Stent placement for treatment of mesenteric artery stenoses or occlusions

Advancements in Treatment Strategies for Chronic Mesenteric Ischemia: A Comprehensive Review

Chronic mesenteric ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability in patient symptoms and the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduction of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate efficacy, patency rates, and long-term outcomes in CMI patients.

Mesenteric artery calcium scoring: a potential screening method for chronic mesenteric ischemia

Objective

A practical screening tool for chronic mesenteric ischemia (CMI) could facilitate early recognition and reduce undertreatment and diagnostic delay. This study explored the ability to discriminate CMI from non-CMI patients with a mesenteric artery calcium score (MACS).

Methods

This retrospective study included CTAs of consecutive patients with suspected CMI in a tertiary referral center between April 2016 and October 2019. A custom-built software module, using the Agatston definition, was developed and used to calculate the MACS for the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery. Scoring was performed by two blinded observers. Interobserver agreement was determined using 39 CTAs scored independently by both observers. CMI was defined as sustained symptom improvement after treatment. Non-CMI patients were patients not diagnosed with CMI after a diagnostic workup and patients not responding to treatment.

Results

The MACS was obtained in 184 patients, 49 CMI and 135 non-CMI. Interobserver agreement was excellent (intraclass correlation coefficient 0.910). The MACS of all mesenteric arteries was significantly higher in CMI patients than in non-CMI patients. ROC analysis of the combined MACS of CA + SMA showed an acceptable AUC (0.767), high sensitivity (87.8%), and high NPV (92.1%), when using a ≥ 29.7 CA + SMA MACS cutoff. Comparison of two CTAs, obtained in the same patient at different points in time with different scan and reconstruction parameters, was performed in 29 patients and revealed significant differences in MACSs.

Conclusion

MACS seems a promising screening method for CMI, but correction for scan and reconstruction parameters is warranted.

Key Points

• A mesenteric artery calcium score obtained in celiac artery and superior mesenteric artery has a high negative predictive value for chronic mesenteric ischemia and could serve as a screening tool.

• Interobserver agreement of the mesenteric artery calcium score is excellent.

• Scan and reconstruction parameters influence the mesenteric artery calcium score and warrant the development of a method to correct for these parameters.

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.

Clinical management of chronic mesenteric ischemia

This

This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, ‘s-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam

review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization.

Percutaneous transluminal angioplasty and stenting in the management of chronic mesenteric angina: A single center experience

INTRODUCTION

The objective of our study was to review the results of percutaneous angioplasty (PTA)/stenting in the treatment of patients who presented with symptoms and angiographic findings of chronic mesenteric ischemia (CMI).

MATERIALS AND METHODS

We performed a retrospective analysis of 13 consecutive patients from a single institution who underwent PTA/stenting for the treatment of symptoms suggestive of CMI.

RESULTS

All 13 patients in our study were men, and most common presenting symptoms were weight loss and postprandial pain. Atherosclerosis was the most common cause. PTA and stenting was performed in 9 patients and PTA alone was done in 4 patients. Primary technical success rate was 92% with complete resolution of symptoms within 2 weeks in all patients. No statistical difference was noted in primary clinical success rate based on the number of vessels treated or the method of treatment. However, in patients whom SMA was treated had longer duration of symptom-free survival as compared to other vessels.

CONCLUSION

PTA and stenting are very effective therapeutic options for patients presenting with CMI symptoms. It should be considered as the first-line of management in such patients.

Chronic Visceral Ischemia: Symptom-Free Survival After Open Surgical Repair

A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p<0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7–21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8–21.9; p< 0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.

Treatment of a Totally Occluded Superior Mesenteric Artery Facilitated by Retrograde Crossing via Collaterals from the Celiac Artery

Purpose:

To present a new approach route for recanalization of a chronically occluded superior mesenteric artery (SMA).

