Prevalence and Prognostic Value of Mesenteric Artery Stenosis in Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract

IntroductionData regarding the prevalence of mesenteric artery stenosis in patients undergoing transcatheter aortic valve implantation (TAVI) are scarce. Whether patients with high-risk features for acute mesenteric ischemia (AMesI) have a worse prognosis compared with those without high-risk features is unknown. We aimed to address these questions.MethodsWe included 361 patients who underwent TAVI between 2015 and 2019. Using pre-TAVI computed tomography exams, the number of stenosed arteries in each patient and the degree of stenosis for the coeliac trunk (CTr), SMA and inferior mesenteric artery (IMA) were analyzed. High-risk features for AMesI were defined as the presence of ≥2 arteries presenting with ≥50% stenosis. Patient demographic and echocardiographic data were collected. Endpoints included 30-day all-cause mortality, mortality and morbidity related to mesenteric ischemia.Results22.7% of patients had no arterial stenosis, while 59.3% had 1 or 2 stenosed arteries, and 18.0% presented stenoses in 3 arteries. Prevalence of significant stenosis (≥50%) in CTr, SMA, and IMA were respectively 11.9, 5.5, 10.8%. Twenty patients at high-risk for AMesI were identified: they had significantly higher all-cause mortality (15.0 vs. 1.2%, p < 0.001) and higher mortality related to AMesI (5.0 vs. 0.3%, p = 0.004), compared with non-high-risk patients.ConclusionsPatients at high-risk for AMesI presented with significantly higher 30-day all-cause mortality and mortality related to AMesI following TAVI. Mesenteric revascularization before TAVI interventions may be beneficial in these patients. Prospective studies are needed to clarify these questions.

Neurovascular Outcomes in Relation With Carotid Artery Stenosis in Patients Undergoing Transcatheter Aortic Valve Implantation

“…Furthermore, a systemic proin ammatory state during the periprocedural period may lead to an increased risk of carotid plaque rupture [13]. The same mechanisms have been used to explain, among others, the pathogenesis of acute mesenteric ischemia and acute kidney injury after TAVI [14,26]. Our analysis of the mechanisms behind the four cases of stroke in patients with CAS suggests that while unilateral CAS is possibly merely a marker of a high comorbidity (in particular vascular disease) burden, with no cerebral lesions directly attributable to it, severe bilateral CAS may indeed be a direct cause of stroke.…”

“…Whether this holds true for TAVI is currently unknown, in particular in the setting of bilateral CAS, even though a few previous studies have been published [10][11][12][13], and recent guidelines do not recommend to systematically screen for CAS before TAVI [1]. From a pathophysiological standpoint, CAS could in theory be a risk factor for ischemic neurovascular complications in patients undergoing TAVI, because the latter may induce transient hypotension and peripheral hypoperfusion via rapid ventricular pacing [14]. Using prospectively collected data from our TAVI registry, we performed the present study to (1) assess the rates of CAS -including moderate, severe or bilateral-, neurovascular complications and mortality in patients undergoing TAVI, and (2) analyze whether there is an association between CAS and the 30-day risk of stroke or TIA, as well as with 30-day all-cause mortality risk.…”

Commentary: Paging vascular surgery: Mesenteric ischemia and outcomes following transcatheter aortic valve replacement

“…These results are consistent with another recent study examining the risk of preoperative MAS in intermediate-risk patients that demonstrated increased risk of AMI and all-cause mortality in patients with MAS in 2 or 3 mesenteric arteries. 3 Both studies suggest the presence of preoperative MAS should prompt consideration for preoperative angioplasty of the stenosed mesenteric vessels. 2,3 However, although mesenteric angioplasty can be performed with a low complication rate, these complications can be severe and life-threatening.…”

“…3 Both studies suggest the presence of preoperative MAS should prompt consideration for preoperative angioplasty of the stenosed mesenteric vessels. 2,3 However, although mesenteric angioplasty can be performed with a low complication rate, these complications can be severe and life-threatening. 4 In fact, clinical practice guidelines from the Society for Vascular Surgery provide a weak recommendation with low level of evidence for discussing revascularization in asymptomatic patients with MAS.…”