Treatment Of Chronic Mesenteric Ischemia Research Articles

Copenhagen Mesenteric stent study (COMESS)—a randomized trial of stent versus covered stent treatment for chronic mesenteric ischemia

BackgroundCurrent management of mesenteric ischemia is primarily endovascular stent treatment. Typical CMI symptoms are postprandial abdominal pain, food fear, weight loss, and diarrhea. Revascularization is often necessary, as mesenteric ischemia may progress to bowel necrosis and death if left untreated. This study aims to compare the outcome using bare metal stent (BMS) or covered stent (CS) in the endovascular treatment of chronic and acute on chronic mesenteric ischemia.MethodsThis is an investigator-driven, prospective, randomized, single-blinded, and single-center, national cohort study at the Copenhagen University Hospital, Denmark. A total of 98 patients with chronic mesenteric ischemia (CMI) and acute-on-chronic mesenteric ischemia (AoCMI) will be randomized to treatment with either BeSmooth BMS (Bentley Innomed GmbH) or BeGraft CS (Bentley Innomed GmbH). Randomization occurs intraoperatively after lesion crossing.DiscussionThere is currently no published data from prospective controlled trials regarding the preferred type of stent used for the treatment of chronic and acute-on-chronic mesenteric ischemia. This trial will evaluate the short- and long-term outcome of BMS versus CS when treating CMI and AoCMI, as well as the benefit of a more intense postoperative surveillance program.Trial registrationClinicalTrials.gov NCT05244629. Registered on February 8, 2022.

Retrospective evaluation of interventional radiological treatments for chronic mesenteric ischemia in Germany based on a four-year period of the DeGIR Registry: comparison of outcomes with international quality standards.

Endovascular treatment has emerged as the gold standard for managing chronic mesenteric ischemia (CMI) resulting from arterial stenosis or occlusion. This study aimed to assess the efficacy and complication rates of continuous interventional radiology treatment for CMI in Germany between 2018 and 2021, comparing these findings with international quality standards. Data for CMI therapy with stenting and percutaneous transluminal angioplasty (PTA) was obtained from the quality management system of the German Interventional Radiological Society (DeGIR). A total of 3752 endovascular procedures for CMI performed from 2018 to 2021 were documented (PTA: n = 675; stenting: n = 3077). Data was analyzed for technical and clinical success rates, as well as major complication rates. Overall technical and clinical success rates for PTA and stenting procedures were 92.03 %/85.9 % and 98.76 %/96.62 %, respectively. The most common major complications were: arterial occlusion (PTA: 0.73 %; stenting: 0.63), major bleeding (PTA: 1.05 %; stenting: 0.68 %), aneurysm formation (PTA: 0.29 %; stenting: 0.72 %), stent dislodgment (PTA: 0 %; stenting: 0.06 %), and organ failure (PTA: 0.43 %; stenting: 0.96 %). Technical and clinical success rates were higher, while complication rates were lower than the corresponding threshold recommended by the Society of Interventional Radiology for the percutaneous management of chronic mesenteric ischemia. Treatment of CMI performed by interventional radiologists in Germany is safe and effective during daily and on-call shifts with results exceeding internationally accepted standards. · Treatment of CMI by interventional radiologists in Germany is effective and safe.. · The interventions are safe and effective regardless of whether they are performed during on-call shifts or the daily routine.. · The clinical and technical success rates favorably surpass the thresholds presented by SIR.. · Different major complications occurred in under 1.1 % of CMI interventions..

Long-term value in open and endovascular repair of chronic mesenteric ischemia

ObjectiveGuidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. MethodsPatient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. ResultsFrom 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P < .01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P < .01), with 55 reinterventions in the ER group and 19 in the OR group (P < .01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P = .91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P = .04), for ER and OR respectively. ConclusionsDespite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.

Management of patients with chronic mesenteric ischemia across three consecutive eras

BackgroundEndovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. MethodsA retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. ResultsA total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). ConclusionsConsistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.

