A Decade's Experience With Retrograde Open Mesenteric Stenting For Acute Mesenteric Ischemia
Salim G. Habib, MD, Dana B. Semaan, MD, Elizabeth A. Andraska, MD, Michael C. Madigan, MD, Georges E. Al-Khoury, MD, Rabih A. Chaer, MD, Mohammad H. Eslami, MD.
University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
OBJECTIVES:Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach as a suitable alternative to bypass surgery.
METHODS:We reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary endpoints were in-hospital, 30-day and 1-year mortality. Kaplan-Meier estimate for 1-year mortality was generated. Secondary endpoints included postoperative 30-day unplanned reinterventions and loss of early primary patency rates. RESULTS:We identified 42 patients admitted for AMI who were treated by ROMS. All had superior mesenteric artery revascularization, but one patient underwent concomitant celiac artery stenting. ROMS was not achieved in 2 patients (technical success=95.2%) and they required a bypass. Four patients (10.0%) required SMA patch angioplasty. 32(80.0%) patients underwent bowel resection: 23(57.5%) during index procedure and 9(22.5%) during second look laparotomies. Most common indications for 30-day surgical reinterventions included hemoperitoneum evacuation (n=6; 15.0%) and unplanned bowel evaluation/resection (n=7; 17.5%). Within one year, 5 patients required stent reintervention: 1 required angioplasty for a crushed stent; 2 required suction thrombectomy for thrombosed stents (subsequently one underwent re-stenting and one bypass); 1 had re-do ROMS for an occluded stent that failed endovascular recanalization. One patient had stent fracture with a portion migrating to the iliac artery: both the SMA and iliac artery required re-stenting for occlusion. In-hospital mortality was 32.5% (cardiac arrest: 2; respiratory failure: 2; septic shock: 2; multisystem organ failure secondary to bowel ischemia: 7). 30-day and 1-year all-cause mortality rates were 22.5% (n=9) and 47.5% (n=19) respectively. Kaplan Meier survival analysis shows a 59.0% survival at 1-year (figure 1).
For AMI patients, ROMS has excellent technical success rate and with lower in-hospital and 30-day mortality as compared to traditional open revascularization approaches described in the literature. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality the initial modality for treatment of AMI.
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