Validation of An Endovascular-First Strategy for the Treatment of Chronic Mesenteric Ischemia
Christopher a. Durham*1, Michael M. Mcnally1, Bryan a. Ehlert1, Walter J. Pories1, Frank M. Parker2, William M. Bogey2, Charles S. Powell2, Michael C. Stoner2
1Surgery, East Carolina University, Greenville, NC; 2Cardiovascular Sciences, East Carolina University, Greenville, NC
Background:On the premise of durability, we have recently advocated open revascularization for chronic mesenteric ischemia (CMI) compared to catheter based techniques in patients less than 70 years of age. The purpose of this study was to examine this hypothesis within the context of morbidity and mortality for both open and endovascular mesenteric revascularization.Methods: Cases of mesenteric revascularization from the National Surgical Quality Improvement Program were combined with cases from a retrospective local database for the period January 2002 - September 2008. Patients were stratified by intervention as well as age. The endpoints of the study were post operative mortality and morbidity within 30 days. Clinical variables including demographics and co-morbidities of all cases were reviewed. Data was analyzed using univariate and multivariate measures and significance assigned as p<0.05.Results: 212 patients underwent mesenteric artery revascularization: 52 underwent percutaneous intervention with balloon angioplasty and stent, 160 had open surgical bypass. Clinical variables of endovascular patients differed from open patients by age (71.5±1.0 vs 66.5±1.4, P<0.01), CAD (51.9 vs 1.3, P<0.01), diabetes (26.9 vs 11.3, P<0.01), hypertension (90.4 vs 76.9, P=0.03), and preoperative albumin levels (3.3±0.2 vs 3.6±0.1, P=0.02). 107 patients were less than 70 years old and 105 were older than 70. In those younger than 70, 21 underwent PTA/stent, and 86 underwent open bypass. The following outcomes were noted in this subset of endovascular and open patients: mortality (0% vs 12%, P=NS) and morbidity (5% vs 34%, p=0.01). In those older than 70, 31 underwent PTA/stent, and 74 underwent open bypass. The following outcomes were noted in this subset of endovascular and open patients: mortality (10% vs 9%, P=NS) and morbidity (13% vs 36%, p= 0.02). Multivariate analysis examining covariates of mortality and morbidity (including patient demographics and comorbidities) demonstrated an open case to be an independent predictor of morbidity and mortality (odds ratio 4.1, 95% CI 1.4-12.4, p=0.01)Conclusion: Although percutaneous mesenteric intervention may have inferior long term durability than open surgical bypass in patients less than 70 years of age, the higher morbidity associated with open revascularization, as well as its status as an independent predictor of morbidity and mortality, does not allow endovascular therapy to be eliminated as a therapeutic option. An aggressive initial attempt at percutaneous mesenteric intervention should be pursued prior to open revascularization, despite the aforementioned durability issues.
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