Management of patients with chronic mesenteric ischemia across three consecutive eras

Endovascular inferior mesenteric artery revascularisation for chronic mesenteric ischaemia in selected clinical scenarios

Background: Experience on endovascular inferior mesenteric artery (IMA) revascularisation for atherosclerotic chronic mesenteric ischaemia (CMI) is limited and its clinical benefit remains uncertain. Patients and methods: This retrospective single-centre study included 12 patients with CMI who underwent endovascular IMA revascularisation between January 2014 and January 2024. Indications were: (1) IMA stenosis with endoscopically confirmed colonic ischaemia, (2) IMA stenosis with retrograde filling of a proximally occluded superior mesenteric artery ineligible for revascularisation, and (3) overall improvement of collateralisation in critical CMI due to multi-vessel disease. Technical success, clinical success and primary clinical patency were assessed. Procedure-related adverse events, symptom recurrence, mortality and survival rates were also analysed. Results: Seven isolated IMA interventions and five IMA revascularisations as part of a multi-vessel approach were performed. Balloon-expandable stents were used in 11 cases; one patient underwent balloon angioplasty with intravascular lithotripsy. Technical success was 83% (10/12); two cases had >50% residual stenosis due to annular aortic calcification impeding stent expansion. Median final residual stenosis was 27% (IQR 23.5). Four minor procedure-related adverse events occurred. Clinical success was 92% (11/12). Median follow-up was 17 months (IQR 20.7). The all-cause mortality rate was 25% (3/12). The mesenteric ischaemia-related mortality rate was 8% (1/12). The symptom recurrence rate was 33% (4/12). At 6 and 12 months, primary clinical patency rates were 71% and 54%, and survival rates were 83% and 72%. Conclusions: Endovascular IMA revascularisation is a viable treatment for CMI in selected scenarios where other options are inappropriate. Despite the specific calcification pattern at the IMA origin predisposing to residual stenosis, most patients had symptom resolution and acceptable clinical patency with low recurrence and mortality rates. However, 33% of patients had early symptom recurrence requiring treatment. It remains difficult to assess whether IMA revascularisation is curative or a bridge to open revascularisation.

Renal and Mesenteric Artery Intervention

Atherosclerotic disease of the abdominal aorta and its visceral branches poses significant health risks due to its potential to cause severe complications. Atherosclerosis affects renal and mesenteric vessels, contributing to renal artery stenosis and mesenteric ischemia, respectively, both of which can result in organ damage and ischemic bowel disease if left untreated. Therapy with guideline-directed medical therapy is advised in all patients. Chronic mesenteric ischemia (CMI) is infrequent and difficult to diagnose illness. Current evidence suggests that compared with open surgical repair, in anatomically suitable lesions, endovascular therapy is the most cost-effective choice for patients with CMI.

Covered Versus Bare-Metal Stents in Chronic Mesenteric Ischemia Treatment: A Systematic Review and Meta-Analysis

BACKGROUND

The main treatment for chronic mesenteric ischemia (CMI) is revascularization, typically achieved through stent angioplasty of the superior mesenteric artery, and in certain cases, the celiac trunk. However, long-term outcomes using bare-metal stents (BMSs) have been less than satisfactory. Therefore, we aimed to compare the performance of covered stents (CSs) versus BMSs in patients treated for CMI.

METHODS

Pubmed, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of patients with CMI who underwent stenting procedures using BMS or CS. The main outcomes were primary patency and freedom from reintervention. Statistical analysis was performed using R version 3.6.

RESULTS

One randomized clinical trial and 5 observational studies were included. In the pooled analysis, patients undergoing the covered stenting approach had a higher primary patency (hazard ratio 0.40; 95% confidence interval 0.23-0.68; P < 0.01). Additionally, CS also demonstrated significantly superior freedom from reintervention when compared to BMS patients (hazard ratio 0.30; 95% confidence interval 0.13-0.71; P < 0.01).

CONCLUSION

In patients undergoing transluminal angioplasty with stent placement both in the celiac trunk and superior mesenteric artery, the use of CS indicated superior primary patency and a higher rate of freedom from reintervention than BMS. These findings indicate superior outcomes with CS and may suggest their use as the preferred stent option in patients with CMI. However, these findings should be interpreted cautiously due to the limited number of studies, the moderate to serious risk of bias in the included data, and the significant heterogeneity observed. Further high-quality clinical trials are necessary to validate these results and strengthen the evidence base for clinical practice.

Natural history of superior mesenteric artery in-stent restenosis

OBJECTIVE

Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence.

METHODS

Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350.

RESULTS

The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups.

CONCLUSIONS

The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.