Implications of Reintervention After Endovascular and Open Bypass Revascularization for Chronic Mesenteric Ischemia

Abstract

Endovascular revascularization (Endo; angioplasty and/or stent) has increasingly supplanted open mesenteric bypass (OMB) to treat chronic mesenteric ischemia (CMI). The short-term benefits of endovascular intervention are well-described; however, concerns regarding durability and implications of reintervention on survival remain poorly understood. Specifically, little is known about the type, magnitude and subsequent outcomes of reintervention after Endo for CMI. The purpose of this analysis was to review our experience with reintervention after Endo compared to reintervention after OMB revascularization for CMI with specific focus on identifying the association with outcomes. A single-center retrospective analysis was performed on all CMI patients undergoing OMB or Endo interventions from 2010 to 2018. The primary end point was freedom from reintervention. Secondary end points included complications after reintervention and survival. Kaplan-Meier methods were used to estimate freedom from secondary end points. A total of 116 CMI patients (OMB, 61% [n = 71]; Endo, 39%[n = 45]) were reviewed. The two cohorts were similarly matched in demographic and comorbidity characteristics. OMB vessels revascularized at index operation were as follows: SMA, 16% (n = 11), superior mesenteric artery (SMA)+Celiac, 83% (n = 59), and SMA+inferior mesenteric artery, 11% (n = 1). Endovascular vessels revascularized included: SMA stent, 49% (n = 19), SMA angioplasty alone, 11% (n = 5), and SMA+Celiac stenting, 40% (n = 16). Within the OMB subgroup, 6% (n = 4) underwent reintervention compared to 24% (n = 11) in the endovascular cohort (P = .005). Specific to OMB reintervention, three had open reconstructions (100% emergent;100% developed a complication) while the remaining patient received an endovascular reintervention(urgent; no complication). In contrast, reintervention after an index Endo procedure resulted in a higher rate of repeat endovascular remediation and elective presentation (6 Endo reintervention [100% elective, no complications]; 5 converted to OMB [60%, elective; no complications]). The median survival of OMB patients who underwent reintervention was significantly lower than Endo patients who underwent reintervention: OMB, 11 months vs Endo, 48 months (Wilcoxon rank-sum P = .03). Notably, there was no difference in overall survival among all CMI patients; however freedom from any reintervention was significantly less for Endo patients (log-rank P = .01; Figs 1 and 2). Reintervention after Endo for CMI is significantly different compared to OMB. Specifically, patients are more likely to present electively and undergo a subsequent endovascular procedure. The complexity and magnitude of reintervention after OMB is underscored by lower long-term survival compared to endovascular patients undergoing reintervention. Although an Endo-first approach may have lower overall durability and likely mandates different surveillance strategies compared to OMB, the magnitude, perioperative risk and implications of reintervention on long-term survival appear to support this approach in all anatomically suiTable patients.Fig 2Freedom from Re-intervention after Revascularization for Chronic Mesenteric Ischemia.View Large Image Figure ViewerDownload Hi-res image Download (PPT)