Covered Stents Reduce Interventions and Improve Patency over Bare Metal Stents for Mesenteric Occlusive Disease
Jessica L Hogan, Charles S Joels, Larry R Sprouse, Jr., Heather Mixon, Jenny M Holcombe
University of Tennessee - Chattanooga, Chattanooga, TN
BACKGROUND - Endovascular therapy is part of the standard treatment algorithm for mesenteric occlusive disease in light of the increased morbidity of traditional bypass surgery. The question remains whether type of stent improves clinical symptoms and long-term patency. Small-scale studies have shown improvement with covered stents; however, decreased need for re-intervention and rate of restenosis have not been demonstrated on a larger scale. The objective of this study is to compare the need for re-intervention and primary patency of bare metal stents (BMS) and covered stents (CS) in the treatment of mesenteric occlusive disease.
METHODS - A prospectively collected database of 500 patients with mesenteric occlusive disease was retrospectively queried to identify patients with initial stent placement from 2005 to 2015. Exclusion criteria included patients with previous mesenteric bypass or atherectomy, or median arcuate ligament syndrome. A comparative cohort study was conducted of the remaining 319 patients treated for mesenteric insufficiency with bare metal stenting (BMS) or covered stenting (CS). Choice of stent type was left to the discretion of the surgeon. Follow up consisted of post-operative and bi-annual ultrasound, and clinical assessment at the surgeon’s discretion for evidence of restenosis and recurrent typical and atypical symptoms. Data analysis was performed using Fisher’s exact test and ANOVA. The primary endpoint was need for re-intervention, with a secondary endpoint of primary patency, defined as time from initial stenting until end of artery patency determined by ultrasound velocities.
RESULTS - Three hundred nineteen patients receiving 543 mesenteric stents met inclusion criteria. Average follow up was 33 months. Table 1 shows demographic information for each stent type (number of stent type, age, gender, stent diameter, and artery treated). Need for re-intervention was significantly higher with bare metal stents, with 46.3% requiring re-intervention, as opposed to 29.5% of covered stents (p=0.001). The time to re-intervention was significantly decreased with covered stents (457 days for bare metal and 412 days for covered stents, p=0.008). Primary patency was improved in covered stents over bare metal stents (48.2% vs. 38.9%, p=0.034). Of the stents that lost patency, covered stents were likely to fail earlier than bare metal stents (105 days vs. 155 days, p=0.02). To assess possible causes for need for re-intervention, a multivariate analysis of various factors including age, gender, stent diameter, symptoms, and artery where the stent was placed was performed. Variables correlating to re-intervention include younger age (70.2 +/-10.6 years, p=0.001), female gender (p=0.001), and stent placement in the SMA (p=0.046), which explains 61.8% of the variance in re-intervention.
CONCLUSION - In endovascular management of mesenteric occlusive disease, covered stents exhibit decreased need for re-intervention and improved primary patency over bare metal stents. For stents requiring re-intervention, covered stents require intervention earlier than bare metal stents, suggesting a different pathophysiology for re-stenosis. Patients who were younger, female, or received an SMA stent were more likely to require re-intervention.
|Number of Stents||Average Age (years)||Gender||Diameter (mm)||Artery Location|
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