Late Vascular Intervention For Acute Mesenteric Ischemia Is Associated With Early Mortality And Extensive Bowel Resection
Lillian M. Tran, M.D., Elizabeth Andraska, M.D., M.S., Rafael Ramos-Jiminez, M.D., Andrew-Paul Deeb, M.D., M.S., Natalie Sridharan, M.D., M.S., Lindsey Haga, M.D., Rabih A. Chaer, M.D., Mohammad H. Eslami, M.D., M.P.H.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in management have been closely associated with high mortality. The impact of timing to vascular surgery consultation and revascularization has yet to be defined. The objective of this study was to determine the effects of delayed intervention on mortality and complications in AMI.
All patients who underwent surgical exploration for acute mesenteric ischemia (AMI) between 2010-2020 at a single institution were divided into two groups based on timing of vascular intervention after diagnosis. Early vascular intervention (EVI) was defined as having both immediate vascular consultation and revascularization at index operation. Late vascular intervention (LVI) was defined as having either delays to or no consultation or revascularization after index operation. A retrospective review of demographic and perioperative data was performed. Effect of LVI on outcomes including 30-day and 1-year mortality, total length of bowel resection, and development of short gut syndrome was measured using χ 2, logistic regression, and Kaplan-Meier survival analysis.
A total of 220 patients were identified. 28 patients found to have a non-survivable degree of bowel ischemia on index operation were excluded from analysis. The EVI group included 87 patients and 91 patients were included in the LVI group. Mean time to OR after diagnosis was 9.36 ± 10.91 hours with EVI compared to 17.7 ± 28.4 hours with LVI, accounting for transfer time from outside institutions (p=0.007). LVI was a significant predictor of 30-day mortality (OR 1.96 [1.03-3.76, p=0.04]) on univariate analysis. Higher 1-year mortality from gastrointestinal causes was also associated with LVI (46.2% vs 35.7%, p=0.23). LVI was a significant predictor of bowel resection length >150 cm (OR 5.96 [2.66-13.35], p<0.001) and total parenteral nutrition (TPN) dependence (OR 2.38 [1.05-5.43], p=0.04) on univariate and multivariate analyses.
Delays to vascular intervention are significantly associated with higher early mortality and major post-operative complications of AMI, particularly extensive bowel resection and short gut syndrome requiring TPN. This provides rationale for both early, if not routine, consultation to vascular surgery and performing revascularization at index operation in all patients with clinically suspected AMI of vascular etiology.
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