Long-term Value in Open and Endovascular Repair of Chronic Mesenteric Ischemia

Guidelines recommend open surgical (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. Patient data was extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payer database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases code for CMI over a 15-year period, with specific exclusion of acute ischemia cases. Propensity match was performed using Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for a final cohort of patients. Multiple linear regression was utilized to determine factors associated with 5-year value, calculated as life-years/$100K in charges adjusted for inflation. Charges were gathered from the index admission and any subsequent admissions over a 5-year period for mesenteric ischemia, mesenteric angiography, or follow-up reintervention. From 2000 to 2014, 744 patients underwent intervention for CMI. Of these, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity matching (n = 209 each group), ER group had higher value at 5 years postprocedure (6.63 ± 8.51 vs 4.52 ± 5.12 life-years/$100K charges; P < .01). All-cause mortality was 53.6% and 68.4% at 5 years (P < .01) for OR and ER, respectively. Reintervention was more common in the ER group (37 vs 17 reinterventions; P = .01). Multiple linear regression analysis found congestive heart failure, dysrhythmia, and cancer were negatively associated with value at 5 years while ER was positively associated (Table). Despite increased reinterventions, value in patients with CMI was higher in those undergoing ER in the largest propensity score matched dataset to date looking at value. Factors negatively associated with 5-year value were OR, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER should be considered over OR based on the superior procedural value. Further research should prospectively examine comorbid conditions, presentation and patient reported outcomes to further validate whether ER is appropriate as the primary treatment modality for CMI.Table IMultiple linear regression for value at 5 yearsβ Coefficient95% confidence intervalP valueER2.040.74-3.35<.01Congestive heart failure(2.35)(4.09-0.62)<.01Dysrhythmia(3.13)(4.83-1.43)<.01Cancer(4.18)(7.69-0.67).02( ) Indicates a negative value. Open table in a new tab

Cost-Effectiveness Analysis of Open Versus Endovascular Revascularization for Chronic Mesenteric Ischemia

Recent studies have shown a trend supporting endovascular revascularization (ER) in the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared the cost effectiveness of ER and open revascularization (OR) for this indication. The purpose of this study is to conduct a cost-effectiveness analysis comparing open versus ER for CMI. We built a Markov model with Monte Carlo microsimulation using transition probabilities and utilities from existing literature for CMI patients undergoing OR versus ER. Costs were derived from the hospital perspective using the 2020 Medicare Physician Fee Schedule. The model randomized 20,000 patients to either OR or ER and allowed for 1 subsequent reintervention with 3 other intervening health states: alive, alive with complications, and dead. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. OR cost $4,532 for 1.03 QALYs while ER cost $5,092 for 1.21 QALYs, leading to an ICER of $3,037 per QALY gained in the ER arm. This ICER was less than our willingness to pay threshold of $100,000. Sensitivity analysis demonstrated that our model was most sensitive to costs, mortality, and patency rates after OR and ER. Probabilistic sensitivity analysis demonstrated ER would be considered cost effective 99% of iterations. This study found that while 5-year costs for ER were greater than OR, ER afforded greater QALYs than OR. Although ER is associated with lower long-term patency and higher rates of reintervention, it appears to be more cost effective than OR for the treatment of CMI.

Chronic mesenteric ischemia

Federation Despite the increased interest of the scientific community in diseases associated with atherosclerosis, the widespread use and availability in clinical practice of diagnostic research methods (Doppler ultrasound, CT, MRI), allowing to visualize the vessels of the abdominal cavity, chronic mesenteric ischemia remains an underestimated, undiagnosed and insufficiently studied disease, mainly due to the lack of knowledge and awareness among doctors, which leads to delays in diagnosis and delayed treatment of patients, which significantly increases the risk of death. Currently, new recommendations for clinical, physical, laboratory and instrumental diagnostics of chronic mesenteric ischemia have been developed and are being implemented. These documents should help primary care physicians in early detection of this disease, optimization of treatment and reduction of mortality from this pathology. The lecture highlights the issues of etiology, pathogenesis, classification, clinical course, laboratory and instrumental diagnostics, as well as the possibilities of conservative and surgical treatment of chronic mesenteric ischemia.

