Acute and chronic mesenteric ischemia: single center analysis of open, endovascular, and hybrid surgery

Percutaneous Endovascular versus Open Non-Endovascular Treatment for Chronic Mesenteric Ischemia-A Meta-Analysis

PURPOSE

Aim of this review is to compare pooled data on early and late outcomes between endovascular and open treatment for chronic mesenteric ischemia (CMI).

MATERIALS AND METHODS

The present systematic review and meta-analysis was conducted under the PRISMA guidelines. The following databases were utilized: Pubmed, Embase, Scopus, and Cochrane Library. All eligible studies published online up to April 2024 were investigated. Eligible studies should compare early and/or late outcomes between endovascular repair (ER) and open surgery (OS) for CMI. Early outcomes included 30-day mortality, myocardial infarction (MI), pulmonary, gastrointestinal, and renal complications. Late outcomes included all-cause survival, symptom recurrence, and re-intervention.

RESULTS

In total, 15 studies (published from 1995 to 2024) were evaluated (12,326 patients under ER versus 6008 patients under OS). Regarding 30-day outcomes, ER was associated with a lower 30-day mortality risk (pooled OR = 0.58; 95% CI [0.347-0.975]; p = 0.039), a lower 30-day MI risk (pooled OR = 0.59; 95% CI [0.351-0.989]; p=0.045), a lower pulmonary complications risk (pooled OR = 0.18; 95% CI [0.075-0.426]; p=0.0001), and a lower 30-day renal complications risk (pooled OR = 0.28; 95% CI [0.146-0.553]; p=.00002). Regarding late outcomes, ER was associated with a lower overall 5-year survival (pooled OR = 0.414; 95% CI [0.291-0.591]; p < 0.0001). ER was also associated with a higher 3-year symptom recurrence risk (pooled OR = 3.77; 95% CI [2.314-6.142]; p < 0.0001) and a higher 5-year re-intervention risk (pooled OR = 2.40; 95% CI [1.538-3.739]; p=0.0001).

CONCLUSIONS

ER is associated with superior early outcomes and worse late outcomes compared to OS among patients treated for CMI.Clinical ImpactThis is the most updated meta-analysis comparing pooled data between percutaneous endovascular repair (ER) and open surgery (OS) for patients with chronic mesenteric ischemia. This review verifies the advantage of endovascular treatment regarding early outcomes. However, this benefit is lost in the long-term as far as mortality and re-interventions are concerned. These findings seem to further support the current endovascular-first approach. One should take into consideration that ER is probably selected for patients of worse clinical status. OS may be more suitable for fitter patients who are not candidates for ER.

Acute mesenteric ischaemia in the elderly - results of combined endovascular and surgical treatment. Primary study

Acute mesenteric ischaemia (AMI) is a sudden onset of impaired bowel perfusion. Has a high mortality rate and is difficult to diagnose. Therapy involves endovascular, surgical, or a combination of both. Because of baseline differences, the comparison between endovascular and open surgical treatment is subject to selection bias. The aim of this study was to evaluate the results of treatment of AMI by open or endovascular approach in combination with laparotomy, and evaluation of treatment strategy in similar situations. Clinical data from 21 patients treated for AMI between 2018 and 2022 were retrospectively reviewed and compared. The primary endpoint of the study was in-hospital mortality. The secondary endpoint was the statistical evaluation of risk factors for mortality. All patients underwent acute endovascular revascularisation. Aspiration thromboembolectomy was performed in nine patients, stenting in seven, PTA in one and surgery in three. Endovascular therapy was unsuccessful for technical reasons in 3 patients. None of the monitored parameters reached statistical significance. The best results were achieved in the early diagnosis group. The overall mortality of acute mesenteric ischaemia in our cohort was 34.8%. Acute mesenteric ischaemia is a serious condition affecting mainly elderly patients with a high mortality rate, but the diagnosis of mesenteric ischaemia is not an automatic death sentence. To achieve the best therapeutic outcome, mesenteric ischaemia needs to be diagnosed and treated at an early stage. The best therapeutic outcomes are achieved in centres with 24-hour access to endovascular revascularisation and surgical therapy.

[Endovascular treatment and selection criteria for acute mesenteric ischemia]

OBJECTIVE

To demonstrate the results of endovascular intervention in patients with acute arterial mesenteric ischemia, while observing the indications developed in the clinic.

MATERIAL AND METHODS

In total, endovascular approach in the treatment of acute mesenteric ischemia were used in 49 patients in the clinic. In compliance with the developed indications and criteria, endovascular intestinal revascularization was performed in 27 patients. Various endovascular intervention techniques were used (aspiration, balloon dilation, artery stenting and their combinations). Extracorporeal filtration techniques were used as a treatment for reperfusion syndrome after intestinal revascularization in 10 patients.

RESULTS

Angiographic success in the form of complete restoration of the main blood flow in the basin of the superior mesenteric artery and its large branches was obtained in 85% of cases. Intestinal viability was preserved in 15 (56%) patients. After successful endovascular surgery, intestinal necrosis was diagnosed on laparoscopy in the remaining 12 (44%) patients, which required extensive (n=2) or non-extensive (n=10) resection. Postoperative mortality was 48% (13 patients).

