Outcomes And Trends Of Endovascular Management In Chronic Mesenteric Ischemia Over Three Sequential Eras
Khaled I. Alnahhal, MD, Ahmed A. Sorour, MD, Sean Lyden, MD, Francis J. Caputo, MD, Jarrad W. Rowse, MD, Jon G. Quatromoni, MD, Hassan Dehaini, MD, Lee Kirksey, MD MBA.
Cleveland Clinic - Main Campus, Cleveland, OH, USA.
Objective: Endovascular intervention (EI) for chronic mesenteric ischemia (CMI) is well established. Despite numerous studies evaluating outcomes of endovascular techniques, comparative data across time is still lacking. This study aims to compare clinical outcomes of EI over three-time eras.
Methods: A retrospective review at a tertiary center from January 2003 to August 2020 was performed to identify patients who underwent EI for CMI. The patients were divided into three groups based on date of intervention: Early (2003-2009), Mid (2010-2014), and Late (2015-2020).
Results: A total of 278 patients were included in the study (Early, 74; Mid, 95;Late, 109 patients). The overall mean age was 71.2 ± 11.2, where 195 (70.1%) were females. No significant differences were observed in patient demographics and comorbidities between the three time periods. The use of pre-op P2Y12 inhibitors decreased over time (Early, 47.3%; Mid, 24.2%; Late, 17.4%; P<.001). However, usage of pre-op novel anticoagulation and high-intensity statin therapy increased (P<.05). High technical success (Early, 98.6%; Mid, 100%; Late, 100%; P=.27) and immediate freedom of symptoms (Early, 84.9%; Mid, 93.7%; Late, 90.8%; P=.16) were noted over the three eras. In both celiac and SMA, the use of bare metal stents declined over time (Early, 100%; Mid, 94.7%; Late, 77.1%; P<.001) with a proportionate increase in covered stents (Early, 2.7%; Mid, 10.5%; Late, 33.9%; P<.001). The utilization of postop antiplatelets (Early, 89.2%%; Mid, 97.9%; Late, 99.1%; P<.001) and anticoagulation increased over time (Early, 17.6%;Mid, 15.8%;Late, 29.4%; P=.046). Overall brachial and femoral accesses complication rates were 14.5% and 2.4%, respectively, with an overall 30-day mortality of 2.4%. The 1- and 2-year primary and primary assisted- patency rates did not change for both celiac and SMA over time (Table I).
Conclusions: This study demonstrates high technical success and clinical resolution of symptoms associated with EI for CMI across three sequential time eras. Over time there was a significant increase in the utilization of covered stents at the expense of the bare metal ones. Our findings validate the role of EI complimented by guideline-directed medical therapy (GDMT) as the first line of therapy for CMI.
| Table I. Event Summaries - Truncated at 2 years | |||||||
| Outcome | Level | N | Event (%) | Year 1 | Year 2 | HR (95% CI) | p-value |
| Symptom Freedom | a.Early (2003-2008) | 74 | 27(36) | 60.8 (49.2, 75.2) | 52.3 (40.3, 67.7) | 1.00 | 0.070 |
| b.Mid (2009-2014) | 95 | 23(24) | 72.5 (63.2, 83.2) | 70.9 (61.3, 81.9) | 0.55 (0.32, 0.96) | . | |
| c.Late (2015-2020) | 109 | 36(33) | 60.4 (50.2, 72.8) | 51.0 (40.1, 64.9) | 0.94 (0.57, 1.54) | . | |
| Primary Patency - Celiac | a.Early (2003-2008) | 28 | 6(21) | 84.4 (69.7, 100.0) | 67.4 (48.9, 92.9) | 1.00 | 0.46 |
| b.Mid (2009-2014) | 33 | 3(9.1) | 84.0 (68.8, 100.0) | 84.0 (68.8, 100.0) | 0.49 (0.12, 1.96) | . | |
| c.Late (2015-2020) | 40 | 9(23) | 77.3 (62.8, 95.1) | 65.9 (48.5, 89.5) | 1.12 (0.39, 3.25) | . | |
| Primary Assisted Patency - Celiac | a.Early (2003-2008) | 28 | 1(3.6) | 100.0 (100.0, 100.0) | 93.8 (82.6, 100.0) | 1.00 | 0.85 |
| b.Mid (2009-2014) | 33 | 1(3.0) | 93.8 (82.6, 100.0) | 93.8 (82.6, 100.0) | 1.44 (0.09, 23.23) | . | |
| c.Late (2015-2020) | 40 | 3(7.5) | 95.8 (88.2, 100.0) | 89.0 (75.3, 100.0) | 1.99 (0.18, 22.13) | . | |
| Primary Patency - SMA | a.Early (2003-2008) | 55 | 16(29) | 64.9 (52.0, 81.0) | 62.2 (49.1, 78.9) | 1.00 | 0.15 |
| b.Mid (2009-2014) | 72 | 13(18) | 79.9 (69.4, 92.0) | 71.8 (59.6, 86.5) | 0.55 (0.27, 1.15) | . | |
| c.Late (2015-2020) | 79 | 12(15) | 84.5 (75.1, 95.2) | 74.6 (61.7, 90.2) | 0.51 (0.24, 1.10) | . | |
| Primary Assisted Patency - SMA | a.Early (2003-2008) | 55 | 4(7.3) | 93.1 (85.8, 100.0) | 93.1 (85.8, 100.0) | 1.00 | 0.95 |
| b.Mid (2009-2014) | 72 | 3(4.2) | 95.8 (90.2, 100.0) | 92.9 (85.3, 100.0) | 0.76 (0.15, 3.78) | . | |
| c.Late (2015-2020) | 79 | 1(1.3) | 100.0 (100.0, 100.0) | 100.0 (100.0, 100.0) | NA | . | |
| HR: Hazard Ratio; CI = Confidence Interval; SMA: Superior Mesenteric Artery; NA: Not Applicable. | |||||||
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