Endovascular treatment of mesenteric ischemia

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review

OBJECTIVE

Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years.

METHODS

Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs).

RESULTS

In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I² = 84%), 26% (95% CI, 0.19-0.33; I² = 33%), and 32% (95% CI, 0.21-0.44; I² = 26%), respectively.

CONCLUSIONS

The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.

Open and Endovascular Management of Acute Mesenteric Ischaemia: A Systematic Review

BACKGROUND

Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency resulting from thromboembolic occlusion of the mesenteric vasculature. Traditional management of AMI has been open revascularisation with or without bowel resection-a procedure which carries considerable morbidity and mortality in an already unwell, compromised patient. Endovascular and more minimally invasive management approaches to AMI have been reported. Proponents of endovascular management suggest this approach may be associated with reduced morbidity and mortality compared with open surgery.

OBJECTIVES

To assess the impact of endovascular approach for AMI on mortality and need for subsequent laparotomy and/or bowel resection.

DATA SOURCES

The search bodies PubMed and Medline were interrogated.

ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

All studies in English with greater than 10 patients examining outcomes for patients undergoing endovascular intervention for acute mesenteric ischaemia were included. All patients over 18 years presenting with a diagnosis of acute mesenteric ischaemia secondary to an arterial thromboembolic source were included. Studies examining endovascular intervention alone or endovascular and open intervention were selected.

RESULTS

The 30-day mortality for endovascular approach from all 13 studies was 16-42%. Of the 7 comparative studies including results of open revascularisation, the 30-day mortality for patient treated with an endovascular approach was 15-39% versus 33-50% for open revascularisation. Laparotomy rates post-initial endovascular intervention ranged from 13 to 73%. Bowel resection post-endovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel resection in the endovascular group ranged 14-28% and 33-63% in the open cohort. Endovascular intervention also demonstrated lower median length (s) of bowel resected.

LIMITATIONS

Heterogeneity of studies and patient populations studied including selection bias.

CONCLUSIONS AND IMPLICATIONS OF FINDINGS

Endovascular management may be associated with reduced mortality and need for/length of bowel resection compared with the traditional open approach, but there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more insidious onset may garner benefit from endovascular intervention.

Risk of acute mesenteric ischemia in patients with diabetes: A population-based cohort study in Taiwan

BACKGROUND AND AIMS

Diabetes is a common and complex endocrine disorder that often results in hyperglycemia, which has been strongly implicated in several cardiovascular and cerebrovascular events that cause disability. Acute mesenteric ischemia (AMI) is a vascular emergency with high mortality rates. We conducted a population-based cohort study that utilizes data from medical claims databases to investigate whether diabetes increases the risk of AMI.

METHODS

Using claims data from Taiwan's National Health Insurance program, 66,624 diabetic patients were enrolled from 1998 to 2009, and a comparison group of 266,496 individually matched subjects without diabetes was selected. The two groups were followed up until diagnosis of AMI, death, or the end of 2011. Incidence rates of AMI were assessed in both groups. Cox proportional hazards models were used to estimate the hazard ratios of diabetes for AMI.

RESULTS

The diabetes cohort had a higher incidence rate than the comparison cohort for AMI (0.56 vs. 0.29 per 1,000 person-years). After adjusting for sex, age, comorbidity, and health system utilization, the adjusted hazard ratio of diabetes was 1.32 (95% confidence interval 1.11-1.56) for AMI. The risk of AMI associated with diabetes was greater in men (adjusted hazard ratio = 1.48, 95% confidence interval 1.17-1.87) than in women (adjusted hazard ratio = 1.17, 95% confidence interval 0.92-1.49).

CONCLUSIONS

There was an increased risk of AMI in patients with diabetes. However, further research is required to understand whether this association is causal or due to a common set of risk factors.

[Endovascular surgery in treatment of patients with acute impairment of mesenteric circulation in the stage of intestinal ischaemia]

Analysed herein are the results of endovascular revascularization of the superior mesenteric artery (SMA). The study included a total of 18 patients with acute impairment of mesenteric circulation in the stage of intestinal ischaemia. The patients underwent multispiral computed tomography (MSCT) and once impairments of blood flow in the SMA were revealed, we performed endovascular revascularization of the artery. Patency of the SMA was assessed by repeat contrast-enhanced MSCT. Thirteen (72.2%) patients were found to have occlusion in the system of the SMA and five (27.8%) were diagnosed as having significant stenoses of the SMA. All 13 patients with occlusion of the SMA underwent vacuum thrombextraction followed by transluminal balloon angioplasty (TBA). Of these, thrombotic masses were obtained in 11 (84.6%) patients. Stents were implanted in 3 cases wherein TBA turned out inefficient. The patients with haemodynamically significant stenoses of the SMA were subjected to TBA followed by stent implantation. Good roentgenoendovascular results of restoration of blood flow through the SMA and its branches were obtained in 83.4% of cases. Assessing blood parameters and patients' condition severity revealed positive dynamics or a tendency towards improvement. The mortality rate amounted to 16.6%. A conclusion drawn is that this technique is efficient and appropriate for SMA lesions of any localization.

Fractured Superior Mesenteric Artery Stent With Stent Displacement Leading to Recurrent Symptoms of Superior Mesenteric Ischemia

We report a case of a patient with recurrent symptoms of superior mesenteric ischemia 7 months after successful percutaneous angioplasty and implantation of a stent in the superior mesenteric artery (SMA). Stent fracture and stent displacement were observed. To the best of our knowledge, this is the first report of SMA stent fracture with stent displacement.

