Outcomes of Antegrade and Retrograde Open Mesenteric Bypass for Acute Mesenteric Ischemia

Abstract

Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Despite increasing adoption of endovascular strategies to manage AMI, few contemporary reports focus on patients undergoing open mesenteric bypass (OMB). This is notable because there is a subset of patients who are poor candidates for peripheral intervention, including those with flush aortic visceral vessel occlusion, long-segment occlusive disease, and thrombosed mesenteric stents or bypass. Historical reports identify a retrograde OMB configuration as the safest choice because of the perception that an antegrade approach has higher risk. The purpose of this analysis was to review our experience with OMB and to compare outcomes of antegrade and retrograde OMB in the treatment of AMI. A single-center, retrospective chart review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. Preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier methodology was used to characterize reintervention and survival. Eighty-two patients (female, 54%; age, 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. History of prior stent or bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass; the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were significantly more likely to be male (53% vs 25%; P = .03) and to have coronary artery disease (48% vs 25%; P = .05), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Additional details regarding comorbidities, procedure-related variables, and outcomes are highlighted in the Table. For all subjects, concurrent bowel resection occurred in 45% (n = 37; antegrade vs retrograde, P = .9), whereas 37% (n = 30) underwent subsequent resection during second-look operations. In-hospital mortality was 34% (n = 28; 30-day mortality, 26%; multiple organ dysfunction, 20; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia; 1, stroke, 1), median length of stay was 16 (interquartile range, 9-35) days, and 76% (n = 64) experienced at least one major complication with no difference between antegrade and retrograde configurations. At mean follow-up of 18 ± 29 (median, 4; interquartile range, 1-26) months, 10 (12%) subjects experienced aortomesenteric bypass reintervention (bypass thrombosis + redo bypass, 4; percutaneous transluminal angioplasty, 3; mycotic pseudoaneurysm + redo mesenteric bypass, 2; femoral vein conduit anastomotic aneurysm, 1; primary patency: 82% ± 6% at 1 year, 82% ± 6% at 3 years [95% confidence interval, 0.7-0.9]). Overall survival at 1 year and 5 years was 57% ± 5% and 50% ± 6%, respectively (Fig). Bypass configuration was not associated with significant differences in complications or survival; however, retrograde bypass had higher risk of reintervention (hazard ratio, 3.7; 95% confidence interval, 1-14; P = .05). OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with outcomes comparable to those of retrograde OMB. The bypass configuration choice should be predicated on the patient's presentation, the anatomy, and the surgeon's preference; however, an antegrade configuration may provide lower risk of reintervention.TablePatient demographics, comorbidities, procedure-specific details, and outcomes of open mesenteric bypass (OMB) for acute mesenteric ischemia (AMI)VariableAll patients (N = 82)Antegrade (n = 62)Retrograde (n = 20)P valueAge, years63 ± 1264 ± 1060 ± 17.6Gender, male46% (38)53% (33)25% (5).03Comorbidities Hypertension889080.24 Smoking815865.06 Peripheral artery disease546035.05 Dyslipidemia465230.09 Coronary artery disease434825.05 COPD455225.03 CRI (eGFR <60)323425.5 Diabetes2223201 CHF161810.5 Cerebrovascular disease161325.3 Arrhythmia7851Admission mode Emergency department272630 Transfer656950 Direct admit85200.1Procedure details Bowel resection (index)4545450.9 Blood loss500 (200-750)500 (250-800)400 (100-500).3 Packed red cells0.5 (0-3)1 (0-3)0 (0).004 Intravenous fluids3000 (3000-4500)3500 (3000-4500)2500 (1800-3100).02Conduit Dacron495625 Autogenous vein352955 Bovine161520.04Vessels bypassed SMA + celiac546840 SMA alone463292<.0001Outcomes LOS, days16 (9-35)22 (9-39)13 (9-17).09 Any complication7877801 30-Day death262335.3 In-hospital death343435.3Disposition Home343435 Rehabilitation unit262430 Death383935 Hospital transfer230.9Reintervention12825.07CHF, Congestive heart failure; COPD, chronic obstructive pulmonary disease; CRI, chronic renal insufficiency; eGFR, estimated glomerular filtration rate; LOS, length of stay; SMA, superior mesenteric artery.Categorical variables are presented as %. Continuous variables are presented as mean ± standard deviation or median (interquartile range). Open table in a new tab