Technique:

Percutaneous treatment of an SMA occlusion can be accomplished in some cases via retrograde crossing through collaterals from the celiac artery. From a right common femoral artery (CFA) approach, an 8-F RDC guide catheter is advanced to the origin of the celiac artery via. Using a 5-F angled Glidecath, a long 0.035-inch stiff Glidewire, and a Choice PT wire, the glide catheter is advanced via the celiac artery into the superior pancreaticoduodenal artery. Using the angled Glidewire and the Choice PT wire, the occluded SMA is cannulated in a retrograde fashion. Through an 8-F sheath in the left CFA, an 8-F RDC guide catheter is advanced into the abdominal aorta. A goose neck snare is used to capture the Choice wire, which is withdrawn through the left catheter and sheath. The SMA occlusion is dilated, and the RDC guide is advanced into the SMA origin over the balloon. Another Choice PT wire and a 0.035-inch Wholey High Torque wire are placed in an antegrade fashion through the now open SMA. Angioplasty and stenting are then completed in the SMA over the Wholey wire.

Conclusion:

Retrograde recanalization of the SMA via celiac collaterals offers a new endovascular approach to treating patients with chronic mesenteric ischemia and a chronically occluded SMA.

Early Outcome of Treatment of Chronic Mesenteric Ischemia

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Chronic mesenteric ischemia and therapeutic paradigm of mesenteric revascularization

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.

Ischemic bowel syndromes

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.

Mesenteric artery complications during angioplasty and stent placement for atherosclerotic chronic mesenteric ischemia

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.

Chronic mesenteric ischemia: diagnosis and management

Chronic mesenteric ischemia (CMI) is the most common vascular disorder involving the intestines, however it is unusual in clinical practice. The redundancy of the visceral circulation with multiple interconnections between the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA) is the most likely explanation for the infrequent occurrence of CMI in clinical practice. Atherosclerosis is by the far the most common etiology of CMI. The increased utilization of diagnostic abdominal cross-sectional imaging has increased the recognition of atherosclerotic mesenteric stenoses. CMI is a clinical diagnosis, based upon symptoms and consistent anatomic findings. The classic setting for CMI is a female patient presenting with post-prandial abdominal discomfort that results in significant weight loss. Endovascular therapy with stenting has become the most common method chosen for revascularization having replaced open surgery with its associated morbidity and mortality.

Acute thrombotic mesenteric ischemia: primary endovascular treatment in eight patients

INTRODUCTION

The purpose of this study was to evaluate our experience with initial percutaneous transluminal angioplasty (PTA) ± stenting as valuable options in the acute setting.

METHODS

Between 2003 and 2008, eight patients with abdominal angio-MDCT-scan proven thrombotic AMI benefited from initial PTA ± stenting. We retrospectively assessed clinical and radiological findings and their management. Seven patients presented thrombosis of the superior mesenteric artery, and in one patient both mesenteric arteries were occluded. All patients underwent initial PTA and stenting, except one who had balloon PTA alone. One patient was treated by additional in situ thrombolysis.

RESULTS

Technical success was obtained in all patients. Three patients required subsequent surgery (37.5%), two of whom had severe radiological findings (pneumatosis intestinalis and/or portal venous gas). Two patients (25%) died: both had NIDD, an ASA score ≥4, and severe radiologic findings. Satisfactory arterial patency was observed after a follow-up of 15 (range, 11-17) months in five patients who did not require subsequent surgery, four of whom had abdominal guarding but no severe CT scan findings. One patient had an ileocecal stenosis 60 days after the procedure.

CONCLUSIONS

Initial PTA ± stenting is a valuable alternative to surgery for patients with thrombotic AMI even for those with clinical peritoneal irritation signs and/or severe radiologic findings. Early surgery is indicated if clinical condition does not improve after PTA. The decision of a subsequent surgery must be lead by early clinical status reevaluation. In case of underlying atherosclerotic lesion, stenting should be performed after initial balloon dilatation.

