Survival, Reintervention, and Value of Open and Endovascular Repair for Chronic Mesenteric Ischemia

Abstract

There are limited analyses of survival and postoperative outcomes in chronic mesenteric ischemia (CMI) using data from large cohorts. Current guidelines recommend open repair (OR) for younger, healthier patients when long-term benefits outweigh increased perioperative risks or for poor endovascular repair (ER) candidates. This study investigates whether long-term survival, reintervention, and value differ between these treatment modalities. A retrospective cohort analysis was performed on data extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payer database containing demographics, diagnoses, treatments, and charges. Patients were selected for CMI and subsequent ER or OR using International Classification of Diseases, Ninth Revision codes. Patients with peripheral arterial disease were excluded to account for ambiguity in the International Classification of Diseases, Ninth Revision procedure code for angioplasty of noncoronary vessels, which includes angioplasty of upper and lower extremity vessels. Kaplan-Meier analysis was used to compare 1-year and 5-year survival and reintervention between treatment modalities using a propensity-matched cohort. Cox proportional hazards testing was performed to find factors associated with 1-year and 5-year survival and reintervention. Analysis of procedural value was performed using linear regression. From 2000 to 2014, 744 patients met inclusion criteria. Of these, 209 (28.1%) underwent OR and 535 (71.9%) ER. No difference between propensity-matched groups was found in 1-year (P=0.46) or 5-year (P=0.91) survival. Congestive heart failure (hazard ratio [HR]: 2.8, 95% confidence interval [CI]: 1.7-4.4; P<0.01), cancer (HR: 2.8, 95% CI: 1.3-5.8; P<0.01), and dysrhythmia (HR: 1.8, 95% CI: 1.1-2.8; P=0.02) correlated with 1-year mortality. Cancer (HR: 2.9, 95% CI: 1.6-5.5; P<0.01), congestive heart failure (HR: 2.2, 95% CI: 1.5-3.2; P<0.01), chronic pulmonary disease (HR: 1.4, 95% CI: 1.0-2.0; P=0.04), and age (HR: 1.03, 95% CI: 1.01-1.05; P<0.01) correlated with 5-year mortality. Treatment modality was not associated with reintervention at 1year on Kaplan-Meier analysis (P=0.29). However, ER showed increased instances of reintervention at 5years (P<0.01). Additionally, ER was associated with an increased 5-year value (0.7±0.9 vs. 0.5±0.5 life years/charges at index admission [$10k], P<0.01; b coefficient: 0.2, 95% CI: 0.1-0.4, P<0.01). This is the largest retrospective propensity-matched single-study cohort to analyze long-term survival outcomes after intervention for CMI. Long-term mortality was independent of treatment modality and rather was associated with patient comorbidities. Therefore, treatment selection should depend on anatomic considerations and long-term value. ER should be considered over OR in patients with amenable anatomy based on the superior procedural value.