Comparing Endovascular Revascularization to Open Surgical Revascularization for Chronic Mesenteric Ischemia

Although the incidence of chronic mesenteric ischemia (CMI) is uncommon, it could become life threatening. With improvements in diagnostic imaging and endovascular therapy over the past few decades, the treatment of CMI has evolved. Even though endovascular revascularization for CMI is prominent, it is unclear if the early advantages outweigh the long-term patency rates. This study conducts a systematic review and meta-analysis to present comprehensive insights into the validity of endovascular revascularization versus open revascularization as effective therapeutic modalities. Studies up to 2022 were searched in MEDLINE, Cochrane Database of Systematic Reviews, Scopus, and Embase. Additionally, references from earlier studies and review papers were manually searched for additional relevant reports. At least two authors examined all the results, making sure they fit the inclusion and exclusion criteria. In the event of disagreement, the authors were able to reach an understanding. Open revascularization is superior to endovascular approaches in maintaining vessel patency and reducing symptoms over the long term. Perioperative problems are more common in patients undergoing open procedures. Each patient's anatomy and physiology call for a different revascularization approach to be applied in treating this condition.

2D-perfusion angiography for intra-procedural endovascular treatment response assessment in chronic mesenteric ischemia: a feasibility study

BackgroundEndovascular revascularization has become the first-line treatment of chronic mesenteric ischemia (CMI). The qualitative visual analysis of digital subtraction angiography (DSA) is dependent on observer experience and prone to interpretation errors. We evaluate the feasibility of 2D-Perfusion Angiography (2D-PA) for objective, quantitative treatment response assessment in CMI.Methods49 revascularizations in 39 patients with imaging based evidence of mesenteric vascular occlusive disease and clinical signs of CMI were included in this retrospective study. To assess perfusion changes by 2D-PA, DSA-series were post-processed using a dedicated, commercially available software. Regions of interest (ROI) were placed in the pre- and post-stenotic artery segment. In aorto-ostial disease, the inflow ROI was positioned at the mesenteric artery orifice. The ratios outflow to inflow ROI for peak density (PD), time to peak and area-under-the-curve (AUC) were computed and compared pre- and post-interventionally. We graded motion artifacts by means of a four-point scale. Feasibility of 2D-PA and changes of flow parameters were evaluated.ResultsMotion artifacts due to a mobile vessel location beneath the diaphragm or within the mesenteric root, branch vessel superimposition and inadequate contrast enhancement at the inflow ROI during manually conducted DSA-series via selective catheters owing to steep vessel angulation, necessitated exclusion of 26 measurements from quantitative flow evaluation. The feasibility rate was 47%. In 23 technically feasible assessments, PDoutflow/PDinflow increased by 65% (p < 0.001) and AUCoutflow/AUCinflow increased by 85% (p < 0.001). The time to peak density values in the outflow ROI accelerated only minimally without reaching statistical significance. Age, BMI, target vessel (celiac trunk, SMA or IMA), stenosis location (ostial or truncal), calcification severity, plaque composition or the presence of a complex stenosis did not reach statistical significance in their distribution among the feasible and non-feasible group (p > 0.05). ConclusionsCompared to other vascular territories and indications, the feasibility of 2D-PA in mesenteric revascularization for CMI was limited. Unfavorable anatomic conditions contributed to a high rate of inconclusive 2D-PA results.

Successful endovascular treatment of severe chronic mesenteric ischemia facilitated by intraoperative positioning system image guidance

We report our initial experience using the intraoperative positioning system (IOPS), a novel endovascular navigation system that does not require contrast or radiation, in the treatment of chronic mesenteric ischemia (CMI). We used IOPS to help treat three of four consecutive patients with CMI. Technical problems prevented successful use in one patient. For the patients for whom IOPS was used effectively, catheterization of the mesenteric artery was accomplished more quickly than for the patient for whom IOPS was not effective. Our experience has shown that IOPS can be safely and effectively used for CMI and can reduce the contrast load and radiation dose.

Comparison of Covered and Bare Metal Stents in Chronic Mesenteric Ischemia

There remains a paucity of studies and no clear treatment algorithm for the treatment of chronic mesenteric ischemia (CMI). However, recent societal guidelines have recommended the use of covered stents (CSs) over bare metal stents (BMSs) for these patients. We sought to characterize the patient population undergoing intervention for CMI and compare the primary patency and postintervention outcomes of BMSs and CSs.

