Open versus endovascular revascularization for chronic mesenteric ischemia: Risk-stratified outcomes

• Published in: Journal of vascular surgery 2009-06, Vol.49 (6), p.1472-1479.e3
• Main Authors: Oderich, Gustavo S., MD, Bower, Thomas C., MD, Sullivan, Timothy M., MD, Bjarnason, Haraldur, MD, Cha, Stephen, MS, Gloviczki, Peter, MD
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Angioplasty, Balloon - adverse effects; Angioplasty, Balloon - instrumentation; Angioplasty, Balloon - mortality; Biological and medical sciences; Chronic Disease; Female; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Ischemia - etiology; Ischemia - mortality; Ischemia - physiopathology; Ischemia - surgery; Ischemia - therapy; Kaplan-Meier Estimate; Length of Stay; Male; Medical sciences; Mesenteric Vascular Occlusion - complications; Mesenteric Vascular Occlusion - mortality; Mesenteric Vascular Occlusion - physiopathology; Mesenteric Vascular Occlusion - surgery; Mesenteric Vascular Occlusion - therapy; Middle Aged; Other diseases. Semiology; Patient Selection; Proportional Hazards Models; Recurrence; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Treatment Outcome; Vascular Patency; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Vascular Surgical Procedures - adverse effects; Vascular Surgical Procedures - mortality
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2009.02.006

Objective Outcomes of open (OR) and endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) were analyzed with respect to clinical risk stratification. Methods The data of 229 consecutive patients treated for CMI with OR (146 patients/265 vessels) or ER (83 patients/105 vessels) between 1991 and 2005 were reviewed. Patients were classified as low-risk or high-risk using standard scoring systems. End points were mortality and morbidity, recurrence-free survival, and patency rates. A subset analysis compared 111 patients (208 vessels) who had OR with 58 patients (76 vessels) who had stenting. Results The ER patients were significantly older (71 ± 15 vs 65 ± 11 years; P < .05), had higher risk (58% vs 31%), and fewer vessels revascularized (1.3 ± 0.5 vs 1.8 ± 0.4). Four (2.7%) procedurally related deaths occurred in the OR and two (2.4%) in the ER group ( P = NS). Mortality was higher for high-risk patients (OR, 6.7% vs 0.9%; ER, 4.8% vs 0%; P < .05), but differences were not significant among low-risk or high-risk OR vs ER patients. OR patients had more complications (36% vs 18%; P < .001) and longer hospitalization (12 ± 8 vs 3 ± 5 days; P < .001). At 5 years, OR had improved ( P < .05) recurrence-free survival (89% ± 4% vs 51% ± 9%), and primary (88% ± 3% vs 41% ± 9%) and secondary patency rates (97% ± 2% vs 88% ± 4%). More restenoses (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.4-10.2), recurrences (HR, 6.7; 95% CI, 3.3-13.8), and reinterventions occurred in the ER group (HR, 4.3; 95% CI, 1.9-9.7). At last follow-up, significant symptom improvement was noted in 137 OR (96%) and 72 ER patients (92%, P = NS). In the subset analysis of patients having first-time operations vs stenting, OR resulted in improved ( P < .05) recurrence-free survival (91% ± 3% vs 56% ± 8% at 5 years) and better primary and secondary patency rates (93% ± 2% and 98% ± 1% vs 52% ± 8% and 93% ± 4% at 3 years). Conclusion OR has similar mortality but higher morbidity and longer hospitalization than ER in low-risk or high-risk patients with CMI. Both treatments effectively improved symptoms, but restenosis, recurrent symptoms, and reinterventions were more likely in ER patients. These findings may guide treatment selection and counseling of low-risk and high-risk CMI patients undergoing OR or ER procedures.