Chronic mesenteric ischemia: endovascular versus open revascularization

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.

Endovascular treatment of chronic arterial mesenteric ischemia: a changing perspective?

Endovascular treatment for chronic mesenteric ischemia is growing in popularity because of its lower periprocedural morbidity and mortality than open surgery. It is especially suitable for the high-risk surgical candidate and for those who have a poor nutritional state, although endovascular surgery may not be possible in patients with ostial occlusions or heavily calcified vessels. A positive response to angioplasty is helpful to secure a diagnosis in patients with slightly atypical symptoms. There are little data at present to suggest that primary stenting is better than angioplasty alone, but insertion of a stent may be valuable as a rescue procedure following dissection, vascular recoil, or thrombosis during angioplasty. The superior mesenteric artery is probably the most important vessel to treat but, where this is impossible, celiac or inferior mesenteric artery dilatation may have therapeutic benefit. However, there is some evidence at present favoring multiple, as opposed to single-vessel, angioplasty or stenting. Long-term patency is better after mesenteric bypass, which may be preferred in the younger and fitter patient. Treatment of the celiac artery compression syndrome is primarily surgical, but stent insertion may have a role as a secondary procedure where there is a residual stenosis after median arcuate ligament division.

Open or percutaneous revascularization for chronic splanchnic syndrome

BACKGROUND

Treatment of chronic splanchnic syndrome remains controversial. In the past 10 years, endovascular repair (ER) has replaced open repair (OR) to some extent. This evidence summary reviews the available evidence for ER or OR of chronic splanchnic syndrome.

METHODS

A systematic literature search of MEDLINE database was performed to identify all studies that evaluated treatment of chronic splanchnic syndrome between 1988 and 2009.

RESULTS

The best available evidence consists of prospectively accumulated but retrospectively analyzed data with a high risk for confounding. Only a few of these studies incorporated functional tests to assess splanchnic ischemia before or after treatment. ER has the advantage of low short-term morbidity but the disadvantage of decreased long-term primary patency compared with OR. ER and OR have similar rates of secondary patency, although the reintervention rate after ER is higher.

CONCLUSION

ER appears to be preferential in the treatment of elderly patients and in patients with comorbidity, severe cachexia, or hostile abdomen. Long-term results after OR are excellent. OR can still be proposed as the preferred option for relatively young and fit patients.

Outcomes of endovascular and open treatment for chronic mesenteric ischemia

PURPOSE

To measure contemporary practice patterns and compare outcomes of open and endovascular repair for chronic mesenteric ischemia (CMI).

METHODS

The New York State Health Department Statewide Planning and Research Cooperative System database was queried for the ICD-9-CM codes for CMI for the years 2000 to 2006. In this time period, 6549 patients were evaluated for CMI in New York State. Of these patients, 666 received an intervention and underwent either open (n = 280) or endovascular (n = 347) repair; 39 patients underwent both treatments and were excluded. Trends in operative management and short-term outcomes were analyzed.

RESULTS

Over the 7-year study period, there was a steady increase in the number of endovascular procedures from 28% in 2000 to 75% in 2006. The overall mortality rate for the 7-year period was significantly lower for endovascular versus open repair (11.0% versus 20.4%, respectively; p = 0.0011). Endovascular repair was associated with a significantly lower rate of mesenteric ischemic complications compared to open repair (6.92% versus 17.1%, respectively; p<0.0001). Moreover, compared with open surgery, endovascular repair resulted in significantly lower rates of cardiac, pulmonary, and infectious complications (p<0.05). Only 37% of patients having open repair were discharged home compared to 55% of patients treated with endovascular procedures (p<0.0001).

CONCLUSION

The number of patients treated for CMI continues to increase and correlates with the increasing utilization of endovascular procedures. The patients undergoing endovascular treatment had fewer complications, lower in-hospital mortality, and a greater likelihood of being discharged home.

