World Journal of Surgery

, Volume 31, Issue 3, pp 562–568

Surgical and Interventional Visceral Revascularization for the Treatment of Chronic Mesenteric Ischemia—When to Prefer Which?

  • Matthias Biebl
  • W. Andrew Oldenburg
  • Ricardo Paz-Fumagalli
  • J. Mark McKinney
  • Albert G. Hakaim
Article

Abstract

Background

The purpose of the present study was to compare surgical and endovascular revascularization for chronic mesenteric ischemia (CMI).

Methods

Forty-nine patients underwent surgical (SG) or endovascular (EG) treatment. Relief of symptoms was considered the primary endpoint; patency, morbidity, and mortality were secondary endpoints. For statistical analysis, significance was assumed if P values ≤ 0.05.

Results

Twenty-six patients (53%) underwent surgical revascularization; 23 patients (47%), endovascular repair. Mean follow-up was 25 ± 21 months (SG) versus 10 ± 10 (EG) months (P = 0.07). Except for body mass indices (SG 18.9 ± 2.7 versus EG 23.6 ± 4.8; P = 0.001), preoperative data were comparable. Freedom from symptoms was 100% (SG) versus 90% (EG) after intervention (P = 0.194), and 89% (SG) versus 75% (EG) at the end of follow-up. Reocclusion or re-stenosis occurred in 8% (SG) versus 25% (EG) (log-rank test: P = 0.003), and mesenteric ischemia developed in 0% (SG) versus 9% (EG) (P = 0.04). Reintervention for CMI was required in 0% (SG) versus 13% (EG) (P = 0.01). Surgical patients experienced more early complications (42% versus EG 4%; P = 0.02) and longer hospital stays (11.6 ± 10.9 days versus EG 1.3 ± 0.5 days; P < 0.001). Overall mortality at the end of follow-up was 31% (SG) versus 4% (EG) (log-rank test: P = 0.08), including all patients with combined open mesenteric and aortic reconstruction (P = 0.001).

Conclusions

Surgical treatment has superior long-term patency and requires fewer reinterventions, but it is also more invasive with greater morbidity and mortality compared to endovascular treatment. Endovascular techniques may be preferable in patients with significant co-morbidities, concomitant aortic disease, or indeterminate symptoms.

