Open Revascularization for Acute Mesenteric Ischemia is Associated with Increased Morbidity and Mortality when Compared to Endovascular Intervention

Objectives

Historically, open approaches have been considered the primary treatment for acute mesenteric ischemia (AMI) due to the potential for bowel resection. However, the use of endovascular therapy is increasing. Given the paucity of current data, this study aims to compare outcomes between open and endovascular interventions for AMI.

Methods

Patients treated for AMI between 2011 and 2022 were identified in the National Surgical Quality Improvement Program (NSQIP) by ICD-9 and ICD-10 codes. Intervention type (open vs. endovascular) was obtained from CPT codes. Demographics, comorbidities, pre-operative laboratory values, and 30-day outcomes were compared between intervention types. Multivariable analysis was utilized to adjust for differences between groups with a patient's need for bowel resection included to account for disease severity.

Results

A total of 1,172 patients underwent revascularization for AMI (1,023 open, 149 endovascular). Among those treated with open revascularization, 577 (56%) underwent thrombectomies/embolectomy, 125 (12%) underwent thromboendarterectomy, and 321 (31%) received bypasses. Of the patients who underwent endovascular revascularizations, 101 (68%) received a stent, 23 (15%) underwent angioplasty without stenting, and 25 (17%) underwent lysis/thrombectomy. Patients who underwent endovascular revascularization had higher rates of smoking (36% open vs. 47% endovascular; P < 0.01), were more likely to have an eGFR less than 30 (6% open vs. 15% endovascular; P < 0.01), and underwent more bowel resections at the time of the initial operation (33% open vs. 48% endovascular; P < 0.01). For outcomes, patients who underwent open repair had longer median hospital stays (10 days vs. 7 days; P < 0.01). All other outcomes including 30-day mortality were similar on univariate analysis. Following adjustment for the need for bowel resection and comorbidities, 30-day-mortality (OR 1.96, 95% CI: 1.28–3.02), failure to wean from ventilator (OR 1.56 95% CI: 1.05–2.34), and length of hospital stay (β 3.7 days, 95% CI: 1.8–5.6) were higher among patients treated with open surgery.

Conclusions

After accounting for the need for bowel resection and comorbidities, open revascularization for AMI is associated with higher peri-operative morbidity and mortality compared to endovascular intervention. Thus, the need for bowel resection should not preclude endovascular treatment for AMI.