Open and endovascular revascularization for chronic mesenteric ischemia: tabular review of the literature

Chronic mesenteric ischemia is an uncommon disease in vascular surgery practice worldwide. Open revascularization remains the best treatment for low-risk patients due to durability and efficacy. Endovascular revascularization for chronic mesenteric ischemia was primarily indicated for elderly and higher-risk patients, but this has changed over the past 10 years due to development of more precise devices and lower morbidity and mortality rates despite the higher recurrence and restenosis rates. Our purpose was to summarize the data on endovascular and open revascularization for chronic mesenteric ischemia in a schematic tabular presentation.

Spontaneous splanchnic dissection: application and timing of therapeutic options

BACKGROUND

Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes.

METHODS

Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3).

RESULTS

All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management.

CONCLUSION

Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Percutaneous endovascular treatment for isolated spontaneous superior mesenteric artery dissection: report of two cases and literature review

Isolated spontaneous superior mesenteric artery (SMA) dissection is a rare and sporadically reported condition. Therapeutic options include medical treatment, surgery, and endovascular treatment. However, the optimal treatment strategy has still not been established. We herein present two patients with acute abdomen due to isolated spontaneous SMA dissection, in whom symptoms remained despite initial anticoagulation therapy. Percutaneous endovascular treatment with stenting of the dissected main trunk to achieve complete coverage of the entry site and balloon angioplasty for the distally involved side branches were performed successfully and resulted in complete resolution of the symptoms. According to our experience and previous case reports, early (within 1 week) elective percutaneous endovascular intervention with background anticoagulation therapy is a feasible and effective treatment strategy for symptomatic patients with isolated SMA dissection.

Surgical Versus Endovascular Reconstruction for Chronic Mesenteric Ischemia: A Contemporary UK Series

Objective: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI). Methods: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (<30 days; technical success, morbidity, mortality, length of hospital stay) and late (>30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed. Results: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P ≥ .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%). Conclusions: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.

Mesenteric ischemia in the elderly

Intestinal ischemia is a relatively common disorder in the elderly and, if not treated promptly, still carries a high morbidity and mortality rate. High degree of clinical suspicion is of paramount importance in diagnosis, because there is no specific laboratory test available and physical examination findings may be subtle. Once the diagnosis is made, management relies on early resuscitation, identification, and treatment of the predisposing conditions, along with careful planning of the therapeutic invasive interventions, which altogether may help reduce the mortality and morbidity associated with this condition.

Management of chronic mesenteric ischemia. The role of endovascular therapy

Chronic mesenteric ischemia is an uncommon disorder manifested most commonly as abdominal pain. Surgical revascularization has traditionally been the treatment of choice. Endovascular management of this entity was originally attempted as an alternative for high-risk patients. Improvements in stent technology, refinement in technique, and increased efficiency of antiplatelet regimens have, over time, increased the popularity of this minimally invasive approach. We present a review of the available series on endovascular treatment of chronic mesenteric ischemia, with emphasis on short- and long-term outcome and morbidity and mortality results. Principles of operative technique and controversial issues and topics of interest are also discussed.

Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience

INTRODUCTION

Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI.

METHODS

During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence.

RESULTS

Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin<3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P<.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49).

CONCLUSIONS

Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.

CTA and MRA in Mesenteric Ischemia: Part 2, Normal Findings and Complications After Surgical and Endovascular Treatment

OBJECTIVE

A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting.

CONCLUSION

We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.

Successful Percutaneous Transluminal Angioplasty and Stenting in Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a life-threatening emergency. The complications are high by the time of diagnosis in most cases and therefore only few data on primary percutaneous intervention with percutaneous transluminal angioplasty (PTA) and stenting in AMI are available. We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea. She had previously undergone percutaneous transluminal embolectomy for an acute occlusion of the left common femoral artery. Due to suspicion of intestinal infarction, conventional angiography of the aorta and the superior mesenteric artery (SMA) was performed and confirmed a proximal occlusion of the SMA. Percutaneous SMA recanalization with balloon dilation and subsequent stent implantation was carried out successfully. The abdominal symptoms subsided after this procedure. In AMI that is diagnosed early, endovascular stenting should be considered as an alternative treatment to the surgical approach that avoids the need for surgical bowel resection.

