Print this pageRetrograde Open Mesenteric Stenting For Acute On Chronic Mesenteric Ischemia
Mark C Wyers, Richard J Powell, Brian W Nolan
Dartmouth-Hitchcock, Lebanon, NH
Introduction and Objectives:
Acute mesenteric ischemia in patients with chronic occlusive disease of the celiac and superior mesenteric artery (SMA) is associated with high morbidity and mortality. Operative bypass has been required. This study reports our emerging experience with emergent mesenteric revascularization using open retrograde endovascular recanalization and stenting of the SMA.
Methods:
All emergent mesenteric revascularizations performed over a four-year period (n=13) were retrospectively reviewed. Revascularization was abandoned in one patient because of extensive bowel infarction and this patient was excluded from analysis.
Results:
Three different revascularization methods were used: open antegrade or retrograde bypass (n=5), percutaneous stenting (n=2), and open, retrograde, SMA stenting (n=5). Satisfactory revascularization was achieved in all cases. Both patients in the percutaneous stent group underwent immediate celiotomy and required bowel resection. All bypass patients and two of five open, retrograde stent patients needed bowel resection. Hospital mortality was lowest in the open retrograde stent group (20%) compared to the open bypass (80%, p=0.06) and percutaneous stent (100%, p=0.06) groups. Of factors analyzed, only the need for bowel resection was predictive of mortality (p=0.01). There was one early bypass occlusion and no stent occlusions. Of the 4 surviving retrograde stent patients, 3 are alive with a mean followup of 8.3 months (range 2-14 months, one died of presumed aneurysm rupture at one month). All three are asymptomatic and have patent stents, but two have in-stent restenoses by duplex criteria.
Conclusions:
Open retrograde mesenteric recanalization and stenting has a high technical success rate, allows concomitant bowel assessment, and provides an attractive alternative to more complex bypass in these critically ill patients. Restenosis rates appear high and patients must be followed closely. Survival is influenced by early diagnosis to avoid bowel infarction. Further study of this new technique is warranted, but this initial report appears promising.