Cost-effectiveness Analysis of Open versus Endovascular Revascularization for Chronic Mesenteric Ischemia

Recent studies have shown a trend supporting endovascular revascularization (ER) in the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared the cost effectiveness of ER and open revascularization (OR) for this indication. The purpose of this study is to conduct a cost-effectiveness analysis comparing open versus endovascular revascularization for CMI.

Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia.

Background: To analyse the long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) in the treatment of chronic mesenteric ischemia (CMI), and to assess predictive factors for a better clinical outcome. Patients and methods: Retrospective analysis of 76 consecutive patients, treated percutaneously for CMI between January 1999 and January 2018 and followed up until the end of 2018. Patients' pre-, peri- and post-interventional clinical and radiological data were gathered from the institutional electronic medical records. The Kaplan Meier method with log rank test or the Cox model were used to analyse overall survival; the cumulative incidence function with Pepe and Mori test or the Fine and Grey model were used to analyse relapse-free survival, considering death as a competing event. Results: Seventy-six consecutive patients with a mean age of 72 years were included in the study. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23 (29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical success was achieved in n=68 (89.5%), and procedural complications were observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n=21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0% and 28.2% after two, five and ten years of follow-up, respectively. A trend towards longer relapse-free survival was found in the circumferential stenosis group (78.2% at five years) compared with the non-circumferential stenosis group (55.5%) (P=0.063). Conclusions: Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite a substantial number of patients experiencing clinical relapse over time. Patients with focal, circumferential stenosis might have longer relapse-free survival than patients with non-circumferential stenosis.

Non-surgical treatment of chronic mesenteric ischemia owing to lesion in the SMA through the SMI: An option for consideration in frail patients

Non-surgical treatment of chronic mesenteric ischemia owing to lesion in the SMA through the SMI: An option for consideration in frail patients

Outcomes Using Uncovered Stents and Covered Stents Are Similar for Management of Chronic Mesenteric Ischemia: A Single-Center Retrospective Experience

Endovascular treatment of chronic mesenteric ischemia (CMI) has been shown to have similar perioperative mortality and shorter hospitalization compared with open repair but increased reinterventions due to restenosis. Covered stents (CSs) are associated with less restenosis, recurrence of symptoms, and reinterventions than bare-metal uncovered stents (UCSs). This study intends to revisit endovascular management of CMI and to evaluate differences in patients who received CSs or UCSs. Clinical data were obtained retrospectively for CMI patients at a single center from 2010 to 2015. Patients included were treated with either UCS or CS, were diagnosed with CMI, and had radiographic evidence of mesenteric disease. Patients who were excluded had acute mesenteric ischemia or procedures performed at an outside hospital. Sixty patients with an average age of 70.7 ± 9.4 years were involved in the study. Comorbidities included type 2 diabetes (21/60), hypertension (51/60), hyperlipidemia (51/60), and smoking history (52/60; Table I). Fisher exact test was performed, and there was a difference between the specific mesenteric vessel intervention completed and the number of diseased mesenteric vessels (P < .001). No difference was seen between UCS and CS with vessel intervened on (P = .290). There was no significant difference in symptom recurrence (48.8% vs 42.1%), reintervention rates (34.2% vs 26.3%), number of reinterventions (1 [1-4] vs 1 [1-2], median [range]), or hospital length of stay (1 [0-28] days vs 1 [0-8] days) between UCS and CS interventions, respectively (P > .05). Reintervention rates were similar despite antiplatelet regimen (no antiplatelet, 40%; single antiplatelet, 48.4%; or dual antiplatelet, 47.4%; P > .05). No significant difference in death rate (43.9% vs 68.4%) was seen, and all-cause mortality from index operation was 2.6 years (0.1-7.2 years; Table II). In this retrospective review, there was no significant difference in success rate for revascularization, recurrence, or complications with the use of CSs or UCSs. Larger randomized studies may be needed to determine the superiority of one stent type over another.Table IDemographics of patients receiving uncovered stents (UCSs) and covered stents (CSs) for chronic mesenteric ischemia (CMI)Age, years70.7 ± 9.4Type 2 diabetes35%Sex63.3% MHypertension85%36.7% FHyperlipidemia85%Total patients60Smoking86.70% Open table in a new tab Table IIDifferences in outcomes between interventions completed for uncovered stents (UCSs) and covered stents (CSs)UCSsCSsSymptom recurrence48.8042.10Incidence of reintervention34.2026.30Total No. of reinterventions1 (1-4)1 (1-2)Hospital length of stay, days1 (0-28)1 (0-8)Death rate43.9068.40Categorical variables are presented as percentage. Continuous variables are presented as median (range). Open table in a new tab

