Results of Single- and Two-Vessel Mesenteric Artery Stents for Chronic Mesenteric Ischemia

Abstract

Conclusions: Stenting of both the celiac artery and the superior mesenteric artery (SMA) for chronic mesenteric ischemia (CMI) does not reduce recurrent symptoms or reinterventions compared with stenting of the SMA alone. Isolated celiac stenting carries a high risk of symptom recurrence. Summary: Mesenteric artery stenting is gaining wider acceptance for the treatment of CMI. It relieves symptoms of CMI in 78% to 100% and has lower morbidity and mortality compared with open reconstruction. However, the durability of mesenteric stenting is questioned. Primary patencies have ranged from 30% to 82%, and 17% to 64% of patients have recurrent symptoms at 2 years of follow-up (Atkins MD et al [J Vasc Surg 2007;45:1162-71]; AbuRahma AF et al [J Endovasc Ther 2003;10:1046-53]). It is generally agreed that the SMA is the primary target vessel for revascularization for patients with CMI. In open surgical procedures, it is debated whether revascularization of the SMA alone is adequate treatment. In endovascular therapy for CMI, it is also unclear whether stenting of the celiac artery in addition to the SMA adds to the durability treatment. The purpose of this study was to describe the outcomes of single-vessel vs two-vessel mesenteric stent placement in patients with CMI secondary to atherosclerotic disease. The authors reviewed 101 patients (41 men, mean age 73 ± 13 years) who were treated with mesenteric artery stents from 1998 to 2008. Patients treated with single-vessel SMA stents (group A), two-vessel celiac artery and SMA stents (group B), and patients treated with isolated celiac artery stenting (group C), were reviewed with respect to clinical data and outcomes. The groups were analyzed for differences in morbidity and mortality and freedom from recurrent symptoms and reintervention. There were 61 patients in group A, 24 in group B, and 16 in group C. Demographics, cardiovascular risk factors, and clinical presentation were similar among the three groups. The three groups had similar early mortality (2%, 4%, and 0%, respectively), morbidity (18%, 26%, and 12%, respectively), and symptom relief (95%, 78%, and 100%, respectively). Freedom from reintervention at 1 and 3 years was similar in group A (86% ± 5% and 50% ± 9%), group B (67% ± 11% and 67% ± 11%), and group C (63% ± 13% and 63% ± 113%). Differences in freedom from restenosis were similar at 1 and 3 years in group A (54% ± 7% and 44% ± 9%), group B (47% ± 12% and 39% ± 12%), and group C (43% ± 13% and 34 ± 13%). Primary and secondary patencies at 3 years were 57% and 96% for SMA stents and 61% and 87%, respectively, for celiac stents (P > .05). Celiac artery stenting alone was associated with symptom recurrence in 38% compared with recurrence rates of 18% in patients who underwent SMA stent placement (P = .06). Two-vessel stenting was associated with more complications (33%) compared with stenting of the SMA (18%) or celiac artery (6%) alone. The higher complication rate was due to more interprocedural complications (residual stenosis or dissection). Comment: There was no added benefit to two-vessel stenting compared with single-vessel stenting for treatment of CMI. Long-term results were similar, with nearly identical rates of restenosis, reintervention, and symptom recurrence. Two-vessel stenting was associated with more complications. The study was limited by its retrospective design. It is possible there was a bias toward placement of two stents in patients with more symptoms or when the anatomy of the SMA was suboptimal for stenting. It is conceivable patients with poor collateralization between the celiac and SMA with significant gastric ischemic manifestations of CMI may benefit from stenting both arteries. Overall, however, the data do not support a policy of routine stenting of the celiac and SMA for treatment of CMI.