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Outcomes of Antegrade and Retrograde Open Mesenteric Bypass for Acute Mesenteric Ischemia
Salvatore T. Scali1, Diego Ayo1, Sarah Gray1, Kristina A. Giles1, Paul Kubilis1, Martin Back1, Javairiah Fatima1, Dean Arnaoutakis1, Adam W. Beck2, Thomas S. Huber1
1University of Florida, Gainesville, FL; 2University of Alabama-Birmingham, Birmingham, AL

INTRODUCTION: Acute mesenteric ischemia(AMI) is a challenging clinical problem associated with significant morbidity and mortality. Despite increasing adoption of endovascular strategies to manage AMI, few contemporary reports focus on patients undergoing open mesenteric bypass(OMB). This is notable, since there is a subset of patients who are poor candidates for peripheral intervention including those with flush aortic visceral vessel occlusion, long-segment occlusive disease, as well as thrombosed mesenteric stents/bypass. Historical reports identify a retrograde OMB configuration as the safest choice due to the perception that an antegrade approach has higher risk. The purpose of this analysis was to review our experience with OMB and compare outcomes of antegrade and retrograde OMB in the treatment of AMI.
METHODS: A single center, retrospective chart review was performed to identify all patients who underwent OMB for AMI from 2002-2016. Preoperative history of mesenteric revascularization, demographics, comorbidities, operative details and outcomes were abstracted. The primary end-point was in-hospital mortality. Secondary end-points included complications, re-intervention and overall survival. Kaplan-Meier methodology was used to characterize re-intervention and survival.
RESULTS: : Eighty-two patients(female, 54%;age 6312 years) underwent aorto-mesenteric bypass (aortoceliac/superior mesenteric, n= 44;aortomesenteric, n=38 ) for AMI. History of prior stent/bypass was present in 20%(n=16). A majority(76%;n=62) underwent antegrade bypass while the remainder received retrograde infrarenal aorto-iliac inflow. Patients receiving antegrade OMB were significantly more likely to be male(53% vs. 25%;p=.03), have coronary artery disease(48% vs. 25%;p=.05), chronic obstructive pulmonary disease(52% vs. 25%;p=.03) and peripheral arterial disease(60% vs. 35%;p=.05). Additional details regarding comorbidities, procedure-related variables and outcomes are highlighted in the Table. For all subjects, concurrent bowel resection occurred in 45%(n=37;antegrade vs. retrograde, p=.9) while 37%(n=30) underwent subsequent resection during second look operations. In-hospital mortality was 34%(n=28; 30-day =26%)(multiple organ dysfunction-20, bowel infarction-4, hemorrhage/anemia-2, arrhythmia-1, stroke-1), median LOS was 16[IQR 9, 35] days and 76%(n=64) experienced at least one major complication with no difference between antegrade/retrograde configurations. At mean follow-up of 1829(median 4, IQR 1, 26) months, 10(12%) subjects experienced aorto-mesenteric bypass re-intervention(bypass thrombosis+redo bypass-4, percutaneous transluminal angioplasty-3, mycotic pseudoaneurysm+redo mesenteric bypass-2, femoral vein conduit anastomotic aneurysm-1)(primary patency: 1-year, 826%; 3-year, 826%[95%CI .7-.9]). Overall survival at 1 and 5-years was 575% and 506%, respectively(Figure). Bypass configuration was not associated with significant differences in complications or survival, however retrograde bypass had higher risk of re-intervention(HR 3.7, 95% CI 1-14;p=.05).
CONCLUSIONS: OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes to retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, and surgeon preference, however an antegrade configuration may provide lower risk of re-intervention.

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