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A Multi-Institutional Study Comparing Antegrade and Retrograde Open Mesenteric Bypass for Chronic Mesenteric Ischemia
Brian Fazzone
1, Salvatore T Scali
1, Peter Albrecht
2, Erik M Anderson
1, Dan Neal
1, Thomas S Huber
1, Eric Endean
2 1University of Florida, Gainesville, FL;
2University of Kentucky, Lexington, KY
Introduction: National and international clinical practice guidelines recommend an endovascular-first approach for chronic mesenteric ischemia (CMI), reserving open mesenteric bypass (OMB) for patients with flush aortic occlusion, long-segment or heavily calcified disease, or failed stents. However, the guidelines are equivocal surrounding the choice of OMB so the optimal configuration remains debated. The antegrade (AG) approach may carry higher perioperative risk due to cross-clamping, whereas the retrograde (RG) approach from the infrarenal aorta or iliac system raises concerns regarding long-term patency. Therefore, we compared perioperative and mid-term outcomes of AG and RG bypass in a pooled multi-institutional cohort.
Methods: We retrospectively reviewed consecutive patients undergoing OMB for CMI at two high-volume centers (2000-2024). Patients with acute mesenteric ischemia were excluded. The primary endpoint was 30-day mortality; secondary endpoints included complications, survival, and patency. Multivariable logistic regression and Cox proportional hazards models adjusted for age, comorbidities, renal function, urgency, and center. Propensity-matched analyses compared AG and RG cohorts. Kaplan-Meier methodology estimated survival and patency.
Results: A total of 210 patients underwent OMB: 130 AG (all from center A) and 80 RG (36 from center A, 44 from center B). Compared with AG, RG patients had more comorbidities (COPD, 70% vs. 44%; p=.002; CHF, 42% vs. 12%;p<.0001), were more often hospital transfers (29% vs. 15%; p=.02), and more frequently received autogenous vein conduit (56% vs. 1%; p<.0001) (
Table). Unadjusted outcomes showed comparable complication rates (22% AG vs. 23% RG, p=1), 30-day mortality (4.4% vs. 10.0%, p=.2), and 90-day mortality (10% vs. 16%, p=.3). Kaplan-Meier estimates demonstrated similar primary patency (1-year: 96±2% AG vs. 97±3% RG; 3-year: 93±4% vs. 93±7%; p=NS:
Figure), but a non-significant trend towards lower survival after RG (1-year: 84±6% vs. 73±4%; 3-year: 68±8% vs. 63±5%;log-rank p=.4;
Figure). In multivariable Cox regression, RG was associated with increased hazard of mortality (HR 1.4, 95%CI 1.3-1.4; p<.001), whereas procedure type was not associated with perioperative complications (OR 0.97, 95%CI 0.4-2.6; p=.95). Propensity-matched analysis (61 AG vs. 61 RG) confirmed no significant difference in 30- or 90-day mortality, complications, or patency, though a trend toward lower 1-year survival persisted (37.8% vs. 16.7%, OR 3.0, 95%CI 0.9-10; p=.07).
Conclusions: In this multi-institutional analysis of CMI patients requiring OMB, antegrade and retrograde configurations yielded similar perioperative morbidity, mortality, and graft patency. Retrograde bypass was associated with lower overall survival, though this likely reflects differences in patient selection, conduit type, and center referral bias rather than configuration alone given the comparable patency. These findings support the safety and efficacy of both approaches, with surgical strategy best individualized to anatomy, conduit availability, patient comorbidity, and surgeon preference.
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