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The Effects Of Age And Skeletal Muscle Wasting On Endovascular Interventions For Chronic Mesenteric Ischemia
Alice P. Alexander, MHS, Andrew H. Smith, MD PhD, Ahmed A. Sorour, MD, Jarrad Rowse, MD, Francis J. Caputo, MD, Levester Kirksey, MD, Sean P. Lyden, MD, Jon G. Quatromoni, MD;
Cleveland Clinic Foundation, Cleveland, OH, USA
Objective: Chronic mesenteric ischemia (CMI) is a wasting condition characterized by inadequate nutritional intake and systemic inflammation of a malperfused gut. The impact of frailty on outcomes of intervention for CMI has not been investigated. This study sought to evaluate the effect of lean skeletal muscle mass and age, two principal markers of frailty, on outcomes of mesenteric stenting for CMI.
Methods: Consecutive patients undergoing primary superior mesenteric artery (SMA) stenting for CMI at the Cleveland Clinic between 2006 and 2020 were identified. All patients with preoperative computed tomography angiography (CTA) were included. Preoperative lean psoas muscle area (LPMA) was calculated at the L3 spinous process in arterial phase CTA. Primary outcomes were midterm mortality and symptom recurrence. Analysis was performed using Kaplan-Meier survival estimates, Spearman correlations, and univariate and multivariable Cox proportional hazards modeling.
Results: A total of 183 patients were included in the study. The mean age of the cohort was 73.0 (range 18-94) and 126 patients (68.9%) were female. SMA stenting was technically successful in all patients. LPMA was significantly associated with mortality in univariable analysis (HR 0.73, 95% CI 0.57-0.95, p=0.017). The survival difference between the lowest quartile (Q1) and the highest quartile (Q4) of LPMA was 67.3% Q1 vs. 87.8% Q4 at 2yrs, 62.5% Q1 vs. 87.8% Q4 at 3yrs, and 57.7% Q1 vs. 82.7% Q4 at 5yrs (HR 0.47, 0.24-0.94). A Spearman correlation demonstrated both age and female gender were significantly associated with low LPMA. When adjusted for age and other confounding factors in multivariable analysis, however, the effect of LPMA on mortality was lost (p=0.90). Age (HR 0.96, 0.94-0.98, p=0.001) and hyperlipidemia (HR 0.44, 0.24-0.77, p=0.005) remained significantly associated with mortality. LPMA had no effect on symptom recurrence. Age (HR 0.96, 0.94-0.98, p=0.001) and tobacco use (HR 0.43, 0.23-0.80, p=0.008) were both predictive of symptom recurrence in multivariable analysis.
Conclusion: Age and female gender were associated with low LPMA. When adjusted for confounding factors, LPMA had no independent effect on mortality or symptom recurrence. Thus, in contrast to other vascular and non-vascular studies, low LPMA alone does not appear to negatively impact outcomes of stenting for CMI. The diminished efficacy of intervention for CMI with advanced age is a novel finding which requires further investigation.
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