Intermediate-term outcomes of endovascular treatment for symptomatic chronic mesenteric ischemia

Abstract

Endovascular therapy for chronic mesenteric ischemia (CMI) has been increasingly utilized. Early outcomes compare favorably with open mesenteric bypass--the current gold standard. The goal of this study is documentation of intermediate-term anatomic and functional outcomes of endovascular mesenteric revascularization for symptomatic CMI. This is a retrospective review of all patients undergoing endovascular treatment of symptomatic CMI from July 2002 to March 2008. Study endpoints included periprocedural mortality, major morbidity, patency, symptomatic recurrence, and survival. Endpoints were analyzed using actuarial methods. Sixty-six mesenteric arteries (78.8% stenotic/21.2% occluded) were treated in 49 patients. One or more vessels were treated in each case; however, four mesenteric artery total occlusions (3 SMAs/1 IMA) could not be crossed. Initial symptom relief was noted in 89.8% (n = 44) with no change in 5 patients. Single-vessel treatments were performed in 32 patients (65.3%) and two-vessel interventions in 17 (34.7%). The 30-day mortality rate was 2.0% (n = 1). Major complications occurred in 8 patients (16.3%). The mean follow-up duration was 37.4 +/- 2.98 months (range, 0-66). Restenosis on follow-up imaging occurred in 64.9% (n = 24) of the 37 patients who had radiographic surveillance at a mean follow-up interval of 8.5 +/- 1.9 months and was diagnosed most often by Duplex scan or computed tomographic angiography (CTA). Fourteen patients (28.6%) developed recurrent symptoms with 13 requiring a reintervention. Actuarial 36-month freedom from symptomatic recurrence was 60.9% +/- 9.4%. Two-vessel treatment was protective against symptom recurrence (P = .0014) and reintervention (P = .0060) by univariate analysis. A total of 19 reinterventions were required in 14 patients (28.6%) at a mean of 17 months from the original treatment. Primary patency at 36 months was 63.9 +/- 8.5%. Actuarial survival at 48 months was 81.1% +/- 6.1% with no CMI-related deaths in the study cohort. Intermediate (3-year) follow-up indicates that significant restenosis and symptom recurrence are common following the endovascular treatment of symptomatic CMI. Thirty percent of the cohort required a reintervention, one-third of which were conversions to surgical reconstruction. Similar to the surgical paradigm of two-vessel revascularization, endovascular treatment of multiple mesenteric arteries produced better outcomes. A first-line endovascular approach to patients with CMI is a reasonable clinical strategy, but close follow-up is mandatory.