Acute mesenteric vascular occlusion: analysis of 39 patients

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies

AIM

The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes.

METHOD

A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model.

RESULTS

The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82).

CONCLUSION

In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.

Identification of risk factors for perioperative mortality in acute mesenteric ischemia

INTRODUCTION

Acute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI).

METHODS

A total of 132 consecutive patients (73 men, 59 women), mean+/-SD age 71.96+/-13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality.

RESULTS

Of 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P=0.01), cardiopathy (P=0.002), digoxin intake (P=0.015), shock (P=0.01), urea plasma level (P<0.001), creatinine (P<0.001), potassium (P=0.042), low pH (P=0.015) and bicarbonate (P=0.035); hemoglobin>or=2.48 mmol/L (P=0.035); time delay to surgery (P=0.023); colonic involvement (P<0.001); small and large bowel involvement (P<0.001); arterial versus venous ischemia (P=0.007); and intestinal resection (P<0.001). In the multivariate analysis, the variables previous cardiac illness (P=0.045), urea plasma levels (P<0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P<0.001) was a favorable predictor.

CONCLUSIONS

Age, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.

Systematic review of survival after acute mesenteric ischaemia according to disease aetiology

BACKGROUND

Differentiation of acute mesenteric ischaemia on the basis of aetiology is of great importance because of variation in disease progression, response to treatment and outcome. The aim of this study was to analyse the published data on survival following acute mesenteric ischaemia over the past four decades in relation to disease aetiology and mode of treatment.

METHOD

A systematic review of the available literature from 1966 to 2002 was performed.

RESULTS

Quantitative analysis of data derived from 45 observational studies containing 3692 patients with acute mesenteric ischaemia showed that the prognosis after acute mesenteric venous thrombosis is better than that following acute arterial mesenteric ischaemia; the prognosis after mesenteric arterial embolism is better than that after arterial thrombosis or non-occlusive ischaemia; the mortality rate following surgical treatment of arterial embolism and venous thrombosis (54.1 and 32.1 per cent respectively) is less than that after surgery for arterial thrombosis and non-occlusive ischaemia (77.4 and 72.7 per cent respectively); and the overall survival after acute mesenteric ischaemia has improved over the past four decades.

CONCLUSION

There are large differences in prognosis after acute mesenteric ischaemia depending on aetiology. Surgical treatment of arterial embolism has improved outcome whereas the mortality rate following surgery for arterial thrombosis and non-occlusive ischaemia remains poor.

Contemporary management of acute mesenteric ischemia: Factors associated with survival

PURPOSE

Acute mesenteric ischemia (AMI) is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the results of current management and the examination of factors associated with survival, we reviewed our experience.

METHODS

The clinical data of all the patients who underwent operation for AMI between January 1, 1990, and December 31, 1999, were retrospectively reviewed, clinical outcome was recorded, and factors associated with survival rate were analyzed.

RESULTS

Fifty-eight patients (22 men and 36 women; mean age, 67 years; age range, 35 to 96 years) underwent study. The cause of AMI was embolism in 16 patients (28%), thrombosis in 37 patients (64%), and nonocclusive mesenteric ischemia (NMI) in five patients (8.6%). Abdominal pain was the most frequent presenting symptom (95%). Twenty-five patients (43%) had previous symptoms of chronic mesenteric ischemia. All the patients underwent abdominal exploration, preceded with arteriography in 47 (81%) and with endovascular treatment in eight. Open mesenteric revascularization was performed in 43 patients (bypass grafting, n = 22; thromboembolectomy, n = 19; patch angioplasty, n = 11; endarterectomy, n = 5; reimplantation, n = 2). Thirty-one patients (53%) needed bowel resection at the first operation. Twenty-three patients underwent second-look procedures, 11 patients underwent bowel resections (repeat resection, n = 9), and three patients underwent exploration only. The 30-day mortality rate was 32%. The rate was 31% in patients with embolism, 32% in patients with thrombosis, and 80% in patients with NMI. Multiorgan failure (n = 18 patients) was the most frequent cause of death. The cumulative survival rates at 90 days, at 1 year, and at 3 years were 59%, 43%, and 32%, respectively, which was lower than the rate of a Midwestern white control population (P <.001). Six of the 16 late deaths (38%) occurred because of complications of mesenteric ischemia. Age less than 60 years (P <.003) and bowel resection (P =.03) were associated with improved survival rates.

CONCLUSION

The contemporary management of AMI with revascularization with open surgical techniques, resection of nonviable bowel, and liberal use of second-look procedures results in the early survival of two thirds of the patients with embolism and thrombosis. Older patients, those who did not undergo bowel resection, and those with NMI have the highest mortality rates. The long-term survival rate remains dismal. Timely revascularization in patients who are symptomatic with chronic mesenteric ischemia should be considered to decrease the high mortality rate of AMI.