Chronic mesenteric ischemia: stenting of mesenteric arteries

This article focuses on stent placement in mesenteric arteries in patients with the rare diagnosis of chronic mesenteric ischemia. We present a survey from the initial stage of recognition of this gastrointestinal disorder and its manifestations to treatment by stenting to avoid further ischemic episodes and bowel infarction and necrosis. The advantages of stent placement in splanchnic arteries are discussed in comparison to open surgical revascularization.

A clinical survey of vascular stents

As a result of the many different potential locations to be treated, it is still difficult to evaluate the indications for efficacy and safety of non-coronary percutaneous transluminal angioplasty (PTA) and stenting versus surgical methods, such as endarterectomy or bypass grafts. This paper reviews pertinent data published in the last 5-10 years and gives an overview of the main peripheral minimally invasive vascular interventional fields.

Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes

BACKGROUND

Percutaneous therapy for symptomatic visceral occlusive disease is rapidly gaining popularity in many centers. This study evaluates the anatomic and functional outcomes of open and endovascular therapy for chronic mesenteric ischemia at an academic medical center.

STUDY DESIGN

We performed a retrospective review of patients who underwent endovascular or open mesenteric arterial revascularization for chronic mesenteric ischemia between January 1989 and September 2003. Indications for revascularization included postprandial abdominal pain (92%) or weight loss (54%). All had atherosclerotic visceral occlusive disease with a median of 2 vessels with more than 50% stenosis or occlusion on angiography. Sixty patients (44 women, mean age 66 years) underwent 67 interventions (43 vessels bypassed, 23 vessel endarterectomies, 22 vessel angioplasty and stents). The median numbers of vessels revascularized were two in the open group and one in the endovascular group.

RESULTS

Thirty-day mortality and cumulative survival at 3 years were similar (open, 15% and 62% +/- 9%; endovascular, 21% and 63%+/-14%, respectively; p=NS). Cumulative patencies at 6 months were 83%+/-7% and 68%+/-14% in the open and endovascular groups, respectively (p=NS). Major morbidity, median postoperative length of stay, and cumulative freedom from recurrent symptoms at 6 months were significantly greater in the open group (open, 46%, 23 days, and 71%+/-7%, respectively; endovascular, 19%, 1 day, and 34%+/-10%, respectively; p < 0.01).

CONCLUSIONS

Endovascular revascularization is attractive because it carries equivalent patency to open revascularization. Symptomatic benefit of endovascular revascularization is not achieved, probably as a result of incomplete revascularization. Despite incomplete revascularization, endovascular therapy has equivalent survival and lower morbidity compared with open revascularization. Complete endovascular revascularization needs further evaluation to determine if it is superior to open revascularization. In the interim, endovascular therapy should be reserved for the patient unable to undergo open revascularization.

Stent Placement with the Monorail Technique for Treatment of Mesenteric Artery Stenosis

PURPOSE

To analyze the immediate and midterm success of stenting of mesenteric arteries by a monorail technique in patients with chronic mesenteric ischemia.

MATERIALS AND METHODS

In this prospective case series, 19 patients (11 male, 8 female; mean age, 62.9 +/- 10.4 y; range, 36-82 y) with 23 symptomatic stenoses of mesenteric arteries were treated with stent placement by a monorail technique in a radiologic intervention center over a period of 4.5 years. Clinical examinations and duplex sonography were used to evaluate the stents' patency and clinical success. Kaplan-Meier graphs were calculated to analyze the patency and freedom-from-symptom rate.

