Editors' commentary

Abstract

Notwithstanding the headline debate about whether an “endovascular-first” or an “open surgery-first” strategy is preferable or safer, the most important issue raised by our debaters—and one which should concern all of us—is that a diagnosis of acute mesenteric ischemia (AMI) is still invariably delayed and usually only considered once the patient has become too ill to undergo any form of meaningful intervention. The data from the United States National Inpatient Sample, which showed that only 15% of AMI patients were actually treated and that only 3% had the chance to benefit from endovascular or open revascularization, make extremely depressing reading. Put another way; almost nine of every 10 patients with a diagnosis of suspected AMI will undergo no active treatment. Such bleak statistics demand that medical professionals (of all disciplines) be made more aware of the importance of at least considering a diagnosis of AMI in their patients. Returning to the “meat” of the debate, our contributors have provided positive and negative data regarding their respective positions. That is not surprising, given the nature of a debate. We suspect, however, that a significant proportion of our surgical readers will rarely (or never) consider an endovascular-first strategy for the treatment of their AMI patients (unlike patients with chronic mesenteric ischemia), largely because of an intuitively held belief (espoused by Drs Orr and Endean) that endovascular strategies have little to offer in these acute life-threatening situations and that emergency laparotomy is mandatory to gauge the severity of ischemia, enable revascularization, as well as allowing the resection of compromised bowel before it worsens and precipitates multiorgan failure. However, Martin Björck has also shown that surgeons may have been wrong to uncritically dismiss a role for an endovascular-first strategy. This is supported by international registries reporting that up to 50% of contemporary arterial revascularizations for AMI now follow an endovascular-first strategy, with bailout surgical bypass possible in up to half of those cases where an endovascular intervention failed to recanalize the superior mesenteric artery. One would not expect to have observed such an increase in the proportion of interventional therapies if an endovascular-first strategy was associated with poorer outcomes compared with the traditional open surgical approach. There are obvious advantages to either strategy. Endovascular therapy is less invasive, can be done under local anesthesia, avoids a major laparotomy in compromised individuals, and (perhaps most importantly) finishes with completion angiography to identify and treat residual thrombus and defects, thereby optimizing the overall quality of the revascularization. The Achilles' heel of an endovascular-first strategy, however, is determining exactly when someone needs a second-look laparotomy to identify the patient with persisting focal bowel ischemia before it perforates. Martin Björck advocates a liberal approach to second-look laparotomy, but when one is required is not always apparent. The open surgery-first approach, as stated by Drs Orr and Endean, is more generalizable and does not require complex endovascular skills, which may not be available in most hospitals. This type of patient is usually too ill to transfer to another more experienced endovascular institution, usually because of the delay in diagnosis. As with most issues in medicine, a “one size fits all” strategy rarely works, and it is inevitable that endovascular and open surgery will evolve complementary roles in the management of AMI. This will be particularly true in the era of hybrid endovascular theaters where the patient can undergo any combination of the two approaches as well as laparoscopy. Moreover, the addition of open retrograde SMA angioplasty or stenting, or both, will increase revascularization options while at the same time permitting the surgeon to inspect the bowel for areas of doubtful viability. However, any meaningful debate about whether an endovascular-first or an open surgery-first strategy is safer in AMI patients is pointless unless the medical profession becomes much better at diagnosing AMI early. That remains the most important challenge facing all of us. Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemiaJournal of Vascular SurgeryVol. 62Issue 3PreviewAcute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Full-Text PDF Open Archive