Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience

INTRODUCTION: Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI. METHODS: During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence. RESULTS: Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin<3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P<.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49). CONCLUSIONS: Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.     

Mesenteric stenting for chronic mesenteric ischemia

BACKGROUND: Mesenteric stenting has not been widely adopted for the treatment of chronic mesenteric ischemia (CMI). The recent availability of embolic protection and low-profile devices with the theoretical ability to decrease perioperative bowel necrosis, led us to begin using mesenteric stenting for patients with CMI. We review our initial experience to examine short-term outcomes. METHODS: We performed a retrospective analysis of all patients who were treated by vascular surgeons with mesenteric stenting for CMI. Patients with acute mesenteric ischemia were excluded. We evaluated perioperative morbidity and mortality, restenosis, recurrent symptoms, and reintervention. Kaplan-Meier methods were used to assess events during follow-up. We also compared these outcomes with a historical control group of patients treated with open surgical revascularization. RESULTS: Fourteen patients underwent mesenteric stenting over the past 3 years. Mean age was 73, and 64% were women. There was no perioperative or 30-day mortality or major morbidity. Early restenosis and recurrent symptoms occurred in 10% and 9% of patients at 6 months. At a mean follow-up of 13 months, 53% of patients underwent reintervention. However, 93% were symptom-free at their last follow-up. Compared with open surgery, stent patients had lower perioperative major morbidity (30% vs 0%, P < .01) and shorter hospital and intensive care unit length of stay (median 10 days vs 2 days, and 3 days vs 0 days, respectively, P < .01 for both). However, stent patients were seven times as likely to develop restenosis (P < .01), four times more likely to develop recurrent symptoms (P < .01), and 15 times more likely to undergo reintervention (P < .01). There was one death 13 months after stenting due to mesenteric infarction in a patient lost to follow-up. One patient was successfully converted to open surgery after a second restenosis. He had regained 20 pounds and was determined to be a better operative candidate than at his initial presentation. There was no perioperative or 30-day mortality or major morbidity with reintervention after mesenteric stenting. CONCLUSION: Mesenteric stenting for CMI can be performed with low perioperative risk. However, stenting is associated with early restenosis and recurrent symptoms requiring secondary procedures. Patients with severe nutritional depletion or high surgical risk may benefit from mesenteric stenting for CMI, but close follow-up is required. Later open surgery can be performed for restenosis if nutritional status and surgical risk are improved, or repeat angioplasty and stenting can be effectively performed if operative risk remains high.     

腹腔动脉和肠系膜上动脉狭窄的介入治疗

目的评价介入技术治疗腹腔动脉（CA）和肠系膜上动脉（SMA）狭窄的安全性和临床疗效。方法对8例CA／SMA局限性狭窄患者进行了经皮穿刺经腔球囊血管成型术（PTA）和支架置入术,单纯CA狭窄2例、单纯SMA狭窄4例、CA和SMA均有狭窄2例。4例患者有典型进餐后腹痛,5例有上腹部血管杂音,8例于发病后均有不同程度的体重下降（平均8kg）。7例患者病因为动脉硬化,1例为膈肌中脚压迫综合征（MALS）所致。结果PTA和支架置人均成功,其中治疗CA狭窄3例、SMA狭窄5例,7例用1个支架,1例用2个支架。治疗结束时复查造影显示置人支架的血管血流通畅,管径接近正常。术后于穿刺侧腹股沟区出现小血肿2例,无须外科处理、自行吸收。术后腹痛完全消失5例、有所减轻2例、无改善1例;术后3个月时,体重恢复至发病前水平者6例。8例患者随访6-72个月（平均42个月,中位值28个月）,复查Doppler超声波无明确再狭窄证据。5例无症状、1例仍然有间歇性腹痛,2例分别于术后14个月、24个月死于其他原因。结论PTA和支架置入术是治疗CA、SMA局限性狭窄的安全有效方法,尤适宜于存在外科治疗高风险的患者。     

Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia

INTRODUCTION: Acute mesenteric ischemia (AMI) caused by arterial occlusive disease requires prompt diagnosis and revascularization to avoid the high mortality associated with this disease. In an attempt to minimize the magnitude of operation for arterial occlusive AMI, we have developed a new technique of endovascular recanalization and open retrograde stenting of the superior mesenteric artery (SMA) during laparotomy so that the bowel can also be assessed and resected if necessary. METHODS: All emergent mesenteric revascularizations for arterial occlusive AMI performed at Dartmouth-Hitchcock Medical Center from 2001 to 2005 (n = 13) were retrospectively reviewed. Outcomes were analyzed with respect to the method of revascularization and other perioperative variables. Restenosis was evaluated with duplex ultrasound imaging. RESULTS: Three different revascularization methods were used: surgical bypass (n = 5), antegrade percutaneous stenting (n = 2), and retrograde open mesenteric (SMA) stenting (ROMS, n = 6). Satisfactory revascularization was achieved in all cases and all methods. ROMS was successfully accomplished in three of six patients after antegrade attempts to cross the SMA from the arm were unsuccessful. At 17%, the ROMS group had the lowest hospital mortality compared with bypass at 80% (P = .08) and percutaneous stent at 100% (P = .11). All five of the surviving patients treated with ROMS were discharged to home after a mean hospital stay of 20 days (range, 6 to 38 days). During a mean follow-up of 13 +/- 7 months, three patients died of unrelated causes, of which two were being followed with asymptomatic recurrent SMA stenosis detected by duplex scan. The two surviving patients are alive and well, but one has required percutaneous SMA stenting of a progressive asymptomatic restenosis. CONCLUSION: Retrograde open SMA stenting during laparotomy for AMI has a high technical success rate and provides an attractive alternative to surgical bypass in these often critically ill patients. Because it is combined with open laparotomy, it honors the essential surgical principles of evaluating and resecting nonviable bowel. Restenosis rates appear to be high, so that patients must be followed closely. Further study and development of this new hybrid technique is warranted.     

Follow-up of renal and mesenteric artery revascularization with duplex ultrasonography

Objective

To evaluate the long-term anatomic results of renal revascularization procedures using duplex ultrasonography.

Design

A case series.

Setting

A university-affiliated hospital.

Patients

Twenty-five patients who had undergone renal percutaneous transluminal angioplasty (PTA) (18 arteries), renal bypass (10 arteries) and mesenteric bypass (6 arteries). The mean follow-up was 22 months (range from 3 to 48 months) for those who underwent renal PTA, 23 months (range from 1.5 to 70 months) for those who underwent renal bypass and 34 months (range from 8 to 144 months) for those who underwent mesenteric bypass.

Main Outcome Measures

Patency rates for the three procedures as assessed by duplex ultrasonography.

Results

Duplex ultrasonography demonstrated patency without stenosis after renal and mesenteric artery revascularization in 14 arteries subjected to renal PTA, 9 arteries subjected to renal bypass and 6 arteries subjected to mesenteric bypass. Three arteries that had renal PTA had recurrent vessel stenosis and one had occlusion. One artery that had renal bypass showed occlusion.

Conclusions

Renal PTA, renal bypass and mesenteric bypass are durable procedures at 2 years of follow-up, and duplex ultrasonography is a valuable method for assessing the patency of arteries after renal and mesenteric revascularization.     

Technique of hybrid retrograde superior mesenteric artery stent placement for acute-on-chronic mesenteric ischemia

Revascularization for acute mesenteric ischemia can be challenging in patients with bowel gangrene, peritoneal contamination, and no good source of inflow for a bypass graft. A 70-year-old female patient presented with acute-on-chronic mesenteric ischemia, flush superior mesenteric artery (SMA) occlusion, and diffuse aorto-iliac occlusive disease. This study describes the technique of hybrid retrograde SMA recanalization and stent placement using a midline laparotomy is described. The mid-portion of the SMA was exposed and jejunal branches were controlled with silastic vessel loop. Retrograde access was established under direct vision and the occluded SMA segment was crossed, pre-dilated, and stented using a balloon-expandable stent. The SMA was flushed through a longitudinal arteriotomy, which was closed using a saphenous vein patch. Retrograde hybrid SMA stenting is an expeditious option to revascularize patients with acute on chronic mesenteric ischemia who have peritoneal contamination and no other good source of inflow to the mesenteric arteries.     

Jejunal arterial access for retrograde mesenteric stenting

Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a “mini-laparotomy” and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.     

Antegrade Revascularization for Chronic Mesenteric Ischaemia

Objective: to evaluate the short-and long-term results, obtained after open revascularization for chronic mesenteric ischaemia as a reference in a field with growing interest for PTA and stenting.

