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Sénémaud JN, Roussel A, Pellenc Q, Chardigny C, Cerceau P, Corcos O, Ben Abdallah I, Castier Y. Retrograde Open Mesenteric Stenting for Acute and Chronic Mesenteric Ischaemia: Results from an Intestinal Stroke Centre. Eur J Vasc Endovasc Surg 2021; 62:55-63. [PMID: 33965329 DOI: 10.1016/j.ejvs.2021.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/09/2021] [Accepted: 03/21/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia. METHODS Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan-Meier time to event method. RESULTS During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% - 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 - 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 - 94) and 92.4% (95% CI 72.8 - 98), respectively. CONCLUSION ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.
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Affiliation(s)
- Jean N Sénémaud
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France.
| | - Arnaud Roussel
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Quentin Pellenc
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Catherine Chardigny
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Pierre Cerceau
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Olivier Corcos
- SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Iannis Ben Abdallah
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
| | - Yves Castier
- Department of Vascular and Thoracic Surgery, Bichat Hospital, Paris (Assistance Publique Hôpitaux de Paris - AP-HP), France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Centre, Assistance Publique Hôpitaux de Paris (AP-HP), France; Université de Paris, Paris, France
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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: 67] [Impact Index Per Article: 13.4] [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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Ben Abdallah I, Sénémaud J, Alsac JM, Corcos O, Julia P, Castier Y, El Batti S. Using the OUTBACK Catheter to Overcome Aortic Reentry Issues in Retrograde Open Mesenteric Stenting. Ann Vasc Surg 2020; 68:559-562. [PMID: 32561244 DOI: 10.1016/j.avsg.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/23/2020] [Accepted: 06/01/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study was to describe the use of the OUTBACK catheter to overcome aortic reentry issues in acute mesenteric ischemia (AMI) treated by retrograde open mesenteric stenting (ROMS). TECHNIQUE The technique is demonstrated in two female patients presenting with late AMI related to flush occlusion of the superior mesenteric artery (SMA). In such cases of thrombotic AMI with clear preoperative evidence of intestinal necrosis, ROMS is the first-line revascularization technique in our intestinal stroke center. Following an open approach of the SMA through laparotomy, the SMA was punctured in a retrograde fashion. Retrograde mesenteric subintimal recanalization was initiated. In case of aortic reentry issue, the OUTBACK Elite (Cordis, Hialeah, Fl) catheter was advanced through the occlusion over a 0.014 guidewire. The aortic reentry was created by puncture of the aortic wall with the OUTBACK needle, positioned in the desired position. After low-profile balloon angioplasty of the reentry site and 0.035 guidewire exchange, ROMS was performed using balloon-expandable covered stent. CONCLUSIONS The OUTBACK catheter appears to be a safe and effective tool to overcome aortic reentry issues in ROMS. This technical tip might therefore increase the technical success rate of challenging ROMS and decrease the need for bailout bypass in the septic context of AMI.
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Affiliation(s)
- Iannis Ben Abdallah
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.
| | - Jean Sénémaud
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Jean-Marc Alsac
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Olivier Corcos
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Pierre Julia
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Yves Castier
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Salma El Batti
- Department of Vascular and Thoracic Surgery, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France; SURVI (Structure d'URgences Vasculaires Intestinales), Intestinal Stroke Center, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, Clichy, France; Department of Vascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
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