Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia

Abstract

The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production.Technical documents specifying the exact consensus and literature review methodologies as well as the institutional affiliations and professional credentials of the authors of this document are available upon request from SIR, 3975 Fair Ridge Dr., Suite 400 N., Fairfax, VA 22033. METHODOLOGYSIR produces its Standards of Practice documents using the following process. Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. A recognized expert is identified to serve as the principal author for the standard. Additional authors may be assigned dependent upon the magnitude of the project.An in-depth literature search is performed using electronic medical literature databases. Then, a critical review of peer-reviewed articles is performed with regard to the study methodology, results, and conclusions. The qualitative weight of these articles is assembled into an evidence table, which is used to write the document such that it contains evidence-based data with respect to content, rates, and thresholds (Fig E1 and Table E1, available online at www.jvir.org).When the evidence of literature is weak, conflicting, or contradictory, consensus for the parameter is reached by a minimum of 12 Standards of Practice Committee members using a modified Delphi consensus method (Appendix A). For purposes of these documents, consensus is defined as 80% Delphi participant agreement on a value or parameter.The draft document is critically reviewed by the Standards of Practice Committee members by telephone conference calling or face-to-face meeting. The finalized draft from the Committee is sent to the SIR membership for further input/criticism during a 30-day comment period. These comments are discussed by the Standards of Practice Committee, and appropriate revisions are made to create the finished standards document. Prior to its publication, the document is endorsed by the SIR Executive Council.

Recanalization of superior mesenteric artery chronic total occlusion using hybrid algorithm and dissection reentry device

“…Due to historically predominant ostial location of celiac or SMA stenotic or occlusive disease, angioplasty alone is associated with elastic recoil and usually necessitates stent placement. Pooled analysis of multiple studies showed technical success rate of angioplasty and stent placement to be significantly higher, 85–94% whereas for angioplasty alone to be 65–79% . Oderich et al reported 7% major complication rate in 156 patients who underwent mesenteric artery angioplasty and stenting, mostly (98%) with balloon expandable bare metal stents (BMS).…”

Chronic Mesenteric Ischemia: Clinical Diagnosis, Imaging Characteristics, and Endovascular Management

“…17,18 For atherosclerotic CMI, endovascular revascularization with PTA and stent placement is now widely accepted as a preferred therapeutic alternative to open surgical approaches in patients with ostial or proximal mesenteric arterial obstruction without bowel infarction. 10,19 Compared with endovascular revascularization, most open surgical procedures still result in higher, long-term patency rates in the published literature, and as a result, patients younger than 50 years often undergo open surgery, and older patients often undergo PTA and stent placement. 16,18,20,21 Stent placement in combination with PTA offers higher rates of technical success than with PTA alone for calcific atherosclerotic lesions.…”

“…23 Distal mesenteric embolization and mesenteric vessel dissection has been reported in 0 to 11% and 0 to 6% of cases, respectively. 19,[24][25][26] Acute bowel infarction necessitating resection occurred in 1 to 4% of cases. 23,27 In MALS, contemporary literature describes laparoscopic and robot-assisted approaches as the developing standards for definitive treatment, although open surgical approaches are still widely used.…”

“…Open surgical options and endovascular options both offer excellent technical success rates in excess of 80% in multiple studies. 1,19,29,30 Endovascular treatment has been found to reduce cost, length of hospital stay, morbidity, and mortality compared with open surgical revascularization. 16,26,31 Oderich et al found that morbidity in the open surgical cohort was 36% versus only 18% in the endovascular cohort.…”

“…43,44 Other risk factors for stent restenosis include female sex, small artery diameter (<6 mm), and diabetes. 19,23,27 Patients who are undergoing endovascular treatment, particularly if they have any of these risk factors, should be counseled on the relatively increased potential for reintervention.…”