent Restenosis of the Superior Mesenteric Artery. Ann Vasc Surg 2021; 74:294-300. [PMID: 33508454 DOI: 10.1016/j.avsg.2020.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/11/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study sought to define duplex ultrasound (DUS) velocity criteria predicting ≥70% stenosis in superior mesenteric artery (SMA) stents by correlating in-stent peak systolic velocity (PSV) with computed tomographic angiography (CTA) measurements of percent stenosis. METHODS A retrospective review of 109 patients undergoing SMA stenting between 2003 and 2018 was conducted at a single institution. Thirty-seven surveillance duplex ultrasound studies were found to have a CTA performed within 30 days of study completion. Bare metal (n = 20) and covered stents (n = 17) were included. Velocities were paired to in-stent restenosis (ISR) measured by mean vessel diameter reduction on SMA centerline reconstructions from CTA. Receiver operating characteristic (ROC) curves was generated and logistic regression models for ≥70% ISR probability were used to define velocity criteria in the stented SMA. RESULTS At a PSV of 300 cm/sec, the sensitivity is 100% and specificity 80% for a ≥70% in-stent SMA stenosis. At a PSV of 400 cm/sec, the sensitivity and positive predictive value (PPV) is 63% and the specificity and negative predictive value (NPV) is 90%. A PSV of 450 cm/sec was consistent with the highest specificity (100%) and PPV (100%) but lower sensitivity (50%) and NPV (87.9%). One patient with a PSV of 441 cm/sec on surveillance DUS died from complications of acute-on-chronic mesenteric ischemia. CONCLUSIONS A PSV of 400 cm/sec on mesenteric DUS can predict ≥70% ISR with high sensitivity and should be considered as a diagnostic threshold for SMA in-stent restenosis.
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Affiliation(s)
- Jessica Green
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Evan Ryer
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA.
| | - Nicholas Borden
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Bilal Ali
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Robert Garvin
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Andrew Yang
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Ammar Hashmi
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - Gregory Salzler
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
| | - James Elmore
- Department of Endovascular & Vascular Surgery, Geisinger Medical Center, Danville, PA
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8
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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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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10
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Jacobs CR, Fatima J, Scali ST, Hodges ZH, Back MR, Arnaoutakis DJ, Shah SK, Huber TS. Surgical Treatment of True Superior Mesenteric Artery Aneurysms. Ann Vasc Surg 2020; 71:74-83. [PMID: 32941966 DOI: 10.1016/j.avsg.2020.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Superior mesenteric artery aneurysms (SMAAs) are a rare clinical problem that can be associated with significant morbidity and mortality. The optimal surgical approach for both mycotic and degenerative SMAAs remains poorly defined. The study was designed to review our institutional experience and develop a treatment algorithm. METHODS A single-institution, retrospective review was performed to document presentation, treatment, and outcomes of patients undergoing surgical repair of SMAAs from 2003 to 2020. The primary end-point was 30-day mortality, and secondary end-points included complications, patency, freedom from reinfection, freedom from reintervention, and survival. RESULTS Eighteen patients (mean age: 46 ± 16 yrs; 50% male; mean diameter 2.4 ± 2.0 cm) underwent treatment of mycotic (50%) or degenerative (50%) SMAAs. Abdominal pain (66%) was the most common presenting symptom, and the diagnosis was confirmed with CT arteriography. Endocarditis secondary to intravenous drug abuse was responsible for most (88%) of the mycotic SMAAs, with a majority (66%) having positive cultures and Streptococcus being the most common organism. The majority (61%) of patients underwent urgent or emergent repair with aneurysmectomy and interposition saphenous vein bypass being the most common treatment of mycotic SMAAs while aneurysmectomy and prosthetic bypass were used most frequently for degenerative aneurysms. The operative mortality rate was 6% with a major complication rate of 17% (n = 3 patients: respiratory failure/reintubation-1, pulmonary embolism-1, necrotizing pancreatitis/graft disruption and death-1). The single death occurred in a patient with a degenerative aneurysm that developed postoperative pancreatitis and multiple organ dysfunction. The mean clinical follow-up time was 25 ± 48 (95% CI 1-48) months. The estimated primary patency, freedom from reinfection, and freedom from reintervention were 93 ± 7 %, 94 ± 5%, and 94 ± 5%, respectively, at 1 year. The overall mean survival was 55 ± 51 (95% CI 30-80) months with an estimated survival at 3 years of 77 ± 10%. CONCLUSIONS SMAAs associated with both degenerative and mycotic etiologies can be treated using a variety of surgical approaches with acceptable morbidity and mortality. Mycotic SMAAs should likely be repaired, regardless of size, while the indications for asymptomatic, degenerative aneurysms remain to be defined by further natural history studies.
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Affiliation(s)
- Christopher R Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, Georgetown University Hospital-Medstar, Washington, D.C
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
| | - Zachary H Hodges
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Samir K Shah
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
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Venermo M, Sprynger M, Desormais I, Björck M, Brodmann M, Cohnert T, De Carlo M, Espinola-Klein C, Kownator S, Mazzolai L, Naylor R, Vlachopoulos C, Ricco JB, Aboyans V. Editor's Choice – Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2019; 58:641-653. [DOI: 10.1016/j.ejvs.2019.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/08/2019] [Indexed: 10/25/2022]
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12
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Acosta S, Björgell O, Ekberg O. Prospective Study on Diagnostic Performance of Color Doppler Ultrasound Using Trans-stenotic Mean Arterial Pressure Gradient as a Reference in Stented Superior Mesenteric Artery. Ann Vasc Surg 2019; 56:294-302. [DOI: 10.1016/j.avsg.2018.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/07/2018] [Accepted: 09/20/2018] [Indexed: 12/26/2022]
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13
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Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68:256-284. [PMID: 29937033 DOI: 10.1016/j.jvs.2018.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.
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Affiliation(s)
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Firas Mussa
- Department of Surgery Palmetto Health/University of South Carolina School of Medicine, Columbia, SC
| | - Steven Leers
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Fulton
- Department of Surgery, Westchester Medical Center, Poughkeepsie, NY
| | - William Pevec
- Division of Vascular Surgery, University of California, Davis, Sacramento, Calif
| | - Andrew Hill
- Division of Vascular & Endovascular Surgery, The Ottawa Hospital & University of Ottawa, Ottawa, Ontario, Canada
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minn
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Pillai AK, Kalva SP, Hsu SL, Walker TG, Silberzweig JE, Annamalai G, Baerlocher MO, Mitchell JW, Midia M, Nikolic B, Dariushnia SR. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol 2018; 29:642-647. [PMID: 29574024 DOI: 10.1016/j.jvir.2017.11.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 11/19/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anil K Pillai
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center, Houston, Texas
| | - Sanjeeva P Kalva
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven L Hsu
- Division of Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - T Gregory Walker
- Division of Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ganesan Annamalai
- Department of Medical Imaging, University of Toronto, Mt. Sinai Hospital & University Health Network, Toronto, Ontario, Canada
| | - Mark O Baerlocher
- Department of Radiology, Royal Victoria Hospital, Barrie, Ontario, Canada
| | - Jason W Mitchell
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Mehran Midia
- Department of Diagnostic Imaging, McMaster University, Hamilton, Ontario, Canada
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, New York
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia.
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