Retrograde Open Mesenteric Stenting Should Be Considered an Initial Approach to Acute Mesenteric Ischemia

Abstract

Retrograde open mesenteric stenting (ROMS) is an alternative to traditional bypass in patients who present with acute mesenteric ischemia (AMI). However, there is a paucity of data comparing outcomes of ROMS with other open surgical approaches. This study represents the largest single-institution experience with ROMS and aims to compare outcomes of ROMS with mesenteric bypass. All patients who presented with AMI from 2008 to 2018 and were treated with either ROMS or mesenteric bypass were included in the study. Patient, procedure, and outcome variables were compared (Table). Bypass and ROMS patients were compared using univariate and multivariable analysis. Variables associated with mortality and reintervention were evaluated using multivariable Cox and logistic regression. There were134 patients who presented with AMI. Of these patients, 31 were included in the study; 15 underwent mesenteric bypass, and 16 underwent ROMS. ROMS patients tended to be older and had higher rates of comorbidities and bowel resections than bypass patients. Comparisons of the two surgical groups are summarized in the Table. Bypass patients were more likely to present with acute-on-chronic symptoms (73.3% vs 31.3%; P = .019). Bypass procedures also took longer than ROMS procedures (316 vs 189 minutes; P = .001). The majority of ROMS were performed with a portable C-arm (75%). Of the 10 (62.5%) ROMS patients who survived the hospital stay, stent patency was confirmed with surveillance duplex ultrasound scan and computed tomography angiography. One ROMS stent thrombosed, requiring mesenteric bypass. One bypass conduit thrombosed, resulting in perioperative death; and one bypass anastomosis stenosed, requiring angioplasty. Complication, unanticipated reintervention, and mortality rates were similar between groups (Table). Multivariable Cox regression at 5 years yielded no difference in reintervention-free survival curves between bypass and ROMS patients (log-rank, P = .572). Complication, reintervention, and mortality rates after ROMS are similar to mesenteric bypass in the setting of AMI with no difference in reintervention-free survival. Given similar outcomes and ability to perform these procedures in a conventional operating room with shorter operative times, ROMS should be considered a first-line option in acute situations when the operator is comfortable performing the procedure.TablePatient, procedural, and outcome dataBypass (n = 15)ROMS (n = 16)P valueDemographics Sex (female)10 (66.7)11 (68.8).901 Age73 (68-77)64 (58-70).993 Prior tobacco use13 (86.7)13 (81.3).682 BMI21.5 (17.9-24.9)26.8 (19.9-31.8).944Comorbidities Diabetes5 (33.3)7 (43.8).552 HTN11 (73.3)13 (81.3).598 HLD7 (46.7)11 (68.8).213 ESRD0 (0.0)4 (25.0).038 CHF0 (0.0)2 (12.5).157 COPD3 (20.0)4 (25.0).739 CAD4 (26.7)8 (50.0).183 Stroke or TIA0 (0.0)1 (6.3).325 PVD5 (33.3)7 (43.8).398 Prior SBR3 (20.0)3 (18.8).930Presenting signs and symptoms Lactate1.6 (1.2-3.3)2.9 (1.7-3.4).885 White blood cell count18.2 (11.5-22.8)23.1 (11.5-27.7).868 Albumin2.8 (2.6-3.4)3.8 (3.4-4.1).858 Creatinine elevated from baseline0 (0.0)3 (18.8).078 Pneumatosis4 (26.7)7 (43.8).474 Acute-on-chronic symptoms11 (73.3)5 (31.3).019Intraoperative data SBR9 (60.0)14 (87.5).080 Transfusion8 (53.3)7 (43.8).715 OR time, minutes316 (227-373)189 (141-254).001 Second look10 (66.7)14 (87.5).166In-hospital complications Bleeding3 (20.0)3 (18.8).924 Sepsis5 (33.3)5 (31.3).893 Cardiac2 (13.3)1 (63).501 TIA or stroke0 (0.0)1 (6.3).326 TPN dependent3 (20.0)2 (12.5).624 LOS16 (14-22)16 (7-31).664 In-hospital death5 (33.3)6 (37.5).809Late complications Reintervention for mesenteric ischemia3 (20.0)5 (31.3).474 All-cause mortality10 (66.7)9 (56.25).552BMI, Body mass index; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; HLD, hyperlipidemia; HTN, hypertension; LOS, length of stay; OR, operating room; PVD, peripheral vascular disease; ROMS, retrograde open mesenteric stenting; SBR, small bowel resection; TIA, transient ischemic attack; TPN, total parenteral nutrition.Categorical variables are presented as number (%). Continuous variables are presented as median (interquartile range). Open table in a new tab