Comparative Outcomes Of Open Mesenteric Bypass After Prior Failed Endovascular Or Open Mesenteric Revascularization For Acute And Chronic Mesenteric Ischemia
Christopher Jacobs, M.D., Salvatore Scali, M.D., Thomas Huber, MD, PhD, Martin Back, MD, Michol Cooper, MD, PhD, Dean Arnaoutakis, MD, Scott Berceli, Md, PhD, Gilbert Upchurch, MD, Kristina Giles, MD.
University of Florida, Gainesville, FL, USA.
OBJECTIVES: Open mesenteric bypass(OMB) for acute or chronic mesenteric ischemia(AMI/CMI) is associated with significant morbidity and mortality. Increasingly, patients present after failed endovascular intervention or OMB. The association of prior failed mesenteric revascularization on OMB outcomes is poorly understood. The purpose of this analysis was to analyze results of OMB after prior failed open or endovascular mesenteric artery revascularization.
METHODS: All AMI/CMI patients from a single center undergoing OMB from 2002-2018 were reviewed. Primary(P-OMB) and ‘redo’ bypass(R-OMB: defined as OMB after failed mesenteric stent and/or OMB) were compared. The primary end-point was in-hospital mortality. Secondary outcomes included complications, restenosis, freedom from re-intervention, and long-term survival. Kaplan-Meier method estimated freedom from secondary end-points and multivariable Cox proportional hazards modeling identified predictors of survival.
RESULTS: 189 OMB procedures(P-OMB, n=133[70%]; R-OMB, n=56[30%]) were reviewed. R-OMB patients were more often female(70% vs. 56%;p=.07) and had lower incidence of smoking history(41% vs. 56%;p=.05). R-OMB was more frequently performed for CMI(70% vs. 52%)(p=.02). R-OMB was performed for failed OMB in 32%(n=18 of 56;CMI-28%;AMI-41%). No other demographic, comorbidity or operative characteristics were detected. Complications(overall-63%), LOS(21±23days), rehab discharge(among survivors-34%) and in-hospital death(overall-22%) were similar irrespective of redo status for the entire cohort and for AMI/CMI indications independently. Redo status did not significantly increase the need for bowel resection for an AMI indication(47% vs. P-OMB-44%;p=.81) or need for secondary operative procedures(41% vs. P-OMB-52%;p=.18). R-OMB was independently associated with higher restenosis/occlusion risk at 1 and 3-years(R-OMB-88±6%, 79±8% vs. P-OMB-97±2%, 93±4%;p=.03) and lower freedom from re-intervention(R-OMB-88±5%, 84±6% vs. P-OMB-95±3%, 95±3%;p=.06). Notably, R-OMB was not an independent predictor of mortality and was associated with a trend toward improved overall 1 and 5-year survival(R-OMB-75±6%, 63±7% vs. P-OMB-70±4%, 42±5%;p=.07)(Figure). Predictors of mortality included chronic kidney disease(OR 1.7,1.1-2.5;p=.02) and CHF(1.8,1.1-3.1;p=0.3) while R-OMB was protective(0.7,0.4-1;p=.05).
CONCLUSIONS: Patients with recurrent AMI/CMI after prior failed endovascular or OMB can anticipate similar outcomes compared to primary OMB subjects. Conduit choice and configuration can be selectively applied depending on anatomic features and surgeon preference to achieve similar outcomes. Re-intervention rates are higher after R-OMB, highlighting the need for implementation of surveillance protocols to optimize long-term durability. 
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