PC170. Impact of National Adoption of Endovascular Revascularization on a Regional Referral Center Specializing in Management of Chronic Mesenteric Ischemia

Abstract

A dramatic increase in the national rates of endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) has occurred; however, the incidence of open mesenteric bypass (OMB) has remained largely unchanged. The impact of ER adoption on referral hospitals specializing in CMI management that may be disproportionately affected by features precluding ability to use ER remains poorly defined. The purpose of this analysis was to determine the temporal variation in management and outcomes within a center with regional specialization for CMI management. A single, large tertiary academic referral institution’s prospectively collected database was queried retrospectively to identify all patients treated for CMI (2002-2018). The primary end point was temporal change in revascularization strategy (ER vs OMB; eras for analysis: 2002-2007, 2008-2013, 2014-2018). Secondary end points included temporal change in complications, reintervention, and survival. Life tables were used to estimate end points. The incidence of organ dysfunction (hepatic, renal, pulmonary, coagulopathy) was examined, and its relationship to outcomes was determined. There were 189 patients identified (OMB, n = 109 [antegrade, 91%; retrograde, 8%]; ER, n = 80 [mesenteric stent, 91%; angioplasty alone, 9%]. There was a significant difference in use of ER and OMB (most recent era, 84% OMB; P < .0001). For either ER or OMB, incidence of in-hospital complications or 30-day mortality was similar over time. OMB patients were significantly younger (66 ± 11 years vs ER, 71 ± 11 years; P = .006) and more likely to have undergone prior ER (OMB, 36%; ER, 17%; P = .005). No significant difference in presenting symptoms (postprandial pain > unintentional weight loss) or comorbidities was present. Major complications were more frequent with OMB (OMB, 54%; ER, 20%; P < .0001); however, 30-day mortality was similar (OMB, 6% [n = 6]; ER, 1% [n = 1]; P = .012). ER had a negligible incidence of postoperative organ dysfunction, whereas OMB was associated with a 75% incidence (threefold or higher transaminitis, 72%; thrombocytopenia [platelet count <40,000], 35%; renal injury, 9%; respiratory failure, 13%). Two-year symptom resolution overall was 69%; however, there was greater frequency of restenosis or recurrent symptoms after ER (50% vs OMB, 9%; P < .0001). Five-year freedom from reintervention or restenosis was significantly higher for OMB (77% ± 7% vs ER, 33% ± 6%; log-rank, P < .0001). There was a nonsignificant trend toward improved 5-year survival after OMB (70% ± 5% vs ER, 60% ± 6%; Cox model, P = .06; Fig). Centers focused on CMI management may not reflect national trends in revascularization strategies as evidenced by the increasing use of OMB. This selection pressure is predominantly due to a significant proportion of prior mesenteric revascularization failures or nonanatomic suitability for ER. Despite specialization and a high-volume referral pattern, complication rates, including frequency of postoperative organ dysfunction, remained similar over time, probably reflecting a cohort of complex patients with significant comorbidities. These findings highlight the significant challenges and resource utilization faced by regional referral centers and provide contemporary benchmarks for outcomes, especially when elective OMB occurs.