References

  1. 1.
    Moneta GL. Diagnosis of interinal ischemia. In Rutherford RB, editor, Vascular Surgery, 5th edition, WB Saunders, Philadelphia, 2000Google Scholar
  2. 2.
    Croft RJ, Menon GP, Marston A. Does intestinal angina exist? A critical study of obstructed visceral arteries. Br J Surg 1981;68:316–318PubMedGoogle Scholar
  3. 3.
    Johnston KW, Lindsay TF, Walker PM, et al. Mesenteric arterial bypass grafts: early and late results and suggested surgical approach for chronic and acute mesenteric ischemia. Surgery 1995;118:1–7PubMedCrossRefGoogle Scholar
  4. 4.
    Rheudasil JM, Stewart MT, Schellack JV, et al. Mesenteric arterial bypass grafts: early and late results and suggested surgical approach for chronic and acute mesenteric ischemia. Surgery 1988;8:495–500Google Scholar
  5. 5.
    Mikkelsen WP, Berne CJ. Intestinal angina: its surgical significance. Am J Surg 1957;94:262–269PubMedCrossRefGoogle Scholar
  6. 6.
    Hansen HJ, Christoffersen JK. Occlusive mesenteric infarction. A retrospective study of 83 cases. Acta Chir Scand Suppl. 1976;472:103–108PubMedGoogle Scholar
  7. 7.
    McMillan WD, McCarthy WJ, Bresticker MR, et al. Mesenteric artery bypass: objective patency determination. J Vasc Surg 1995;21:729–741PubMedCrossRefGoogle Scholar
  8. 8.
    Park WM, Cherry KJ Jr, Chua HK, et al. Current results of open revascularization for chronic mesenteric ischemia: a standard for comparison. J Vasc Surg 2002;35:853–859PubMedCrossRefGoogle Scholar
  9. 9.
    Christensen MG, Lorentzen JE, Schroeder TV. Revascularisation of atherosclerotic mesenteric arteries: experience in 90 consecutive patients. Eur J Vasc Surg 1994;8:297–302PubMedCrossRefGoogle Scholar
  10. 10.
    Kasirajan K, O’Hara PJ, Gray BH, et al. Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting. J Vasc Surg 2001;33:63–71PubMedCrossRefGoogle Scholar
  11. 11.
    Mateo RB, O’Hara PJ, Hertzer NR, et al. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes. J Vasc Surg 1999;29:821–832PubMedCrossRefGoogle Scholar
  12. 12.
    Allen RC, Martin GH, Rees CR, et al. Mesenteric angioplasty in the treatment of chronic intestinal ischemia. J Vasc Surg 1996;24:415–423PubMedCrossRefGoogle Scholar
  13. 13.
    Sharafuddin MJ, Olson CH, Sun S, et al. Endovascular treatment of celiac and mesenteric arteries stenoses: applications and results. J Vasc Surg 2003;38:692–698PubMedCrossRefGoogle Scholar
  14. 14.
    Matsumoto AH, Angle JF, Spinosa DJ, et al. Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and long-term follow-up. J Am Coll Surg 2001;194(Suppl 1):S22–S31Google Scholar
  15. 15.
    Maspes F, di Pietralata GM, Gandini R, et al. Percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia: results and 3 years of follow-up in 23 patients. Abdom Imaging 1998;23:358–363PubMedCrossRefGoogle Scholar
  16. 16.
    Brown DJ, Schermerhorn ML, Powel RJ, et al. Mesenteric stenting for chronic mesenteric ischemia. J Vasc Surg 2005;42:268–274PubMedCrossRefGoogle Scholar
  17. 17.
    Silva JA, White CJ, Collins TJ, et al. Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol 2006;47:944–950PubMedCrossRefGoogle Scholar
  18. 18.
    Robinson JD, Lupkiewicz SM, Palenik L, et al. Determination of ideal body weight for drug dosage calculations. Am J Hosp Pharm 1983;40:1016–1019PubMedGoogle Scholar
  19. 19.
    Moneta GL, Yeager RA, Dalman R, et al. Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion. J Vasc Surg 1991;14:511–520PubMedCrossRefGoogle Scholar
  20. 20.
    Valentine RJ, Martin JD, Myers SI, et al. Asymptomatic celiac and superior mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses. J Vasc Surg 1991;14:195–199PubMedCrossRefGoogle Scholar
  21. 21.
    Shaw RS, Maynard EP. Acute chronic thrombosis of mesenteric arteries associated with malabsorption: report of two cases successfully treated by thrombendarterectomy. N Engl J Med 1958;258:874–878PubMedCrossRefGoogle Scholar
  22. 22.
    Tabriziani H, Shieu A, Frishman WH, et al. Drug therapies for mesenteric vascular disease. Heart Dis 2002;4:306–314PubMedCrossRefGoogle Scholar
  23. 23.
    Steinmetz E, Tatou E, Favier-Blavoux C, et al. Endovascular treatment as first choice in chronic intestinal ischemia. Ann Vasc Surg 2002;16:693–699PubMedCrossRefGoogle Scholar
  24. 24.
    Rose SC, Quigley TM, Raker EJ. Revascularization for chronic mesenteric ischemia: comparison of operative arterial bypass grafting and percutaneous transluminal angioplasty. Soc Cardiol Intervent Radiol (SCVIR) 1995;340:339–349Google Scholar
  25. 25.
    Hollier LH, Bernatz PE, Pairolero PC, et al. Surgical management of chronic intestinal ischemia: a reappraisal. Surgery 1981;90:640–946Google Scholar
  26. 26.
    McAfee MK, Cherry KJ Jr, Naessens JM, et al. Influence of complete revascularization on chronic mesenteric ischemia. Am J Surg 1992;164:220–224PubMedCrossRefGoogle Scholar
  27. 27.
    Foley MI, Moneta GL, Abou-Zamzam AM, et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg 2000;32:37–47PubMedCrossRefGoogle Scholar
  28. 28.
    Liu Y, Coresh J, Eustace JA, et al. Association between cholesterol level and mortality in dialysis patients–role of inflammation and malnutrition. JAMA 2004;291:451–459PubMedCrossRefGoogle Scholar
  29. 29.
    Seelig MH, Klingler PJ, Oldenburg WA. Simultaneous aortic surgery and malnutrition increase morbidity after revascularisation of the mesenteric arteries. Eur J Surg 2000;166:721–776CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2007

Authors and Affiliations

  • Matthias Biebl
    • 1
    • 3
  • W. Andrew Oldenburg
    • 1
  • Ricardo Paz-Fumagalli
    • 2
  • J. Mark McKinney
    • 2
  • Albert G. Hakaim
    • 1
  1. 1.Section of Vascular Surgery, Department of SurgeryMayo ClinicJacksonvilleUSA
  2. 2.Interventional RadiologyMayo ClinicJacksonvilleUSA
  3. 3.Department of General and Transplant SurgeryMedical UniversityInnsbruckAustria

Personalised recommendations