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Superior Mesenteric Endarterectomy for Long-Segment Extra-Orificial Occlusive Disease
Michael John Fassler
1, Griffin Stinson
2, Brian Fazzone
1, Chris R. Jacobs
3, Benjamin N. Jacobs
1, Martin R. Back
1, Thomas S. Huber
1 1University of Florida Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL;
2University of Florida College of Medicine, Gainesville, FL;
3Mayo Clinic - Jacksonville - Division of Vascular Surgery and Endovascular Therapy, Jacksonville, FL
Background: Open revascularization is indicated for patients with chronic mesenteric ischemia (CMI) when endovascular revascularization is not feasible. Both antegrade (aorto/SMA) and retrograde (ilio/SMA) bypasses are effective for typical orificial atherosclerotic occlusive disease of the SMA. However, the optimal treatment for extensive occlusive disease (>4 cm) extending beyond the orifice of the SMA remains undefined. We adopted an aggressive approach combining bypass and SMA endarterectomy with patch angioplasty using either a separate patch or long tongue of the bypass conduit. The purpose of this study is to describe our experience with this technique and to compare outcomes to patients receiving bypass alone.
Methods: We performed retrospective analysis on patients undergoing SMA endarterectomy for CMI at our institution from January 2002 to April 2024. Patients were identified through query of a Current Procedure Terminology (CPT) database using the code for mesenteric thromboendarterectomy and cross-referenced with a database of patients who underwent mesenteric bypass for CMI during the same interval. Those receiving intervention for acute mesenteric ischemia, dissection, or with aortic reconstruction were excluded. Primary outcomes were mortality and patency at 30-days and 1-year, reintervention, and symptom recurrence. Univariate analysis was performed on demographic, operative, and outcome variables, with the Wilcoxon Two-Sample nonparametric test utilized for continuous variables, and Fisher’s Exact test for categorical.
Results: A total of 166 patients were analyzed. Twenty-eight (16.87%) had SMA endarterectomy with bypass for extensive atherosclerotic disease, while 138 (83.13%) had bypass alone. No significant demographic differences were identified between cohorts. A significant majority of bypass alone patients (112 [81.16%] vs. 17 [60.71%]; P=0.03) received an antegrade mesenteric bypass with an associated aorto-celiac bypass (94 [68.12%] vs. 12 [42.86%]; P=0.02). Dacron was the most frequently selected conduit, significantly in those with bypass alone (116 [84.06%] vs. 15 [53.57%] P=<0.001). Fourteen (50.0%) patients with long-segment SMA disease received a separate patch angioplasty while the remaining were treated with a long tongue of the conduit. No significant differences were identified between in-hospital (6 [4.35%] vs 1 [3.57%]) or post-discharge mortality rates (30-day: 0 [0%] vs 0 [0%]; 1-year: 13 [9.85 %] vs 2 [7.41%]; overall: 44 [33.33%] vs 6 [22.22%]). No differences in patency were found at 30-days (107 [100.0%] vs 22 [95.65%]) although the bypass alone patients had improved patency rates at 1-year (63 [100.0%] vs 12 [85.71%]; P=0.03). Reintervention rates were similar in both cohorts. Patients with long-segment SMA disease that required reintervention presented earlier (0.03 vs. 1.71 years; P=0.03). There was no difference in length of follow-up or symptom recurrence during this interval. Patients with long-segment SMA disease experienced on average 0.82 ± 1.1 in-hospital complications [23 total, 9 (39.1%) pulmonary, 6 (26.0%) cardiac].
Conclusions: SMA endarterectomy in combination with bypass is an effective treatment strategy in patients with CMI associated with long-segment, extra-orificial atherosclerotic occlusive disease. The outcomes are comparable to patients undergoing bypass alone for less extensive disease.
Table 1: Patient demographics, operative details, and outcomes| Variable | All patients (n=166) | SMA bypass only (n=138) | SMA Endarterectomy and bypass (n=28) | p-value |
| Age (years) | 71.00 (64.00, 76.00) | 70.00 (64.00, 76.00) | 72.00 (66.27, 76.82) | 0.348 |
| Male sex | 52 (31.33%) | 41 (29.71%) | 11 (39.29%) | 0.373 |
| BMI at index operation (kg/m2) | 23.30 (19.85, 27.69) | 23.89 (19.90, 27.83) | 21.80 (19.30, 26.50) | 0.222 |
| Previous mesenteric intervention | 35 (21.08%) | 27 (19.57%) | 8 (28.57%) | 0.312 |
| Bypass configuration | | | | |
| Antegrade | 129 (77.71%) | 112 (81.16%) | 17 (60.71%) | 0.025 |
| Retrograde | 37 (22.29%) | 26 (18.84%) | 11 (39.29%) |
| Additional aorto-celiac bypass | 106 (63.86%) | 94 (68.12%) | 12 (42.86%) | 0.017 |
| Bypass conduit | | | | |
| Dacron | 131 (78.92%) | 116 (84.06%) | 15 (53.57%) | <0.001 |
| PTFE | 24 (14.46%) | 19 (13.77%) | 5 (17.86%) |
| Vein | 11 (6.63%) | 3 (2.17%) | 8 (28.57%) |
| Patch Technique/Material |
| Bypass conduit tongue | | | 14 (50.00%) |
| Separate patch angioplasty | | | 14 (50.00%) |
| Vein | | | 8 (57.14%) |
| Bovine pericardium | | | 6 (42.86%) |
| Mortality | | | | |
| In-hospital mortality | 7 (4.22%) | 6 (4.35%) | 1 (3.57%) | 1.000 |
| 30-day post-discharge mortality | 0 (0%) | 0 (0%) | 0 (0%) | N/A |
| 1-year post-discharge mortality | 15 (9.43%) | 13 (9.85%) | 2 (7.41%) | 1.000 |
| Confirmed patency | | | | |
| 30-day Patency (n=130 surviving with imaging) | 129 (99.23%) | 107 (100.00%) | 22 (95.65%) | 0.177 |
| 1-year Patency (n=77 surviving with imaging) | 75 (97.40%) | 63 (100.00%) | 12 (85.71%) | 0.031 |
| SMA reintervention rate (n=159 surviving past discharge) | 8 (5.03%) | 6 (4.55%) | 2 (7.41%) | 0.624 |
| Open | 7 (4.40%) | 6 (4.55%) | 1 (3.70%) | 0.251 |
| Endovascular | 1 (0.63%) | 0 (0%) | 1 (3.70%) |
| None | 151 (94.97%) | 126 (95.45%) | 25 (92.59%) |
| Time from index operation to reintervention (years, n=9, patients with reintervention) | 1.39 (0.08, 3.33) | 1.71 (0.29, 3.68) | 0.03 (0.00, 0.05) | 0.028 |
| Total length of postoperative follow-up (years, n=159, surviving past discharge) | 1.30 (0.45, 3.54) | 1.49 (0.47, 3.57) | 1.10 (0.36, 3.70) | 0.640 |
| Rate of CMI symptom recurrence (n=159, surviving past discharge) | 10 (6.29%) | 9 (6.82%) | 1 (3.70%) | 1.000 |
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