Current results of open revascularization for chronic mesenteric ischemia: a standard for comparison

Questions remain concerning the optimal site of graft origin and the extent of revascularization necessary to achieve excellent results for chronic mesenteric ischemia (CMI). Endovascular therapy also is performed for CMI. These factors prompted us to review our results to provide a current standard.

Ninety-eight patients who underwent operation for CMI from 1989 to 1998 were reviewed. Patients with acute ischemia and arcuate ligament syndrome were excluded.

Seventy-six women (78%) and 22 men (22%), with an average age of 66 years (range, 36 to 87 years), participated in the study. Abdominal pain was present in 95 patients (97%), and weight loss in 92 patients (94%). The superior mesenteric artery was severely diseased (70% to 99% stenosis or occlusion) in 90 patients (92%), the celiac artery in 81 patients (83%), and both arteries in 76 patients (78%). Bypass grafts were performed in 91 patients (93%), 77 antegrade and 14 retrograde. Of the other seven patients, five had endarterectomies, one reimplantation, and one patch angioplasty. Multivessel reconstruction was performed in 79 patients (81%), and single-vessel reconstruction in 19 (19%). Twelve patients had concomitant aortic reconstruction. Three early graft thromboses were seen. Five hospital deaths occurred (5.1%); one case had concomitant aortic reconstruction (1/12 versus 4/86; P = not significant). All five patients who died were older than 70 years (5/41 versus 0/57; P =.011). The median follow-up period was 1.9 years (range, 0 to 9.6 years). Follow-up was complete in all survivors. The 1-year, 5-year, and 8-year survival rates were 83%, 63%, and 55%, respectively. These rates were worse than the rates of the age-matched/gender-matched control subjects (P <.001). Survival was worse in patients greater than 70 years of age (P =.0013). Survival was unaffected by the number of vessels revascularized. The patients with retrograde grafts had decreased median survival rates (4.0 versus 5.7 years; P =.026), but they were older (75 versus 65 years; P =.0013). The 1-year and 5-year symptom-free survival rates were 95% and 92%, respectively. Symptoms recurred in six patients (6%): four had recurrent stenosis/occlusion and two had patent grafts. Symptom-free survival was unaffected by the number of vessels revascularized or by graft orientation.

Operation for CMI was successful for most patients, with low operative mortality and excellent long-term relief of symptoms. Selective concomitant aortic procedures did not increase mortality rates. The rate of symptomatic recurrences was not different for single-vessel versus multiple-vessel reconstructions or for antegrade versus retrograde grafts. Patients older than 70 years had increased operative mortality and decreased survival rates. Endovascular therapy may be appropriate for this subset of patients.