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Chronic visceral ischemia: symptom-free survival after open surgical repair
William P English1, Jeffrey D Pearce, Timothy E Craven
1Division of Surgical Sciences, Section on Vascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
Insights
Open surgical repair for chronic visceral ischemia (CVI) shows durable graft patency and symptom-free survival. Early recognition and treatment of CVI are crucial to prevent intestinal gangrene and reduce mortality.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Surgical Outcomes
Background:
- Chronic visceral ischemia (CVI) presents diagnostic and therapeutic challenges.
- Surgical intervention is a primary treatment modality for CVI.
- Understanding long-term outcomes of open surgical repair is essential.
Purpose of the Study:
- To evaluate the primary patency and symptom-free survival after open surgical repair of CVI.
- To compare outcomes between chronic CVI (C-CVI) and acute-on-chronic CVI (A-CVI).
Main Methods:
- Retrospective review of 58 patients undergoing open surgical repair for CVI between 1990 and 2003.
- Analysis of patient demographics, disease characteristics, operative management, and follow-up data.
- Estimation of symptom-free survival and graft patency using product limit estimates.
Main Results:
- Open antegrade visceral artery repair demonstrated 5-year primary patency of 81% and primary assisted patency of 89%.
- Estimated symptom-free survival for hospital survivors was 57% at 70 months.
- Perioperative mortality was significantly higher in A-CVI (54%) compared to C-CVI (10%).
- Intestinal gangrene at presentation was a strong predictor of both perioperative and follow-up death.
Conclusions:
- Open antegrade visceral artery repair for CVI is a durable procedure with favorable long-term patency and symptom relief.
- Prompt diagnosis and treatment of CVI before the development of intestinal gangrene are critical for improving patient survival, especially in A-CVI cases.
Abstract:
A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p < 0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7-21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8-21.9; p <0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.