Materials and methods: we reviewed 14 patients with 15 antegrade revascularizations for chronic intestinal ischaemia, between 1996 and 2003: ten bypasses either to the celiac trunk or to the mesenteric artery and five bifurcated bypasses to both arteries were performed. There was one reimplantation for Wilki syndrome. Graft patency was monitored for a mean period of 24 months (range 1–84 months) by clinical examination and duplex scanning. Main results: one patient had recurrence of symptoms that disappeared after successful reoperation. There was one perioperative death All the other patients (84%) had a long-term symptom free survival.

Conclusion: antegrade mesenterial revascularization through an upper abdominal approach is an excellent technique with good long-term results. It sets a high standard that will be difficult to obtain with mesenteric PTA and stenting. It remains the preferred method of revascularization in low-risk patients.     

How to manage chronic mesenteric ischemia? A deliberated strategy

Abstract

Chronic mesenteric ischemia is a rare and challenging clinical entity with non-specific complaints. It concerns mainly elderly patients with a diffuse atherosclerotic burden affecting other vascular beds. Most surgeons have limited experience with the management of symptomatic occlusive disease of the superior mesenteric artery or coeliac trunk. Last decades, the mesenteric revascularisation debate has also been implicated by the endovascular vogue. An endovascular-first strategy has been adopted in most centres, considering its less invasive character, with lower peri-procedural morbidity and mortality and more rapid recovery. The volume of mesenteric artery stenting has steadily increased over time. However, the long-term results of percutaneous mesenteric angioplasty and stenting are worse than those obtained with open surgery. Currently, many centres reserve open repair for cases in whom PTA failed. This extensive literature review aims to orientate decision-making and choice of revascularisation modality for chronic mesenteric ischemia, considering a significant patient heterogeneity.     

Endovascular treatment of celiac and mesenteric arteries stenoses: applications and results

PURPOSE: To evaluate the safety and assess the role of endovascular therapy in a variety of conditions related to celiac and mesenteric vascular occlusive disease.Patients and methods Our retrospective study population included 25 consecutive patients (mean age, 66 years), in whom 28 procedures were performed on 26 stenosed or occluded mesenteric vessels (superior mesenteric artery [SMA] or celiac artery [CA]). Indications included chronic mesenteric ischemia (21 patients), including 2 patients who underwent stenting prior to a planned operative repair of a juxtamesenteric AAA. Three liver transplantation patients underwent stenting of an associated CA stenosis. One patient with a splenorenal bypass underwent stenting on an associated CA stenosis. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency on duplex sonography and sustained clinical benefit. The need for additional interventions was noted. RESULTS: All procedures but one were technically successful (96%). Major complications occurred in three patients (one transient contrast-induced nephrotoxicity and two pseudoaneurysms). Immediate clinical success was achieved in 22 patients (88%). The three clinical failures included two patients with an excellent angiographic outcome, but with single-vessel moderate severity disease. Survival table analysis of delayed clinical outcome showed primary and primary-assisted clinical benefits at 11 months of 85% and 91%, respectively. Primary and primary-assisted stent patencies, as assessed by duplex sonography and/or angiography, at 6 months were both 92%. Angiographically documented restenosis occurred in three patients. Restenosis in two patients with CA stents was due to extrinsic compression, and it was without symptoms in one patient and was treated satisfactorily by restenting in the other patient. Restenosis in one patient with an SMA stent was successfully treated by restenting. CONCLUSIONS: Our experience suggests a potential role for endovascular therapy of celiac and mesenteric arterial occlusive disease in a variety of clinical scenarios, with a low incidence of complications and a high technical success rate.     

