Comparison of open and endovascular treatment of acute mesenteric ischemia

Abstract

Introduction: Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding the rates of bowel resection following endovascular vs open repair of AMI.

Methods: Using the National Inpatient Sample database, admissions from 2005 through 2009 were identified according to International Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities were also examined. Outcome measures included mortality, length of stay, the need for bowel resection (45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization. Statistical analysis was conducted by χ(2) tests and Wilcoxon rank-sum comparisons.

Results: Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025).

Conclusions: Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.