Chronic mesenteric ischemia: current state of the problem

Chronic mesenteric ischemia until now represent the difficult tasks of primary diagnosis and ambiguous approaches to therapy. This review analyzes domestic and foreign research articles from the PubMed database, the eLibrary scientifi c digital library over the past decades. A review of literary sources allowed to provide modern data on the epidemiology, diagnosis and treatment of chronic mesenteric ischemia from the standpoint of evidence-based medicine.

Long-term Stent Outcomes for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia is a disease process that has significant morbidity and mortality. Stent placement for treatment of mesenteric occlusive disease had offered a minimally invasive alternative to open surgery. The objectives of this study were to identify long-term outcomes for mesenteric stenting in the setting of chronic mesenteric ischemia. A single vascular group’s database was retrospectively reviewed for all patients who underwent mesenteric artery stenting for chronic mesenteric ischemia between 2000 and 2019. Demographics, indications, operative details, and long-term results were recorded and compared. Standard statistics using life tables and t-tests were used. There were 275 patients who had stents placed: 186 superior mesenteric artery (SMA) stents, 61 celiac stents, and 28 both SMA and celiac stents. Average age was 71 years (range, 30-91 years). Demographic characteristics were as follows: hypertension, 39% (106/275); hyperlipidemia, 26% (70/275); tobacco, 20% (56/275); coronary disease, 21% (57/275); chronic obstructive pulmonary disease, 10% (28/275); and diabetes, 15% (41/275). Median follow-up was 60 months (range, 1-120 months). Celiac stent patency was 100%, 98%, 97%, 93%, and 87% at 1 month, 3 months, 6 months, 12 months, and 24 months, respectively. SMA stent patency was 97%, 96%, 93%, 90%, and 83% at 1 month, 3 months, 6 months, 12 months, and 24 months. Reintervention was required in 28% (77/275), of which 66% (51/77) was repeated angioplasty and 34% (26/77) was stent graft placement. The SMA stent length was 34.4 mm, and the celiac stent length was 33.7 mm. In the reintervention group, stent length was 33.7 mm; in the nonreintervention group, stent length was 42.3 mm (P = .001). Twenty-two patients crossed over to open mesenteric bypass (14 SMA, 8 celiac). Of the crossover patients, all 22 had reinterventions before converting to open repair (9 repeated stent placements as a reintervention before failure and 13 angioplasty procedures). Stenting for treatment of chronic mesenteric ischemia offers excellent patency and freedom from open bypass surgery. Very few stents fail and require open surgery. Shorter stent lengths appear to require statistically more reinterventions to maintain patency.

Early- and Long-term Outcome After Endovascular Treatment of Chronic and Acute on Chronic Mesenteric Ischemia in a Large National Cohort