RESULTS

Initial technical success rate was 22/23 (96%). Mean follow-up was 17 months (range, 1-58 mo). Primary patency and primary clinical success rates were 82% and 78%, respectively. According to Kaplan-Meier tables, the patency rates were 96%, 87%, 76%, and 61% at 0, 1, 15, and 24 months, respectively, and the freedom-from-symptom rates were 95%, 90%, 72%, and 54% at 0, 1, 24, and 30 months, respectively. No peri-interventional complications occurred. Two patients died of cardiac failure in the hospital within 30 days after intervention; deaths were not related to the intervention.

CONCLUSIONS

Stent placement by a monorail technique in mesenteric arteries is an effective and safe treatment for symptomatic stenoses in patients with chronic mesenteric ischemia after a mean follow-up of 17 months.

Percutaneous management of chronic mesenteric ischemia: outcomes after intervention

PURPOSE

To assess the efficacy and durability of percutaneous transluminal angioplasty (PTA)/stent placement for treatment of chronic mesenteric ischemia (CMI).

MATERIALS AND METHODS

A retrospective review of patients treated from January 1986 to August 2003 was conducted. Twenty-nine patients (mean age, 62 years) were treated for clinical symptoms consistent with CMI. Clinical diagnosis was verified with angiographic assessment and PTA with or without stent placement was performed based on angiographic and/or pressure gradient findings. Outcomes were estimated with the Kaplan-Meier method.

RESULTS

A total of 63 interventions were performed in 29 patients during the study period. Of these 63 interventions, 46 PTA and 17 stent implantation procedures were performed. Thirty-four interventions were performed for SMA stenosis/occlusion, 17 interventions for celiac artery stenosis/occlusion, and four interventions were performed on aorto-mesenteric graft stenoses. Technical success was 97%, and clinical success (defined as clinical resolution of symptoms) was 90% (26 of 29 patients). Mean duration of follow-up was 28.3 months. Primary patency for all interventions at 3, 6, and 12 months was 82.7% (95% CI: 68.7-96.7), 78.9% (66.7-91.1), and 70.1% (55.1-85.6), respectively. Primary assisted patency for all interventions at 3, 6, and 12 months was 87.9% (79.0-95.3), 87.9% (79.2-95.1), and 87.9% (77.3-98.3), respectively. An average of 1.9 interventions per patient was required. One major complication occurred (3.4%). There were three minor complications (10.3%).

CONCLUSIONS

Percutaneous intervention for CMI is safe with durable early and midterm clinical success. However, repeated intervention is often required for improved primary assisted patency.

Endovascular treatment of arterial mesenteric ischaemia: a retrospective review

Mesenteric ischaemia is a condition that has traditionally been managed surgically. It poses a challenging diagnostic and therapeutic problem, particularly in the acute setting. We review a small series of eight patients managed with endovascular techniques for either acute or chronic mesenteric ischaemia at The Royal Melbourne Hospital, from 1997 to 2002. We describe our results and relate these to the recent published literature regarding endovascular and surgical management of mesenteric ischaemia. Our experience confirms the valuable contribution of angioplasty and stenting in chronic mesenteric ischaemia, which compares favourably with surgery with regards to complication rates and mortality. We suggest the need for further studies to compare the long-term efficacy of endovascular techniques compared with surgery in the management of chronic mesenteric ischaemia. Furthermore, we demonstrate a role for endovascular management in acute mesenteric ischaemia, in the appropriate clinical setting.

Chronic Mesenteric Ischemia Resulting from Isolated Lesions of the Superior Mesenteric Artery

Atherosclerosis is a common cause of chronic mesenteric ischemia, generally affecting 2 or more arterial branches supplying the gut. The authors present a case in which symptomatic mesenteric ischemia was the result of 2 tandem atherosclerotic lesions in the superior mesenteric artery. Both the celiac axis and inferior mesenteric arteries were fully patent. The patient experienced complete relief of symptoms after percutaneous deployment of an intravascular stent across the proximal arterial narrowing. The case also documents the existence of an atheroma in a distal mesenteric artery.

