Refining patient stratification and treatment decision-making in acute SMA occlusion

This prospective multinational substudy of the AMESI project provides critical insights into managing acute SMA occlusion. By comparing endovascular versus surgical revascularization, the authors demonstrate that baseline illness severity, reflected by elevated lactate levels and mechanical ventilation requirements, dominates prognostic outcomes, with adjusted analyses confirming no independent mortality effect from treatment modality (surgery OR 1.59, 95% CI 0.57–4.37). Notably, unadjusted mortality rates varied substantially (endovascular-effective: 2.9% vs. surgical: 45.8%), primarily attributable to patient selection bias toward higher disease severity in the surgical cohort. The inability to identify reliable thresholds for endovascular efficacy underscores the necessity of individualized decision-making based on etiology and physiological status, challenging time-based intervention paradigms.