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Endovascular Repair Can Treat Mesenteric Insufficiency


 

PALM BEACH, FLA. - Many patients with chronic mesenteric vascular insufficiency can be treated with an endovascular approach - either angioplasty or stenting with bare metal or covered devices.

Unlike open procedures, the endovascular approach carries a low risk of postoperative morbidity and mortality, Dr. Phillip Burns said at the annual meeting of the Southern Surgical Association. However, he noted, the recurrence rate for stenosis or occlusion was high in his retrospective series, with about one-third of patients requiring a second, or even third, intervention within the first 2 years after surgery.

Thus, an intensive follow-up is necessary for patients who undergo endovascular reconstruction. Under his protocol, patients return every 6 months for a clinical exam and duplex ultrasound, said Dr. Burns of the University of Tennessee, Chattanooga.

"Secondary procedures are often indicated for recurrent stenosis, and you have to look for this carefully," he said. Signs and symptoms might not be observed initially, "but if you continue to search for them, you will find them and be able to perform the reinterventions."

Dr. Burns and his colleagues presented a retrospective study of 107 patients with 127 vessels treated from 2004 to June 2010. All of the procedures were performed by a vascular specialist in an endovascular operating suite.

Patients were usually referred for gastrointestinal symptoms and already had undergone a GI workup. Most (88%) complained of abdominal pain; 55% had experienced weight loss and 29% reported nausea. All underwent an abdominal ultrasound that showed mesenteric vascular abnormalities.

The patients' average age was 59 years (range 18-90 years). Most (70%) were women. As a group, they displayed several important comorbidities, including hypertension, diabetes, coronary artery disease, and smoking.

Of the 127 vessels treated, 68 were superior mesenteric arteries, 52 were celiac arteries, and 7 were inferior mesenteric arteries. A balloon-expandable bare metal stent was most commonly used (66%; 87 patients) followed by balloon angioplasty (22%; 29), covered stent (10%; 14), and one self-expanding stent (1%; 1). All patients were put on either aspirin or clopidogrel therapy for at least 30 days after surgery. Patients also received continuing treatment for the hyperlipidemia that caused their atherosclerotic disease.

At 1 year, primary patency was seen in 67% of those with angioplasty, 54% of those with bare metal stents, and 100% of those with covered stents. The patency rates for the two stent types were significantly different.

More than half of the patients (57%; 55) experienced complete resolution of their symptoms, but 38% of these (21) required a second intervention. Of the 43% (41) who reported partial symptom relief, more than half (59%; 24) required a reintervention.

"That led to 45 patients going back for at least one other intervention," Dr. Burns said. "Five were not deemed treatable endovascularly and were done as open procedures. All others were done endovascularly, with 25 requiring a second reintervention and 8, a third reintervention."

In the reinterventions, 1-year patency was 86% with angioplasty, 97% with bare metal stents, and 100% with covered stents. There were 11 deaths in the cohort, 2 of which were due to chronic mesenteric vascular disease.

"In our opinion, both of those were in patients who did not follow up appropriately," said Dr. Christopher J. LeSar, also of the University of Tennessee, who closed the paper. "It's our belief that in treating this disease, the endovascular approach is reasonable if it's married to a very stringent follow-up protocol. Patients were counseled to be very wary of any recurrent symptoms and to act on them immediately if they occurred."

During the discussion, Dr. Eugene M. Langan III "facs" of the Greenville (S.C.) Hospital System University Medical Center, asked if the good outcomes associated with the covered stent are enough to recommend its use as the primary reconstruction method.

It's too early to make the assumption, said Dr. LeSar. The covered stents were only used in only 25 patients with an average follow-up of just 6 months. "This was related to the fact that we discovered [the covered stent success] later in our clinical experience," said Dr. LeSar. "In this population, one of the main problems was recurrent disease, and we found that only four patients with a covered stent required additional reinterventions, which led us to consider placing this type of stent as the primary answer for prevention of stenosis."

The crux of the issue is how to predict who can reap the biggest benefit from endovascular repair, leaving open surgery only to those who really require it, said Dr. Marc Mitchell of the University of Mississippi, Jackson. That seems to remain an unknown, said Dr. LeSar.

"We don't know why many develop hyperplasia, but some tend to and it seems to be random," he said.

Neither Dr. Burns nor Dr. LeSar reported any financial conflicts.

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