Outcomes of Endovascular Treatments for In-stent Restenosis in Patients with Mesenteric Atherosclerotic Disease
Yi Zhou, MD, Evan J. Ryer, MD, Robert P. Garvin, MD, Ksenia Orlova, MD, Anh Pham, MD, Jeremy Irvan, MD, James R. Elmore, MD.
Geisinger Medical Center, Danville, PA, USA.
OBJECTIVES: Mesenteric angioplasty and stenting (MAS) has surpassed open revascularization as the treatment of choice for mesenteric ischemia. Despite its lower peri-operative mortality, the need for re-intervention is not infrequent. The purpose of this study is to review the outcomes of patients treated for mesenteric artery in-stent restenosis. METHODS: Data between 2003 and 2017 were summarized, retrospectively analyzed and standard statistical analysis performed. RESULTS: Ninety-one patients underwent primary MAS over the study period. In total, one hundred and thirteen mesenteric vessels were treated with 20 covered stents and 93 bare-metal stents. Overall primary patency was 69% at 2 years. Primary patency at 2 years was 83% for covered stents compared with 65% for bare metal stents (P=0.17). Of these 91 primary MAS patients, 27 (29%) were treated for mesenteric artery in-stent restenosis (32 vessels). Two covered stent patients developed significant restenosis (11%) compared with 25 (34%) bare-metal stent patients (P=0.05). Average age of patients requiring re-intervention was 69 years (36% male) and average BMI was 23 kg/m2. Most patients had a history of tobacco use (89%), hypertension (78%) and hyperlipidemia (70%). Fourteen re-intervention patients (52%) presented with recurrent symptoms, 10 (37%) had asymptomatic restenosis, and 3 (11%) developed intestinal ischemia. Twelve patients (44%) underwent re-intervention with balloon angioplasty alone and 15 (56%) underwent repeat stent placement (7 covered stents and 8 bare-metal stents placed). 30-day mortality rate was 0%. Post-operative complications occurred in 15% of patients (myocardial infarction (4%), reversible kidney injury (4%), and bowel ischemia (7%)). There was no difference in the peri-operative morbidity when comparing symptomatic and asymptomatic patients undergoing re-intervention. Mean follow-up after mesenteric re-intervention was 31 months with one-third of patients (n=9) requiring another re-intervention either due to recurrence of symptoms or asymptomatic high-grade re-stenosis. Assisted primary patency at 2-years was 66% following re-intervention with balloon angioplasty and 57% for repeat stent placement with no statistical significant difference between the groups (P=0.66). CONCLUSIONS: Treatment of mesenteric in-stent restenosis is associated with low mortality but significant morbidity. Durability following re-intervention is similar regardless of whether it is performed with balloon angioplasty alone or with repeat stent placement. While careful patient selection is crucial to ensuring a favorable outcome, the initial use of covered stents will reduce the need for re-intervention.
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