Incidence and Predictors of Gastrointestinal Hemorrhage following Mesenteric Revascularization.

Abstract

Objectives: Post-operative gastrointestinal hemorrhage (GIH) following mesenteric revascularization when performed either open (OR) or endovascularly (ER) has been clinically observed but not reported. The aim of the study is to assess the incidence and predictors of GIH in patients undergoing mesenteric revascularization.

Methods: Single-center retrospective review of consecutive patients treated with open or endovascular mesenteric revascularization from 2009-2019. Patients with non-occlusive mesenteric ischemia, intraoperative or perioperative death within 24 hours, or no post-operative follow-up were excluded. Primary endpoints were incidence and predictors of clinically significant GIH within 30- and 60 days postoperatively. Clinically significant GIH (CS-GIH) was defined if patients required RBC transfusion, hospital re-admission, escalation to intensive care, prolonged discontinuation of anticoagulation, or need for endoscopy/colonoscopy.

Results: A total of 260 patients presented with mesenteric ischemia and underwent OR/ER. 205 patients met inclusion criteria (139 female [68%], mean age of 69.9 years [range 18-92 years]). Presentation was chronic mesenteric ischemia in 128 patients (62%), acute-on-chronic in 45 (22%) and acute in 32 (16%). 93 (45%) underwent OR, 93 (45%) ER, and 19 (9%) hybrid. 50 patients (24%) presented with GIH, 44 (21%) within 30 days of OR/ER, at a median time of 6.5 days postoperatively. CS-GIH occurred in 37 patients (18%), which led to death in two patients (1%), prolongation of ICU course or transfer to ICU in 28 patients (14%), RBC transfusion in 21 (10%), diagnostic/therapeutic endoscopy/colonoscopy in 18 (9%), and hospital readmission in 14 patients (7%). Endoscopy/Colonoscopy was diagnostic in 9 patients (ulcer in five patients, angioectasia in two, and anastomotic bleeding or colonic necrosis in one each), therapeutic in four, and identifying one patient with diffuse bleeding requiring operative intervention. Factors associated with increased risk of CS-GIH were bowel resection during index hospitalization (OR 11.29, p < 0.001), acute presentation (OR 5.42, p < 0.001), atrial fibrillation (OR 3.01, p = 0.004), first-time initiation of antiplatelet therapy (OR 2.61, p = 0.01), and treatment with stenting (2.31, p = 0.03 OR) (Table I).

Conclusion: Patients undergoing mesenteric revascularization are at high risk for postoperative gastrointestinal hemorrhage, which increases morbidity and hospitalization resources in nearly 20% of patients. Specific patient groups are at high risk for CS-GI hemorrhage. Post-operative care pathways should consider these risk factors to reduce CS-GIH after mesenteric revascularization to improve outcomes.