CONCLUSION

Endovascular surgery in acute mesenteric ischemia is an effective method of intestinal revascularization. To optimize the indications for these interventions, it is necessary to gain experience and conduct large-scale studies.

Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis

OBJECTIVE

This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI).

METHODS

This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence.

RESULTS

A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031).

CONCLUSIONS

Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.

Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition's variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed.

PURPOSE

Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia.

METHODS

A narrative review of all relevant studies from January 2022 through September 2023.

RESULTS

A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review.

CONCLUSIONS

Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.

Advancements in Revascularization Strategies for Acute Mesenteric Ischemia: A Comprehensive Review

Even with modern advancements in the management of acute mesenteric ischemia over the past decade, morbidity and mortality remain high, and the best primary treatment modality is still debated amongst interventionalists. Traditionally, interventionalists have favored an open surgical approach but are now trending for endovascular interventions due to apparent reduced mortality and complications. Newer studies suggest hybrid approaches, and intestinal stroke centers may be superior to either strategy alone. This narrative review will explore the natural history of acute mesenteric ischemia with the aim of increasing interventionalist awareness of modern advancements in revascularization strategies for this devastating disease.

Factors that may affect the outcome of acute occlusive mesenteric ischemia. A single-center study

BACKGROUND

Acute mesenteric ischemia is a rare but lethal disease. Acute occlusive mesenteric ischemia consists of mesenteric artery embolism, mesenteric artery thrombosis, and mesenteric vein thrombosis. This study aimed to investigate the factors that may affect the outcome of acute occlusive mesenteric ischemia.

METHODS

Data from acute occlusive mesenteric ischemia patients admitted between May 2016 and May 2022 were reviewed retrospectively. Patients were divided into 2 groups according to whether complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission. Demographics, symptoms, signs, laboratory results, computed tomography angiography features, management and outcomes were analyzed.

RESULTS

59 patients were enrolled in this study. Complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission in 17 patients. Transmural intestinal necrosis, peritonitis, white blood cell count, percentage of neutrophils, percentage of lymphocytes, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, creatine kinase isoenzyme, cardiac troponin I, laparoscopic exploration rate, open embolectomy rate, enterostomy rate, length of necrotic small bowel, length of healthy small bowel, surgical time and intraoperative blood loss differed significantly between groups. Creatine kinase isoenzyme (OR = 1.415, 95% CI: 1.060-1.888) and surgical time (OR = 1.014, 95% CI: 1.001-1.026) were independent risk factors associated with complications(Clavien‒Dindo ≥ 2).

CONCLUSIONS

Our analysis suggests that acute occlusive mesenteric ischemia patients with a creatine kinase isoenzyme level greater than 2.22 ng/mL or a surgical time longer than 156 min are more likely to experience complications'(Clavien‒Dindo ≥ 2) occurrence within 6 months of the first admission.

A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia

OBJECTIVE

Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI.

DATA SOURCES

Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI.

REVIEW METHODS

The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis.

RESULTS

Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes.

CONCLUSION

Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.

Exploring Outcomes Related to Residential Determinants in Acute Mesenteric Ischemia Patients

INTRODUCTION

To access the relationship between residential status and outcomes in surgical acute mesenteric ischemia (AMI) patients.

METHODS

Retrospective chart review of 153 AMI patients admitted to our institution between 2007 and 2021. Residential median income and Rural-Urban Commuting Area (RUCA) code were used as residential proxies.

RESULTS

Being of the female sex (odds ratio [OR] = 3.116 [1.276-7.609] P = 0.013) and having a vascular intervention performed (OR = 2.927 [1.087-7.883] P = 0.034) were both associated with a threefold increase in the risk of mortality. Increased age (OR = 1.037 [1.002-1.073] P = 0.039), elevated blood urea nitrogen (OR = 1.032 [1.012-1.051] P = 0.001), and living in higher residential income area (OR = 1.049 [1.009-1.091] P = 0.017) had a small, but statistically significant, increased risk of mortality. Patients in higher median income areas were less likely to undergo colonic resection (OR = 0.953 [0.911-0.997] P = 0.038) and tended to have a lower likelihood of receiving an ostomy (OR = 0.963 [0.927-1] P = 0.051). Being from urban or rural areas was not associated with mortality (OR = 1.565 [0.647-3.790] P = 0.321, although rural patients were more likely to undergo colon resection (OR = 2.183 [0.938-5.079] P = 0.070). Furthermore, rural patients were much more likely to be readmitted than urban dwellers (OR = 4.700 [1.022-21.618] P = 0.047).

CONCLUSIONS

AMI patients living in rural or small-town areas were more likely to be readmitted and tended to undergo colonic resection. Patients residing in higher income areas had a slightly higher risk of mortality but tended to be less likely to require ostomy or colonic resection. These findings suggest a potential need for postoperative care initiatives focused on AMI patients living in rural and lower income areas.