Outcomes of Mesenteric Reinterventions for In-Stent Restenosis in Patients Treated for Atherosclerotic Mesenteric Artery Disease

Abstract

Objective: Mesenteric artery stents (MAS) for chronic mesenteric ischemia (CMI) have been plagued by high restenosis and reinterventions rates. This study reviewed the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR) with open surgical (OR) or redo endovascular mesenteric revascularization (ER). Methods: The clinical data of 157 patients (190 MAS) treated for CMI were entered into a prospective database (1998-2010). Fifty-six patients (37%) developed MAISRs, defined by duplex ultrasound peak systolic velocity >350 cm/s or angiographic stenosis >60%. We reviewed the clinical data and outcomes of patients undergoing reinterventions for MAISR. End points were procedure-related mortality and morbidity, and late patient survival, symptom recurrence, reintervention, and patency rates. Results: There were 30 patients (19%) treated for MAISR, including 25 women and 5 men, with a mean age of 69 ± 14 years. Twenty-four patients presented with recurrent symptoms (27 chronic and 3 acute), and 6 had asymptomatic preocclusive lesions. Twenty-six patients (87%) had endovascular reintervention, including stent placement in 19 (15 uncovered and 4 covered) or percutaneous transluminal angioplasty (PTA) in 7. Four patients (13%) underwent OR, including one with acute ischemia. There was one death (3%) in a patient with acute ischemia treated with redo stenting. Seven patients (27%), all treated by ER, developed complications, including access site problems in four, and distal embolization with bowel ischemia, congestive heart failure or SMA reocclusion in one each. Symptom improvement was noted in 23 of the 24 symptomatic patients (96%). After a mean follow up of 29 ± 12 months, 11 patients developed a second restenosis, and 7 required treatment for recurrent symptoms. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/7, 3/7, and 2/7 for PTA, 5/14, 8/14, and 5/14 for uncovered stents, and 1/4, 4/4, and 0/4 for OR. For all patients, freedom from recurrent symptoms, restenosis and reinterventions were 70% ± 10%, 50% ± 11% and 60% ± 11% at 2 years. For patients treated with ER, secondary patency rates were 73 ± 11 at the same interval. Conclusion: Nearly 40% of patients developed mesenteric in-stent restenosis, of which half required reintervention because of symptom recurrence or a preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), a high complication rate (27%), and excellent symptom improvement (96%).