Early- and Long-term Outcome After Endovascular Treatment of Chronic and Acute on Chronic Mesenteric Ischemia in a Large National Cohort

Abstract

Introduction: Treatment of chronic mesenteric ischemia has evolved from open surgery towards endovascular revascularization in most centers(1). The endovascular approach includes a low early morbidity, shorter lengths of hospital stay (LOS) and early recovery despite higher risk of restenosis and lower patency compared to open repair(2,3). Long-term outcome after endovascular treatment remains to be proven in larger series. The objective of this study was to assess early- and long-term outcome after endovascular revascularization of chronic (CMI) and acute on chronic (AoCMI) mesenteric ischemia in a large national cohort. Methods: All patients treated endovascularly due to CMI or AoCMI between 2011 and 2015 were included. Patients with acute mesenteric ischemia (embolic) or previous open mesenteric revascularization were excluded. Treatment of mesenteric ischemia in our country is centralized to one tertiary vascular referral center, why this study represents a national cohort. Prospectively entered data were extracted from the National Vascular Registry. Subsequently, electronic records and PACS were manually and retrospectively assessed. Endpoints included technical success rate, early- (mortality, bowel resection, complications, LOS) and long-term- (1-3 year mortality, symptom relief) outcome. Potential outcome predictors were evaluated. Results: In total, 246 patients with CMI or AoCMI were included. The clinical presentation was CMI in 178 patients (mean age 70; women 68%) and AoCMI in 68 patients (mean age 69; women 69%). 30-day mortality in the CMI and AoCMI group was 2% (n=3) and 16% (n=11), respectively (p < .0001). The CMI group had significantly better survival rates after one and three years, with Kaplan Meier (KM) estimates of 85% (95% CI 78.7-89.3) and 73% (95% CI 66.0 - 79.3) in the CMI group compared to 66% (95% CI 53.4 - 76.0) and 53% (95% CI 40.3 - 64.4) in the AoCMI group (figure 1). Independent predictors of death were AoCMI vs CMI (HR = 1.8 (p< .01)) and hypertension in the CMI group (HR =2.7 (p=.001)). Based on angiography, we found no correlation between outcome and number of diseased vessels. Five patients (3%) in the CMI group and 30 patients (44%) in the AoCMI group underwent bowel resection. LOS was seven times longer in the AoCMI group (mean 20 days (95% CI 12.4-27.6)) compared to the CMI group (2.9 days (95% CI 2.4-3.3)). Symptom relief after one year was identical; (60% (n=107) vs. 53% (n=36) in the CMI and AoCMI group, respectively (p= .3). Reintervention due to symptom recurrence and target artery restenosis was performed only in 10 patients (6%) in the CMI group and 1 patient (1%) in the AoCMI group after mean 219 days (95% CI 89.1-349)) and 423 days respectively. Five access-related complications (2%) needed reintervention, target-vessel related complications were seen in 7 patients (3%) and 1 patient had cerebral embolization. Conclusion: First-line endovascular treatment of CMI and AoCMI is related with acceptable short- and long-term outcome and a low risk of symptomatic restenosis. As expected, patients suffering AoCMI have significantly higher mortality, more bowel resection and longer LOS compared to CMI patients, underlining the importance of early diagnosis and treatment of CMI. Disclosure: Nothing to disclose