The role of endovascular therapy in acute mesenteric ischemia

Background:Abdominal exploration followed by vascular bypass has been the standard of care for acute mesenteric ischemia (AMI), but there is increasing use of endovascular treatment with selective exploratory laparotomy.Methods:We performed a retrospective review of patients diagnosed with AMI who underwent mesenteric artery angioplasty or stenting at a single institution from 2010-2017. Patients were divided into 3 groups: those who did not undergo exploratory laparotomy; those who received endovascular treatment before laparotomy (post-reperfusion laparotomy group); and those who had endovascular treatment after laparotomy (pre-reperfusion laparotomy group).Results:Patients who did not undergo exploratory laparotomy showed 85.7% (12/14) survival, compared with 63.6% (7/11) in the post-reperfusion group and 25.0% (2/8) in the pre-reperfusion group, P=0.077). Time to reperfusion was significant (P=0.009) in predicting survival for patients who underwent exploratory laparotomy.Conclusion:Emergent endovascular treatment prior to laparotomy seems to be associated with a higher survival.

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“…Technical success was high at 100% (33/33), similar to previously reported data [9]. Stents were placed in 28/33.…”

Section: Resultssupporting

confidence: 87%

Effect of timing on endovascular therapy and exploratory laparotomy outcome in acute mesenteric ischemia

Hsu

Bhattacharya

Chan

et al. 2019

aog

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“…The application of a funnel-shaped aspiration catheter may also be beneficial during acute thromboembolic occlusion of vessels other than cerebral arterial vessels, like mesenteric arteries. Commonly, no stent-retriever is used during endovascular recanalization in acute mesenterial ischemia; the clot is removed through aspiration with a so called aspiration catheter, only 23 . The use of an aspiration catheter with a self-expanding funnel-shaped tip would occlude the vessel, enabling easier aspiration and diminishing the risk of clot migration.…”

Section: Discussionmentioning

confidence: 99%

In vitro testing of a funnel-shaped tip catheter model to decrease clot migration during mechanical thrombectomy

Tanyildizi¹,

Payne²,

Gerber³

et al. 2020

Sci Rep

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one limitation of mechanical thrombectomy (Mt) is clot migration during procedure. this might be caused by abruption of the trapped thrombus at the distal access catheter (DAc) tip during stentretriever retraction due to the cylindrical shaped tip of the DAc. Aiming to solve this problem, this study evaluates the proof-of-concept of a new designed funnel-shaped tip, in an experimental in vitro setting. two catheter models, one with a funnel-shaped tip and one with a cylindrical-shaped tip, were compared in an experimental setup. for Mt a self-made vessel model and thrombi generated from pig's blood were used. MT was performed 20 times for each device using two different stent-retrievers, 10 times respectively. For the funnel-shaped model: for both stent-retrievers (Trevo XP ProVue 3/20 mm; Trevo XP ProVue 4/20 mm) MT was successful at first pass in 9/10 (90%), respectively. For the cylindricalshaped model: MT was successful at first pass in 5/10 (50%) with the smaller stent-retriever and in 6/10 (60%) with the larger stent-retriever. The experiments show a better recanalization rate for funnelshaped tips, than for cylindrical-shaped tips. these results are indicating a good feasibility for this new approach, thus the development of a prototype catheter seems reasonable.Mechanical thrombectomy (MT) has become the standard technique in the treatment of acute ischemic stroke in large vessel occlusion (LVO). Multiple randomized controlled trials (RCTs) demonstrated a safe and efficient use of MT in comparison to intravenous tissue plasminogen activator (IV t-PA) use alone 1-6 .Recently updated international and national guidelines 7,8 recommend MT for patients suffering from acute stroke up to 24 hours after the onset of symptoms, as well as for patients with wake-up strokes with an unknown time window, thus emphasizing the increasing relevance of endovascular treatment. The so-called "big five" 1-5 reports for MT in LVO show a good recanalization rate of 71%. A meta-analysis of 12 studies reports a successful recanalization rate (TICI 2b/3 score) of 81% for MT with stent-retriever in acute M2 occlusion 9 . Different techniques are possible for MT, like Direct Aspiration First Pass Technique (ADAPT), Stent-retriever Assisted Vacuum-locked Extraction (SAVE) or primary combined approach (PCA) of an aspiration catheter and stent-retriever 6,10 .Even though MT in combination with IVT is the state-of-the-art treatment for LVO, there are still limitations. Balami et al. 11 report an embolization to new vascular territories in 1-8.6% for most randomized controlled trials (RCTs) and in 1-12.5% for the non-RCTs. This can be caused by clot migration to proximal vessels during the retraction of the stent-retriever or persistence in the same vessel. Furthermore, the clot can break and dissipate www.nature.com/scientificreports www.nature.com/scientificreports/ learning algorithms to produce pixel based segmentations are available online 18,19 . Images were further processed and transformed into grayscale images. Then a binary im...

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“…In fact, in recent single-center studies and systematic reviews, the recommendation for endovascular therapy first has been suggested: endovascular interventions improve mortality, lowers length of hospitalization and transfusion requirements, lowers rates of pneumonia and sepsis and decrease cost of care. 8,[23][24][25] In Europe, the ESTES guidelines created in 2016 10 aimed to improve outcomes for patients with AMI. Despite a lack of randomized controlled trials for the management of AMI, recommendations regarding diagnosis, treatment, and follow-up are given at various levels of evidence, including the use of contrast-enhanced computed tomography angiography of the abdomen/pelvis, use of broadspectrum antibiotics, use of endovascular or open embolectomy, use of systemic anticoagulation, and supportive intensive care unit measures.…”

Section: Discussionmentioning

confidence: 99%

Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival

et al. 2020

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Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4–3.2], p = 0.0005) and moderate (HR: 1.5 [1.03–2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2–1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01–1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.

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The role of endovascular therapy in acute mesenteric ischemia

Cited by 22 publications

References 43 publications

Effect of timing on endovascular therapy and exploratory laparotomy outcome in acute mesenteric ischemia

Effect of timing on endovascular therapy and exploratory laparotomy outcome in acute mesenteric ischemia

In vitro testing of a funnel-shaped tip catheter model to decrease clot migration during mechanical thrombectomy

Acute Mesenteric Ischemia Remains a Highly Morbid Diagnosis after Initial Hospitalization Survival

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