股浅动脉首期置入自膨式支架与球囊扩张成形的疗效比较

目的 比较股浅动脉狭窄闭塞长段病变一期置入自膨式支架与一期球囊扩张成形的中期疗效.方法 回顾性分析2005年12月至2007年2月收治的症状性股浅动脉硬化狭窄或闭塞109例患者的临床资料,其中支架组53例(73条肢体)首期置入自膨式支架;扩张组56例(76条肢体)首期单纯球囊扩张成形.比较患者术后6、12及24个月的再狭窄、再闭塞率及临床分级改善程度.结果 支架组与扩张组的治疗段平均长度分别为(16±8)cm和(15±7)cm;经血管超声检杳支架组与扩张组术后6个月再狭窄率分别为13.7%(7例)和30.2%(16例),两组差异有统计学意义(X2=4.09,P<0.05);12个月分别为25.5%(12例)和46.9%(23例),两组差异有统计学意义(X2=4.75,P<0.05);24个月分别为38.1%(16例)和65.9%(29例),两组差异有统计学意义(X2=6.66,P<0.01);且支架组较扩张组临床分级改善显著而持久.结论 对于股浅动脉硬化狭窄或闭塞长段病变,首期置入自膨式支架的中期疗效较单纯球囊扩张血管成形术更为理想.     

Endovascular treatment as a bridge to successful surgical revascularization for chronic mesenteric ischemia

Chronic mesenteric ischemia (CMI) can be treated with surgical revascularization or with angioplasty and stenting. As experience has been gained, endovascular treatment appears safe and effective in selected patients. Currently, surgical revascularization has better success and patency rates but also a higher short- and midterm mortality and morbidity, especially in patients at high surgical risk. A 72-year-old female with severe respiratory dysfunction presented with CMI resulting in profound malnutrition. Serial percutaneous interventions averted urgent surgery and reversed the mesenteric ischemia. Nine months later, after repeated angioplasty and stenting had failed, elective uncomplicated iliomesenteric bypass, in a medically optimized patient, resolved the ischemia. At an 18-month follow-up, the graft remained widely patent and the patient asymptomatic with a body weight corresponding to her ideal body weight. Compared to surgical revascularization, reocclusion or restenosis occurs more frequently after endovascular treatment of CMI, and reintervention may be necessary. Nevertheless, percutaneous intervention effectively provides relief from mesenteric ischemia and has lower perioperative complication rates compared to surgery in patients at high surgical risk. After initial relief of the CMI, the patient's condition may improve, allowing for more definitive secondary surgical revascularization, if needed.     

Results of retrograde open mesenteric stenting for acute thrombotic mesenteric ischemia

Objective

Acute mesenteric ischemia (AMI) is an emergent event with a high mortality rate; survivors have high rates of intestinal failure. Restoration of blood flow using endovascular or surgical revascularization is associated with better outcome in terms of survival rate and intestinal resection. Retrograde open mesenteric stenting (ROMS), which is a hybrid technique, combines two benefits: prompt blood flow restoration with an endovascular approach and inspection and resection of the small bowel. The aim of the study was to assess the results of ROMS in thrombotic AMI in a retrospective multicenter study.

Superior mesenteric artery stent fracture producing stenosis and recurrent chronic mesenteric ischemia: case report

Endovascular modalities are being increasingly employed in the treatment of a variety of vascular diseases. With new technologies come novel complications, and one such complication unique to endovascular surgery is stent fracture. We present two cases of stent fracture following stenting of the superior mesenteric artery and discuss possible causes and treatments.     

Acute thrombosis of a mesenteric artery drug-eluting stent following clopidogrel cessation

LEARNING OBJECTIVE: To describe thrombosis of sirolimus-coated mesenteric arterial stents following cessation of clopidogrel therapy. BACKGROUND: Cardiac drug-eluting stent thrombosis following cessation of antiplatelet therapy with clopidogrel has been associated with increased mortality. The application of such stents in the mesenteric arterial system and the subsequent need for clopidogrel therapy has not been studied. This is the first case report of acute thrombosis of a drug-coated stent in the mesenteric circulation. CLINICAL FINDINGS: Acute mesenteric ischemia secondary to thrombosis of a mesenteric arterial stent following clopidogrel cessation is described. CONCLUSION: Drug-eluting stents represent an option for mesenteric revascularization in the surgically complicated abdomen. As in the setting of cardiac stenting, acute thrombosis of these devices following cessation of clopidogrel therapy is a concern. Indefinite clopidogrel therapy following deployment of drug-coated stents should be considered.     