Outcome of primary percutaneous stent-revascularization in patients with atherosclerotic acute mesenteric ischemia

Background Patients with acute mesenteric ischemia (AMI) often exhibit severe co-morbidities and significant surgical risks, leading to high perioperative morbidity. Purpose To investigate the feasibility of primary percutaneous stent-revascularization (PPSR) in atherosclerotic AMI and its impact on patients' outcome. Material and Methods Retrospective analysis of 19 consecutive patients (7 women, 12 men; median age, 69 years) with AMI caused by atherosclerotic, non-embolic stenoses/occlusions of the splanchnic arteries and PPSR. Alternative minimally invasive techniques were excluded. Clinical characteristics including the Charlson Comorbidity Index adjusted by age (CCIa) and symptom duration, technical and clinical success of PPSR, clinical course, 30-day mortality, and follow-up were evaluated and compared to literature data for surgical approaches. Technical success was defined as residual stenosis of <30% in diameter. Clinical success was defined as resolution of symptoms of AMI and/or normalization of serum lactate after sole PPSR. Results The majority of patients presented with severe co-morbidities (CCIa >4 in 17 of 19 patients, 89%). Median symptom duration was 50 h. Technical and clinical success rates of PPSR were 95% (21 of 22 arteries) and 53% (10 of 19 patients). Seven patients underwent subsequent laparotomy with bowel resection in four cases. Thirty-day mortality was 42% (8 of 19 patients). Conclusion In our study population of patients with atherosclerotic AMI, severe co-morbidities, prolonged acute symptoms, and significant perioperative risks PPSR of splanchnic stenoses were technically feasible and the clinical outcome was acceptable.

Systematic review and meta-analysis of endovascular treatment for acute mesenteric ischaemia

Introduction Acute mesenteric ischaemia is associated with a significant morbidity and mortality. Endovascular techniques have emerged as a viable alternative treatment option to conventional surgery. Our objective was to conduct a systematic review of the literature and perform a meta-analysis of reported outcomes. Methods Our review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards and the protocol was registered in PROSPERO (CRD42016035667). We searched electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic lists of relevant articles to identify studies reporting outcomes of endovascular treatment for acute mesenteric ischaemia of embolic or thrombotic aetiology. We defined 30-day or in-hospital mortality and bowel resection as the primary outcome measures. We used the Newcastle-Ottawa scale to assess the methodological quality of observational studies. We calculated combined overall effect sizes using random effects models; results are reported as the odds ratio and 95% confidence interval. Results We identified 19 observational studies reporting on a total of 3362 patients undergoing endovascular treatment for acute mesenteric ischaemia. The pooled estimate of peri-interventional mortality was 0.245 (95% confidence interval 0.197-0.299), that of the requirement for bowel resection 0.326 (95% confidence interval 0.229-0.439), and the pooled estimate for acute kidney injury was 0.132 (95% confidence interval 0.082-0.204). Eight studies reported comparative outcomes of endovascular versus surgical treatment for acute mesenteric ischaemia (endovascular group, 3187 patients; surgical group, 4998 patients). Endovascular therapy was associated with a significantly lower risk of 30-day mortality (odds ratio 0.45, 95% confidence interval 0.30-0.67, P = 0.0001), bowel resection (odds ratio 0.45, 95% confidence interval 0.34-0.59, P < 0.00001) and acute renal failure (odds ratio 0.58, 95% confidence interval 0.49-0.68, P < 0.00001). No differences were identified in septic complications or the development of short bowel syndrome. Conclusion Endovascular treatment for acute mesenteric ischaemia is associated with a considerable mortality and requirement of bowel resection. However, endovascular therapy confers improved outcomes compared to conventional surgery, as indicated be reduced mortality, risk of bowel resection and acute renal failure. An endovascular-first approach should be considered in patients presenting with acute mesenteric ischaemia.

Management of Acute Mesenteric Ischemia

Background:

Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence.

Methods:

A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate.

Results:

Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review.

Conclusion:

Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis

OBJECTIVES

Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED.

METHODS

In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project.

RESULTS

The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated.

CONCLUSIONS

The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.

Percutaneous mechanical thrombectomy of superior mesenteric artery embolism

Background

The present series present three consecutive cases of successful percutaneous mechanical embolectomy in acute superior mesenteric artery ischemia. Superior mesenteric artery embolism is a rare abdominal emergency that commonly leads to bowel infarction and has a very high mortality rate. Prompt recognition and treatment are crucial for successful outcome. Endovascular therapeutic approach in patients with acute SMA embolism in median portion of its stem is proposed.

Case reports.

Three male patients had experienced a sudden abdominal pain and acute superior mesenteric artery embolism in median portion of its stem was revealed on computed tomography angiography. No signs of intestinal infarction were present. The decision for endovascular treatment was made in concordance with the surgeons. In one patient 6 French gauge Rotarex^® device was used while in others 6 French gauge Aspirex^® device were used. All patients experienced sudden relief of pain after the procedure with no signs of intestinal infarction. Minor procedural complication – rupture of a smaller branch of SMA during Aspirex^® treatment was successfully managed by coiling while transient paralytic ileus presented in one patient resolved spontaneously. All three patients remained symptom-free with patent superior mesenteric artery during the follow-up period.

Conclusions

Percutaneous mechanical thrombectomy seems to be a rapid and effective treatment of acute superior mesenteric artery embolism in median portion of its stem in absence of bowel necrosis. Follow-up of our patients showed excellent short- and long-term results.