Results of Open and Endovascular Revascularization for Acute Mesenteric Ischemia

Abstract

Acute mesenteric ischemia (AMI) accounts for only 1–2 per 1,000 hospital admissions but continues to be a highly complex clinical problem with a relatively high mortality rate. In a population-based autopsy study, the incidence of thromboembolic occlusion of the superior mesenteric artery with intestinal gangrene was 6.0/1,000 deaths, with the diagnosis carrying a mortality of 93 %. The problem was suspected antemortem in only 1/3 of patients. The mortality rate from AMI has declined only very moderately from 80–90 % in the 1970s to 60–70 % in the 1980s. This was largely attributed to a higher index of suspicion among clinicians, advances in radiographic diagnosis, and an aggressive surgical approach with better perioperative care. However, following this, traditional treatment yielded no further improvement in mortality over the previous two decades. In order to further impact the grave outcome of AMI, an endovascular first treatment paradigm has been championed over the last decade. Indeed, endovascular treatment does offer some definite advantages and has been utilized very effectively in the more elective treatment of chronic mesenteric ischemia (CMI). While it is being increasingly used for revascularization in AMI, the main drawback is that it does not allow for immediate assessment of intestinal viability, limiting its applicability to select patients in whom immediate laparotomy is not indicated. In addition, personnel with advanced endovascular skills and an extensive inventory of endovascular devices and equipment may not be readily available in many facilities. It is, therefore, more ideally suited for patients presenting somewhat subacutely and without peritoneal signs.