Mesenteric revascularization: management and outcomes in the United States, 1988-2006

Abstract

Background Recent reports have suggested that angioplasty +/− stenting (PTA/S) may have lower perioperative mortality than open surgery for revascularization of acute and chronic mesenteric ischemia (AMI and CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is in fact a mortality benefit. Methods We identified all patients undergoing mesenteric revascularization, either surgical (bypass, endarterectomy, or embolectomy) or PTA/S from the Nationwide Inpatient Sample from 1988–2006. A diagnosis by ICD-9 coding of AMI or CMI was required for inclusion. We evaluated trends in management over this time period and compared in-hospital mortality and complications between surgical bypass and PTA/S for the years 2000–2006. Results From 1988 to 2006 there were 6,342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily over time surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. Mortality was lower after PTA/S than bypass for both CMI (3.7% vs 13%, P<0.01) and AMI (16% vs 28%, P<0.01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P<0.01) and this subgroup showed an increased in-hospital mortality for both repair types (54% and 25%). Conclusion PTA/S in being utilized with increasing frequency for revascularization of both CMI and AMI. Based on lower in-hospital mortality for patients as they are currently being selected, PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.

Clinical Effectiveness of Percutaneous Angioplasty for Acute and Chronic Mesenteric Ischemia: A Six Case Series

“…19,20 Recently, it has been proven that a well-timed combined use of PTA and stent placement is effective and safe even for AMI. 5,6 In our last 2 AMI cases, urokinase, thrombectomy, and stent placement were used successfully after diagnosis of SMA occlusion. Each follow up period is 16 and 9 months respectively, and the patients have done well so far.…”

“…6,17 Recently, more than 70% of patients with mesenteric ischemia are treated with mesenteric angioplasty and stent placement. 17 According to a literature review, the mean angiographic success rate was 94%, the clinical success rate was 85%, and the primary patency rate was 74%.…”

“…4 Recently, a well-timed study found that combined use of aspiration thrombectomy with angioplasty and stent placement proved effective and safe. 5,6 However, clinical experience of angioplasty is not sufficient to draw a conclusion.…”

Percutaneous Angioplasty and Stenting for Mesenteric Ischaemia

“…Acute mesenteric ischemia is associated with a daunting mortality rate of greater than 50% (Schermerhorn et al, 2009). Prompt diagnosis and institution of revascularisation therapy are crucial for a successful outcome.…”

“…With evolving expertise and technological advancements in endovascular therapy, there has been an increase in the use of endovascular revascularisation for treatment of AMI. In the US registry study of 5237 patients treated for AMI, the outcomes of patients who were treated with endovascular intervention were compared to those who were treated with www.intechopen.com (Schermerhorn et al, 2009). Patients who were treated with endovascular measures tended to have higher rates of cardiovascular comorbidities than those undergoing open surgical repair, including hypertension, peripheral vascular disease, coronary artery disease and chronic renal failure.…”