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Multicenter experience with retrograde open mesenteric artery stenting via laparotomy for treatment of acute and chronic mesenteric ischemia
Rodrigo Almeida Coelho Macedo, M.D.1, Gustavo S. Oderich, MD1, Kalra Manju, M.D.1, David Stone, M.D.2, Edward Woo, M.D.3, Jean Panneton, M.D.4, Timothy Resch, M.D.5, Marc Schermerhorn, M.D.6, Jason Lee, M.D.7, John Fallon, M.D.2, Tareq Massimi, M.D.4, Ben Herdrich, M.D.3, Tommy Curran, M.D.6, Peter Gloviczki, M.D.1, Audra Duncan, M.D.1, Mark Fleming, M.D.1, Randall De Martino, M.D.1, Thomas Bower, M.D.1.
1Mayo Clinic, Rochester, MN, USA, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 3University of Pennsylvania, Philadelphia, PA, USA, 4Eastern Virginia medical school, Norfolk, VA, USA, 5Skane University Hospital, Malmo, Sweden, 6Beth Israel Deaconess medical center, Boston, MA, USA, 7Stanford University, Stanford, CA, USA.
Objective: Retrograde open mesenteric stenting (ROMS) via laparotomy was introduced as an alternative to surgical bypass in patients with acute mesenteric ischemia (AMI). The purpose of this study was to evaluate the indications and outcomes of ROMS for treatment of acute and chronic mesenteric ischemia (CMI).
Methods: We reviewed the clinical data and outcomes of all consecutive patients treated by ROMS in seven academic centers from 2001 to 2013. ROMS was performed via laparotomy with retrograde access into the target mesenteric artery and stent placement using retrograde and/or antegrade approach. End-points were early and late (>30 days) mortality, morbidity, patient survival, patency rates and freedom from symptom recurrence and re-intervention.
Results: There were 54 patients, 13 male and 41 female, with mean age of 71±11 years. Indications for ROMS were AMI in 44 patients (81%) and CMI with flush mesenteric occlusions in 10 (19%). Fifty-three superior mesenteric artery and 4 celiac axis lesions were treated by stenting; mean stent length was 42±25mm. Retrograde mesenteric access was used in all patients, but 16 required simultaneous antegrade approach. The retrograde puncture was closed primarily in 35 patients or with patch angioplasty in 17 and manual compression in one. Bowel resection was needed in 29 patients (54%) with AMI because of perforation or gangrene. Technical success was 98%. One patient failed attempted ROMS and was treated by bypass. Early mortality was 41% (18/44) for AMI and 10% (1/10) for CMI (P<0.01). Early morbidity was 73% for AMI and 50% for CMI (P<0.01). Mean follow up was 11±19 months. Patient survival at 1-year was 36±11% for AMI and 68±12% for CMI (P=0.29). For the entire cohort, primary and secondary patency were 65±11% and 73±13% at 3-years. Freedom from symptom recurrence and re-interventions were 75±10% and 71±10% at same interval.
Conclusion: ROMS offers an alternative to bypass and percutaneous stenting in patients with AMI who require abdominal exploration for suspected bowel gangrene and for those with flush mesenteric occlusions who are not ideal candidates for percutaneous stenting. The technique can be performed with high technical success. Mortality remains high in patients with AMI. Morbidity is high for patients with AMI and CMI. Patency rates and freedom from symptom recurrence and re-interventions are comparable to results of stenting using percutaneous technique.
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