Differences in anatomy and outcomes in patients treated with open mesenteric revascularization before and after the endovascular era.

OBJECTIVE: To compare the clinical characteristics, anatomy, and outcomes of patients treated with open mesenteric revascularization (OR) for chronic mesenteric ischemia (CMI) before and after the preferential use of endovascular revascularization (ER).

METHODS: We reviewed a prospective database of 257 patients treated for CMI with OR or ER from 1998 to 2009. Treatment trends were analyzed to identify changes in practice paradigm. Prior to 2002, OR was used in 58 of 81 patients (72%). Since 2002, ER surpassed OR as the most common treatment option; OR was indicated in 58 of 176 patients (33%) who either failed ER or had unfavorable lesions for stent placement. We analyzed differences in clinical data, anatomical characteristics, and outcomes in 116 patients treated with OR before (Pre-Endo, n = 58) and after 2002 (Post-Endo, n = 58). Anatomical characteristics were determined by a blinded investigator using conventional angiography, magnetic resonance angiography, and computed tomography angiography with centerline of flow measurements.

RESULTS: Both groups had similar demographics, risk factors, and clinical presentation, with the exception of higher (P < .05) rates of hypertension, hyperlipidemia, cardiac interventions, dysrhythmias, and higher comorbidity scores in the Post-Endo group. This group also had more extensive mesenteric artery disease, including higher incidence of three-vessel involvement (76% vs 57%; P = .048) and superior mesenteric artery (SMA) occlusion (67% vs 41%;P = .005). There were no differences (P > .05) in the number of vessels revascularized (1.8 ± 0.4 vs 1.7 ± 0.5) and in graft configuration (antegrade, 91% vs 78%; retrograde, 9% vs 22%; two-vessel, 69% vs 81%) in the Pre- and Post-Endo groups, respectively. There were no differences in operative mortality (1.7% vs 3.4%), morbidity (43% vs 53%), length of stay (12 ± 1 vs 12 ± 1 days), and immediate symptom improvement (88% vs 86%) in the Pre- and Post-Endo groups, respectively. Mean follow-up was 57 ± 6 months for patients treated before 2002 and 29 ± 6 months for those treated after 2002 (P = .0001). At 5 years, primary and secondary patency rates and recurrence-free survival were 82%, 86%, and 84% in the Pre-Endo and 81%, 82%, and 76% in the Post-Endo groups (P > .05).

CONCLUSION: OR has been used in approximately one-third of patients treated for CMI since 2002. Despite more comorbidities and more extensive mesenteric artery disease in patients now treated with OR, outcomes have not changed compared with those operated prior to the preferential use of mesenteric stents before 2002.