Introduction: Treatment of chronic mesenteric ischemia has evolved from open surgery towards endovascular revascularization in most centers(1). The endovascular approach includes a low early morbidity, shorter lengths of hospital stay (LOS) and early recovery despite higher risk of restenosis and lower patency compared to open repair(2,3). Long-term outcome after endovascular treatment remains to be proven in larger series. The objective of this study was to assess early- and long-term outcome after endovascular revascularization of chronic (CMI) and acute on chronic (AoCMI) mesenteric ischemia in a large national cohort. Methods: All patients treated endovascularly due to CMI or AoCMI between 2011 and 2015 were included. Patients with acute mesenteric ischemia (embolic) or previous open mesenteric revascularization were excluded. Treatment of mesenteric ischemia in our country is centralized to one tertiary vascular referral center, why this study represents a national cohort. Prospectively entered data were extracted from the National Vascular Registry. Subsequently, electronic records and PACS were manually and retrospectively assessed. Endpoints included technical success rate, early- (mortality, bowel resection, complications, LOS) and long-term- (1-3 year mortality, symptom relief) outcome. Potential outcome predictors were evaluated. Results: In total, 246 patients with CMI or AoCMI were included. The clinical presentation was CMI in 178 patients (mean age 70; women 68%) and AoCMI in 68 patients (mean age 69; women 69%). 30-day mortality in the CMI and AoCMI group was 2% (n=3) and 16% (n=11), respectively (p < .0001). The CMI group had significantly better survival rates after one and three years, with Kaplan Meier (KM) estimates of 85% (95% CI 78.7-89.3) and 73% (95% CI 66.0 - 79.3) in the CMI group compared to 66% (95% CI 53.4 - 76.0) and 53% (95% CI 40.3 - 64.4) in the AoCMI group (figure 1). Independent predictors of death were AoCMI vs CMI (HR = 1.8 (p< .01)) and hypertension in the CMI group (HR =2.7 (p=.001)). Based on angiography, we found no correlation between outcome and number of diseased vessels. Five patients (3%) in the CMI group and 30 patients (44%) in the AoCMI group underwent bowel resection. LOS was seven times longer in the AoCMI group (mean 20 days (95% CI 12.4-27.6)) compared to the CMI group (2.9 days (95% CI 2.4-3.3)). Symptom relief after one year was identical; (60% (n=107) vs. 53% (n=36) in the CMI and AoCMI group, respectively (p= .3). Reintervention due to symptom recurrence and target artery restenosis was performed only in 10 patients (6%) in the CMI group and 1 patient (1%) in the AoCMI group after mean 219 days (95% CI 89.1-349)) and 423 days respectively. Five access-related complications (2%) needed reintervention, target-vessel related complications were seen in 7 patients (3%) and 1 patient had cerebral embolization. Conclusion: First-line endovascular treatment of CMI and AoCMI is related with acceptable short- and long-term outcome and a low risk of symptomatic restenosis. As expected, patients suffering AoCMI have significantly higher mortality, more bowel resection and longer LOS compared to CMI patients, underlining the importance of early diagnosis and treatment of CMI. Disclosure: Nothing to disclose

Open surgery for the treatment of chronic mesenteric ischemia results in a better long-term survival without recurrence and a mortality comparable with endovascular treatment: a multicentric study

Endovascular treatment (EV) is currently used in first intention for chronic mesenteric ischemia (CMI) due to a lesser postoperative morbi-mortality compared to open surgery (OS), but what are the long term results? The aim of this study was to evaluate the survival and the patency of the vessels revascularized by these two techniques in a multicentric cohort.

Endovascular treatment of chronic mesenteric ischemia

Atherosclerosis occurring in the digestive arteries is rare and often asymptomatic. When it becomes symptomatic, surgical care is indicated. Conventional procedures are giving way to improved endovascular techniques applied to the mesenteric arteries. The aim of this single-center study was to evaluate short- and mid-term outcome after endovascular revascularization of the mesenteric arteries. We report a retrospective study about patients who underwent endovascular treatment of chronic mesenteric ischemia between 2013 and 2018. Our population consisted of 10 patients. The average age was 60 years [range 45-78]. Clinical symptomatology associated abdominal pain and weight loss. All patients underwent computed tomographic angiography (CTA). Severe stenosis (>70%) involved the superior mesenteric artery (SMA) in ten cases, the celiac trunk in four cases and the inferior mesenteric artery in three. The procedure was performed under local anesthesia in all cases. The superior mesenteric artery was revascularized in all cases and the celiac trunk in two. Transluminal angioplasty was followed by deployment of a stent in all cases. The postoperative course was satisfactory. Outcome was good with all patients being symptom-free at one month. Our average follow-up was three years [range 1-5]. All patients underwent a Duplex ultrasound every six months. Recurrence of symptomatology was reported in two patients at 18 months and 24 months. The first patient underwent CTA that showed superior mesenteric artery and celiac trunk stent stenosis. The patient underwent a second transluminal angioplasty with a drug eluting balloon. The second patient was admitted to the emergency room for acute mesenteric ischemia related to acute thrombosis of the superior mesenteric artery stent. Laparotomy enabled extensive resection of the small bowel and aorto-mesenteric venous antegrade bypass, but the patient died the same day. Endovascular treatment has an important role to play in the management of chronic mesenteric ischemia. It is associated with a high rate of technical success. Patients should be carefully followed-up because of the mid-term risk of recurrent symptoms associated with intra-stent restenosis or thrombosis.