Damage control surgery and angiography in cases of acute mesenteric ischaemia

BACKGROUND

Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60-80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia.

METHODS

A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed.

RESULTS

Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel.

CONCLUSIONS

Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2-3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available.

Mesenteric stenting for chronic mesenteric ischemia

BACKGROUND

Mesenteric stenting has not been widely adopted for the treatment of chronic mesenteric ischemia (CMI). The recent availability of embolic protection and low-profile devices with the theoretical ability to decrease perioperative bowel necrosis, led us to begin using mesenteric stenting for patients with CMI. We review our initial experience to examine short-term outcomes.

METHODS

We performed a retrospective analysis of all patients who were treated by vascular surgeons with mesenteric stenting for CMI. Patients with acute mesenteric ischemia were excluded. We evaluated perioperative morbidity and mortality, restenosis, recurrent symptoms, and reintervention. Kaplan-Meier methods were used to assess events during follow-up. We also compared these outcomes with a historical control group of patients treated with open surgical revascularization.

RESULTS

Fourteen patients underwent mesenteric stenting over the past 3 years. Mean age was 73, and 64% were women. There was no perioperative or 30-day mortality or major morbidity. Early restenosis and recurrent symptoms occurred in 10% and 9% of patients at 6 months. At a mean follow-up of 13 months, 53% of patients underwent reintervention. However, 93% were symptom-free at their last follow-up. Compared with open surgery, stent patients had lower perioperative major morbidity (30% vs 0%, P < .01) and shorter hospital and intensive care unit length of stay (median 10 days vs 2 days, and 3 days vs 0 days, respectively, P < .01 for both). However, stent patients were seven times as likely to develop restenosis (P < .01), four times more likely to develop recurrent symptoms (P < .01), and 15 times more likely to undergo reintervention (P < .01). There was one death 13 months after stenting due to mesenteric infarction in a patient lost to follow-up. One patient was successfully converted to open surgery after a second restenosis. He had regained 20 pounds and was determined to be a better operative candidate than at his initial presentation. There was no perioperative or 30-day mortality or major morbidity with reintervention after mesenteric stenting.

CONCLUSION

Mesenteric stenting for CMI can be performed with low perioperative risk. However, stenting is associated with early restenosis and recurrent symptoms requiring secondary procedures. Patients with severe nutritional depletion or high surgical risk may benefit from mesenteric stenting for CMI, but close follow-up is required. Later open surgery can be performed for restenosis if nutritional status and surgical risk are improved, or repeat angioplasty and stenting can be effectively performed if operative risk remains high.

Endovascular Recanalisation in Occlusive Mesenteric Ischemia—Feasibility and Early Results

OBJECTIVE

To evaluate a single centre experience of endovascular treatment of mesenteric ischemia caused by vascular occlusion.

DESIGN

Retrospective study.

MATERIAL AND METHODS

Between 1995 and 2002 17 patients (12 females; mean age 61 years) with symptoms of bowel ischemia were treated endovascularly for arterial occlusion. Vessels were evaluated with angiography and pressure gradient measured. A mean gradient of > 20 mmHg or a stenosis of > 50% was considered significant. Patient data were recorded prospectively and follow-up was supplemented with retrospective chart review. Fifteen patients had follow up imaging, median 10 months (3-29 months) postoperatively. Median clinical follow up was 14 months (5-42 months).

RESULTS

Recanalisation was successful in 16 patients (94%). The average number of stents used was 1.6 per patient. For one patient recanalisation failed with subsequent SMA dissection. A celiac artery stenosis was stented but symptoms remained postoperatively. Perioperative mortality was 5.8% (n = 1). 14/17 patients (82%) displayed symptom relief/improvement. Six patients required secondary endovascular intervention; PTA (n = 3); stent/stentgraft (n = 3). Two of these patients required a third procedure. 4/6 patients that underwent secondary intervention were asymptomatic and of recurrent stenosis > 75% and a gradient > 15 mmHg mean pressure gradient on imaging. Two patients were treated because of a combination of angiographic findings and/or significant pressure gradient combined with clinical symptoms.

