Open Mesenteric Approach Still Useful


SCOTTSDALE, ARIZ. -- Despite the fact that open surgery for patients with chronic mesenteric ischemia tends to be reserved for sicker, more complicated patients who aren't good candidates for endovascular revascularization, outcomes have not declined over time.

A single-center review of 116 patients with 203 obstructed mesenteric arteries who underwent open repairs since 1998 found no significant differences in outcomes in 58 patients treated before endovascular treatment became the norm and 58 treated with open surgery during the endovascular era. "We believe that open revascularization still plays an important role in the treatment of this disease," Dr. Evan Ryer and his associates reported at the annual meeting of the Society for Clinical Vascular Surgery.

All patients were symptomatic and had open surgery at the Mayo Clinic, Rochester, Minn., which adopted endovascular treatment in 2002 for most cases of chronic mesenteric ischemia. Starting in that year, approximately 70% of patients with the disease were treated using endovascular revascularization.

"Since 2002, open mesenteric revascularization has been used in only 58 of 176 patients (33%) treated for chronic mesenteric ischemia at the Mayo Clinic," Dr. Ryer said in an interview. "Endovascular revascularization, which is our primary modality of treatment in most patients with suitable lesions, was not performed in these cases because it had failed previously or the anatomy was considered unfavorable because of chronic occlusion, severe calcification, or long-segment stenosis," he explained.

Patients in the pre-endovascular era (1998-2001) and post-endovascular era (2002-2009) who underwent open surgery reported similar durations of symptoms and degrees of weight loss. Compared with the pre-endovascular era patients, however, the post-endovascular era group had significantly higher rates of hypertension (86% vs. 66%), hyperlipidemia (76% vs. 36%), coronary artery disease requiring intervention (29% vs. 14%), cardiac dysrhythmias (28% vs. 7%), postprandial pain (88% vs. 72%), food fear (71% vs. 45%), and need for total parenteral nutrition (10% vs. 2%), as well as higher Society for Vascular Surgery comorbidity severity scores (7 vs. 5).

The extent of disease was greater in post-endovascular era patients, who were more likely to have three-vessel disease (79% vs. 59%) and occluded superior mesenteric arteries (67% vs. 45%) compared with pre-endovascular era patients, Dr. Ryer said. Two-vessel disease accounted for 81% of cases in the pre-endovascular era and 69% of cases in the post-endovascular era. Only 1% of patients in the post-endovascular era and none in the earlier time period had single-vessel disease. The differences between eras in two- and single-vessel disease rates were not significant.

The two time periods did not differ significantly in the technical details of the open procedures or in any outcomes, he added.

In the pre- and post-endovascular eras, patients averaged 4 and 5 days in the intensive care unit, respectively, and 13 and 12 days in the hospital. Among short-term outcomes, symptoms improved in 56% and 54% of patients treated in the pre- and post-endovascular eras, respectively. Two patients in the earlier era and three patients in the more recent era died, and major complications developed in 17 and 21 patients, respectively. These differences between groups were not significant.

After 5 years of follow-up, survival rates were 84% for pre-endovascular era patients and 78% for those in the post-endovascular era. Recurrence-free survival rates were 84% and 76%, respectively, primary patency rates were 82% and 81%, and secondary patency rates were 86% and 82%. None of the differences in outcomes were significant between groups.

The investigators declared they had no conflicts.