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Updated: Apr 14, 2026
Rodent Model of Intestinal Ischemia-Reperfusion Injury via Occlusion of the Superior Mesenteric Artery
Published on: October 20, 2023
A multi-institutional study comparing antegrade and retrograde open mesenteric bypass for chronic mesenteric ischemia
Brian J Fazzone1, Salvatore T Scali1, Peter Albrecht2
1Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL.
Insights
Open mesenteric bypass (OMB) for chronic mesenteric ischemia (CMI) showed similar perioperative outcomes and excellent patency for antegrade (AG) versus retrograde (RG) configurations. Bypass choice did not independently affect outcomes, supporting individualized selection.
Area of Science:
- Vascular Surgery
- Gastroenterology
- Surgical Outcomes Research
Background:
- Current guidelines favor endovascular therapy for chronic mesenteric ischemia (CMI), reserving open mesenteric bypass (OMB) for complex cases.
- Optimal configuration for OMB (antegrade vs. retrograde) remains debated due to differing risk profiles and patency concerns.
Purpose of the Study:
- To compare perioperative and mid-term outcomes of antegrade (AG) versus retrograde (RG) open mesenteric bypass (OMB) for chronic mesenteric ischemia (CMI).
Main Methods:
- Retrospective review of 209 CMI patients undergoing OMB at two high-volume centers (2000-2024).
- Primary endpoint: 30-day mortality. Secondary endpoints: complications, survival, and graft patency.
- Adjusted analyses included multivariable regression and propensity-matched cohorts; Kaplan-Meier methods assessed survival and patency.
Main Results:
- No significant differences in unadjusted complication rates or 30/90-day mortality between AG and RG groups.
- Excellent and comparable primary patency rates at 1 and 3 years for both configurations.
- Multivariable analysis showed bypass configuration was not independently associated with mortality or complications.
- Propensity-matched analysis revealed higher 1-year mortality after RG bypass (36.8% vs. 16.3%).
Conclusions:
- Antegrade (AG) and retrograde (RG) OMB configurations demonstrate similar perioperative morbidity and excellent graft patency in CMI patients.
- Bypass configuration is not an independent predictor of early or mid-term outcomes in adjusted analyses.
- Individualized selection of OMB configuration is supported, considering patient anatomy, comorbidities, and available resources.
Introduction:
Contemporary clinical practice guidelines recommend an endovascular-first approach for chronic mesenteric ischemia (CMI), reserving open mesenteric bypass (OMB) for flush ostial vessel occlusion, long-segment disease, heavily calcified lesions, or failed stents. However, guidelines are equivocal regarding bypass configuration, leaving the optimal strategy debated. The antegrade (AG) approach may carry higher perioperative risk due to supramesenteric aortic cross-clamping, whereas the retrograde (RG) approach from the infrarenal aorta or iliac vessels raises concerns about long-term patency. Therefore, we compared perioperative and midterm outcomes of AG and RG bypass in a multi-institutional cohort.
Methods:
We retrospectively reviewed consecutive patients undergoing OMB for CMI at two high-volume centers (2000-2024). The primary end point was 30-day mortality; secondary end points included complications, survival, and patency. Adjusted comparisons were performed using multivariable logistic regression, Cox models, and propensity-matched cohorts. Kaplan-Meier methods estimated survival and patency.
Results:
A total of 209 patients underwent OMB: 130 AG (all from center A) and 79 RG (36 from center A, 43 from center B). Compared with AG, RG patients had higher rates of cardiopulmonary comorbidity, including chronic obstructive pulmonary disease (57% vs 44%; P = .08) and congestive heart failure (26% vs 12%; P = .01), were more frequently transferred from other hospitals (29% vs 15%; P = .02), and more often received autogenous vein conduit (55% vs 1%; P < .0001). Unadjusted complication rates (22% vs 22%; P = 1), 30-day mortality (4.4% vs 8.7%; P = .3), and 90-day mortality (10% vs 15%; P = .5) were similar between groups. Primary patency was excellent and comparable (1-year: 97% ± 2% AG vs 98 ± 2% RG; 3-year: 90% ± 8% vs 90% ± 9%; P = NS). On multivariable analysis, bypass configuration was not independently associated with mortality (hazard ratio, 1.4; 95% confidence interval [CI], 0.7-2.7; P = .3) or perioperative complications (odds ratio, 0.93; 95% CI, 0.3-2.5; P = .9). In the propensity-matched cohort (65 AG vs 65 RG), early outcomes and patency remained similar; however, 1-year mortality was higher after RG bypass (36.8% vs 16.3%; odds ratio, 3.0; 95% CI, 1.2-8; P = .02). Overall survival in the full cohort did not differ significantly by Kaplan-Meier analysis (log-rank P = .5).
Conclusions:
In this multi-institutional analysis of patients with CMI undergoing OMB, AG and RG configurations demonstrated similar perioperative morbidity and excellent graft patency. Bypass configuration was not independently associated with early or midterm outcomes in adjusted analyses, although higher 1-year mortality was observed after RG bypass in a propensity-matched cohort. These findings support individualized selection of bypass configuration based on anatomic considerations, conduit availability, patient comorbidity, and institutional expertise.