CONCLUSIONS

Endovascular treatment of mesenteric ischemia due to vessel occlusion is feasible with acceptable short-term results and limited complications. Most patients experience relief/improvement of symptoms. A significant number of patients might need endovascular re-intervention because of restenosis.

Endovascular treatment of chronic mesenteric ischemia: results in 14 patients

We evaluated immediate and long-term results of percutaneous transluminal angioplasty (PTA) and stent placement to treat stenotic and occluded arteries in patients with chronic mesenteric ischemia. Fourteen patients were treated by 3 exclusive celiac artery (CA) PTAs (2 stentings), 3 cases with both Superior Mesenteric Artery (SMA) and CA angioplasties, and 8 exclusive SMA angioplasties (3 stentings). Eleven patients had atheromatous stenoses with one case of an early onset atheroma in an HIV patient with antiphospholipid syndrome. The other etiologies of mesenteric arterial lesions were Takayashu arteritis (2 cases) and a postradiation stenoses (1 case). Technical success was achieved in all cases. Two major complications were observed: one hematoma and one false aneurysm occurring at the brachial puncture site (14.3%). An immediate clinical success was obtained in all patients. During a follow-up of 1-83 months (mean: 29 months), 11 patients were symptom free; 3 patients had recurrent pain; in one patient with inflammatory syndrome, pain relief was obtained with medical treatment; in 2 patients abdominal pain was due to restenosis 36 and 6 months after PTA, respectively. Restenosis was treated by PTA (postirradiation stenosis), and by surgical bypass (atheromatous stenosis). Percutaneous endovascular techniques are safe and accurate. They are an alternative to surgery in patients with chronic mesenteric ischemia due to short and proximal occlusive lesions of SMA and CA.

Endovascular Management of Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a rare condition caused by occlusive disease of the mesenteric vessels. While the traditional therapy in symptomatic patients has been surgery, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Mesenteric angioplasty and stenting has a technical success rate of 80 to 100% with a clinical efficacy of 80 to 95%. Published studies indicate a primary patency of 75 to 85%. This article presents a review of the literature and the technical aspects of the procedure.

Angioplasty/stenting of the superior mesenteric artery and celiac trunk: early and late outcomes

PURPOSE

To analyze the early results and durability of angioplasty/stenting of the superior mesenteric artery (SMA) and celiac trunk (CT).

METHODS

Twenty-two patients (19 women; mean age 69.2 years, range 52-88) with 24 symptomatic SMA or CT stenotic lesions were treated with dilation/stenting over a recent 4.5-year period. Two patients had lesions in both the SMA and CT treated. Clinical follow-up and duplex exams were done to evaluate long-term patency. Kaplan-Meier life-table analyses estimated the freedom from recurrent stenosis and recurrent symptoms, as well as survival rates.

RESULTS

The initial technical and clinical success rates were 96% (23/24) and 95% (21/22), respectively, with no perioperative mortality or major morbidity. During a mean follow-up of 26 months (range 1-54), the primary late clinical success rate was 61% (11/18; 4 lost to follow-up), and freedom from recurrent stenosis (> or =70%) was 30% (6/20). The freedom from recurrent stenosis at 1, 2, 3, and 4 years were 65%, 47%, 39%, and 13%; freedom from recurrent symptoms was 67% at all 4 intervals. The survival rates were 93%, 93%, 80%, and 53% at 1 to 4 years, respectively.

CONCLUSIONS

Angioplasty/stenting of SMA and CT stenoses has a high initial technical success rate and acceptable early and late clinical outcomes; however, it is associated with a high incidence of late restenosis based on strict Doppler criteria.