Comparison of the results of percutaneous transluminal angioplasty and stenting with medical treatment for claudicants who have superficial femoral artery occlusive disease

The outcomes of medical management of peripheral vascular disease localized to the superficial femoral artery (SFA) were compared with those obtained by percutaneous transluminal angioplasty (PTA) with or without stenting in a review of selected studies. The natural history of localized SFA disease is favorable, with major amputation rates less than 10% and revascularization in only 18% of patients over a 10-year interval. Conservative treatment of claudicants shows increases (150%) in walking distance if the ankle brachial index (ABI) is over 0.6 and patients stop smoking. Analysis of 10 trials (882 patients) of PTA with or without stenting found that the overall primary patency rates at 12 months were 71.1% for PTA plus stenting and 58.3% for PTA alone. Technical success with PTA with or without stenting is over 90%, and early results at 6 months are superior to those with exercise. In three randomized controlled trials, however, the difference between PTA and medical treatment at 2 years, whether measured by walking distance or ABI, was not significant, nor was the quality of life. For long-term improvement in walking distance (> 1 year) in the claudicant, intervention is not superior to medical treatment and a monitored exercise program. Consideration should be given to including a nonintervention control group and 2-year outcomes in the evaluation of new SFA stents.     

Isolated spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement: case report

Acute ischemia due to spontaneous dissections of the superior mesenteric artery are uncommon events, with sporadic reports. Therapeutic options include clinical management, direct artery repair, bowel resection, and more recently, endovascular stenting. We present a case of abdominal pain due to superior mesenteric artery spontaneous isolated dissection treated with stent placement and with a favorable 31-month follow-up period.     

Percutaneous transluminal angioplasty and stenting of coeliac artery stenosis in the treatment of mesenteric angina: a case report and review of therapeutic options

We report the case of a 72-year-old gentleman with mesenteric angina who was successfully treated with stenting of a coeliac artery stenosis using a Palmaz stent, and review the therapeutic options in the management of mesenteric angina.     

Stenting for localised arterial stenoses in the aorto-iliac segment.

OBJECTIVE: to determine complications and patency following angioplasty (PTA) and stenting of aorto-iliac stenoses. Setting: District General Hospital in U.K. Design: prospective observational study. PATIENTS AND METHODS: between December 1994 and June 2000, 50 patients (38 men), median age 64 (41-89) years underwent aorto-iliac stenting. A total of 61 stents were placed. Indications were intermittent claudication in 38 and rest pain, ulceration or gangrene in 12. Sites stented were aorta 11, common iliac artery 32, external iliac artery 14, common and external iliac arteries two. Bilateral iliac procedures were carried out in nine. Two stents were used to correct residual stenoses after aortic stenting. Some 11 recurrent stenoses were treated. The other reasons for stenting were residual stenoses greater than 30% after PTA, tight calcified stenoses or when a stenosed iliac artery was being used as a donor prior to crossover or femoropopliteal bypass. RESULTS: two immediate technical failures occurred due to malposition. Residual stenoses were corrected by PTA. Two further patients sustained minor complications. None of the aortic stents occluded through two required secondary procedures. Primary-assisted patency was thus 100% at three years. Primary patency following iliac stenting for claudication and critical ischaemia were 97% and 86% at three years respectively. CONCLUSION: PTA and stenting of aorto-iliac stenoses can be safely achieved with durable results.     

膝下动脉硬化闭塞症腔内治疗的效果分析

目的探讨经皮腔内血管成形结合支架植入术对膝下动脉硬化闭塞症的治疗效果。方法回顾性分析我院2005年10月~2009年5月182例（210条肢体）膝下动脉硬化闭塞症的临床资料,采用常规或内膜下成形技术对狭窄或闭塞性病变进行球囊扩张,38条肢体在胫腓干植入冠脉支架。结果 195条肢体获得影像学成功（残余狭窄率〈30%）,技术成功率为92.9%（195/210）。并发症主要有动脉穿孔（3例）、痉挛（4例）、管壁夹层（6例）及穿刺点血肿（5例）,给予相应处理后缓解。182例术后肢体疼痛、麻凉感等临床症状均改善,踝/肱指数（AB I）由术前的0.40±0.11增至术后7 d的0.83±0.15（t=33.50,P〈0.0001）。术后6、12个月肢体血流通畅率分别为89.0%（187/210）和73.3%（154/210）,术后12个月肢体保全率和存活率分别为91.4%（192/210）、93.3%（196/210）。结论腔内治疗膝下动脉硬化闭塞症的临床成功率高、并发症少、保肢率高,是安全有效的治疗方法。