VESS21. Mesenteric Artery Stenting Using Embolic Protection Device for Treatment of Acute or Chronic Mesenteric Ischemia

Abstract

This study reports the feasibility and results of mesenteric artery stenting (MAS) using embolic protection devices (EPD) to treat acute (AMI) and chronic mesenteric ischemia (CMI). We retrospective reviewed all patients who underwent MAS with EPDs from 2007 to 2016. EPDs were used selectively in patients with occlusions, severe calcification, or acute thrombus. A two-wire technique with SpiderRX 0.014-inch Filter-Wire (Medtronic, Minn) combined with a 0.018-inch wire was used to provide support and facilitate filter retrieval. Presence of macroscopic debris in the EPD was recorded and graded as minor (minimal debris) or major (large thrombus or plaque). End points were technical success, presence of EPD debris, embolization, and early morbidity and mortality. A total of 179 patients underwent MAS, of which 65 patients (36%) had EPDs. There were 49 female patients (75%), with mean age of 73 ± 11 years. Clinical presentation was CMI in 48 patients (74%) and AMI in 17 (26%). Brachial access was used in 59 patients (91%). Indications for EPD were severe calcification in 22 patients (34%), acute thrombus in 18 (28%), and total occlusion in 16 (25%). Bare-metal stents were used in 33 patients, covered stents in 26, and both types in six. Adjunctive therapy included thrombolysis in seven patients, thrombectomy in four, and atherectomy in three. Technical success was 100%. Embolization was noted in four patients (6%), of which two had AMI. All large emboli were treated using catheter aspiration devices, but one small distal emboli was left untreated, with no clinical consequences. There were no arterial injuries caused by the EPD. Two patients had vessel spasm treated by nitroglycerin. Macroscopic debris was noted in 43 patients (66%) and was major in 21 (49%; Fig) or minor in 22 (51%). Of the patients with AMI, five (29%) required exploratory laparotomy, and four (23%) had bowel resection. Eight additional patients (12%) had early complications (5 CMI, 3 AMI), including cardiac, brachial hematoma, acute cholecystitis, and ARDS in two patients each. There were no deaths among CMI patients and two early deaths (12%) among those who had AMI. Embolic protection during MAS is safe using the two-wire technique, with no instances of filter wire retention or arterial trauma induced by filter wire manipulation. Macroscopic debris was noted in two-thirds of the patients when EPDs were used selectively in patients with acute symptoms, occlusions or severely calcified lesions. Despite the use of EPD, distal embolization in 6% of patients was successfully treated using catheter aspiration devices.