Endovascular Therapy for Acute Mesenteric Ischemia: An NSQIP Analysis

Abstract

Acute mesenteric ischemia (AMI) continues to carry high morbidity and mortality. Endovascular strategies have been increasingly used in the management of AMI. The purpose of this study was to evaluate the impact of endovascular therapy on outcomes of patients with AMI. The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency surgical intervention for AMI. Demographics, clinical data, interventions, and outcomes were extracted. Patients were compared according to treatment (endovascular versus hybrid versus open revascularization). Over the six-year study period, a total of 439 patients were found to have AMI [27 (6.2%) endovascular, 23 (5.2%) hybrid, and 389 (88.6%) open revascularization]. A total of 16 (59.3%) patients in the endovascular group avoided laparotomy. There was a trend toward lower transfusion requirements (intraoperative transfusion: 3.7% for endovascular vs 17.4% for hybrid vs 19.3% for open, adjusted. P = 0.127) and complications in particular pneumonia (22.2% vs 39.1% vs 27.8%, respectively, Adj. P = 0.392) and sepsis (25.9% vs 21.7% vs 35.5%, adjusted P = 0.260). Endovascular therapy was associated with a 2.5-fold decrease in the risk of death [odds ratio, 95% confidence interval: 0.4 (0.2, 0.9), adjusted P = 0.018]. In this analysis of morbidity and mortality, endovascular therapy was associated with decreased need for laparotomy and a trend toward lower transfusion requirements and complications, in particular pneumonia and sepsis. Endovascular first therapy was associated with a 2.5-fold decrease in the risk of death. Further prospective evaluation of these results is warranted.

The role of endovascular therapy in acute mesenteric ischemia

“…Angioplasty and stenting, if performed early, have been shown to prevent intestinal infarction and obviate the need for laparotomy [ 33 , 34 ]. The hybrid approach facilitates endovascular intervention and represents a useful technique for the management of patients with AMI who require emergency laparotomy [ 35 , 36 ].…”

“…Successful recanalization does not preclude laparotomy to check or resect the intestine. Dead bowel has to be resected before the patient falls into profound septic shock [ 36 ].…”

Surgical Abdomen

“…The initial technical success rate is 94-100% (Luther et al 2018). A major drawback of endovascular therapy is inability to assess the bowel (Branco et al 2015). In this study as well as others reported in the literature there exists selection bias, no mention of the severity of the disease and presence of peritonitis.…”

Effect of timing on endovascular therapy and exploratory laparotomy outcome in acute mesenteric ischemia

“…When we further divided the exploratory laparotomy patients into 2 groups, endovascular intervention before or after reperfusion, we saw significant differences in both 30-day survival and reperfusion times: a shorter time to reperfusion was associated with a higher survival percentage. Branco et al showed that “endovascular therapy first” was associated with a decrease in risk of death compared to traditional laparotomy as first approach (odds ratio 0.4, 95% confidence interval 0.2-0.9; P=0.018) [10]. Dhamnaskar et al also demonstrated that time was a significant factor in the survival of patients with AMI [10].…”