Comparative Outcomes of Open Mesenteric Bypass after Prior Failed Endovascular or Open Mesenteric Revascularization for Acute and Chronic Mesenteric Ischemia

Abstract

INTRODUCTION: Open mesenteric bypass (OMB) for acute or chronic mesenteric ischemia (AMI/CMI) is associated with significant morbidity and mortality. Increasingly, patients present after failed endovascular intervention or OMB. The association of prior failed mesenteric revascularization on OMB outcomes is poorly understood. METHODS: Methods: All AMI/CMI patients from a single center undergoing OMB from 2002-2018 were reviewed. Primary (P-OMB) and ‘redo’ bypass (R-OMB: defined as OMB after failed mesenteric stent and/or OMB) were compared. The primary end-point was in-hospital mortality. Secondary outcomes included complications, restenosis, freedom from re-intervention, and long-term survival. RESULTS: 108 OMB procedures (P-OMB, n = 66 [61%]; R-OMB, n = 42 [39%]) were reviewed. R-OMB patients had equivalent incidence of smoking, Plavix and anticoagulant use. The majority of the study subset were for CMI indication (n = 102 [94%]) which was equivalent for primary and redo status (95% vs 93%, p = .68). R-OMB was performed for failed OMB in 31% (n = 13 of 42). Complications (overall - 54%), LOS (17 ± 17days), and in-hospital death (overall -11%) were similar irrespective of redo status for the entire cohort and for AMI/CMI indications independently. Redo status did not significantly increase the need for bowel resection for an AMI indication (33% vs P-OMB - 66%; p=1) or need for secondary operative procedures (21% vs P-OMB - 20%; p = .81). R-OMB was independently associated with higher restenosis/occlusion risk at 1 and 3-years (R-OMB - 88 ± 6%, 79 ± 8% vs P-OMB - 97 ± 2%, 93 ± 4%; p = .03) and lower freedom from re-intervention (R-OMB - 88 ± 5%, 84 ± 6% vs P-OMB - 95 ± 3%, 95 ± 3%; p = .06). CONCLUSION: Patients with recurrent AMI/CMI after prior failed endovascular or OMB can anticipate similar outcomes compared to primary OMB subjects. Re-intervention rates are higher after R-OMB, highlighting the need for implementation of surveillance protocols to optimize long-term durability.