Professor of Surgery NYU Langone Health New York, New York
Objectives: The primary objective of this study was to review our experience utilizing angioplasty and stenting for mesenteric ischemia compared to open bypass revascularization.
Methods: This was a retrospective review of patients undergoing vascular intervention for chronic mesenteric ischemia at NYU Langone Health. The primary end point was to analyze the risk-stratified outcomes in patients treated for mesenteric ischemia with open revascularization or endovascular revascularization via follow-up duplex ultrasonography restenosis rate. Secondary end points include subjective symptomatic relief, and cumulative incidence of major adverse events.
Results: Seventeen patients with chronic mesenteric ischemia were surgically treated at NYU Langone Hospital between 2016 and 2021. Five of these patients were male, and nine female with the most prevalent comorbidities being hypertension 94%, coronary artery disease 53%, hyperlipidemia 47%, diabetes 35%, and 70% being former smokers. The mean age at intervention was 70 years and all patients were symptomatic with abdominal pain and an average weight loss of 15lbs. The celiac artery was treated in nine patients and the superior mesenteric artery was treated in twelve with disease ranging from moderate stenosis to complete occlusion and duplex velocities ranging from 277-969 cm/sec.
Three patients underwent open revascularization with bypass graft and fourteen underwent endovascular revascularization with angioplasty and stenting. The endovascular rate of re-intervention for restenosis was 35% and no indication for re-intervention was found for the open bypass group though one patient had a diagnostic angiogram to prove bypass patency. The patients who underwent re-intervention were able to have endovascular procedures including balloon angioplasty, atherectomy, and new stent placement. The combined 5y mortality rate was 17.6%, for open bypass it was noted to be 33% and for stenting 7%. While a variety of stents were placed, only one was noted to have fractured though there was a concern for an external component of compression with median arcuate ligament syndrome. Of the stents that were found to have areas of restenosis, Herculink, Omnilink, and iCAST with Herculink having two documented reports of in-stent stenosis requiring re-intervention.
Conclusions: Endovascular revascularization appears to be a safe and effective method for treatment of chronic mesenteric ischemia. Management of external compression and stent fracture warrants further investigation. A larger comparative study would need to be performed to allow stent specific recommendations to be made.