Park Woosup M, Cherry Kenneth J, Chua Heidi K, Clark Rita C, Jenkins Gregory, Harmsen William S, Noel Audra A, Panneton Jean M, Bower Thomas C, Hallett John W, Gloviczki Peter
Division of Vascular Surgery, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA.
J Vasc Surg. 2002 May;35(5):853-9. doi: 10.1067/mva.2002.123753.
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.
关于慢性肠系膜缺血（CMI）的最佳移植物来源部位以及实现良好效果所需的血管重建范围仍存在疑问。CMI也可采用血管内治疗。这些因素促使我们回顾我们的结果以提供当前的标准。
回顾了1989年至1998年接受CMI手术的98例患者。排除急性缺血和弓状韧带综合征患者。
76名女性（78%）和22名男性（22%）参与了研究，平均年龄66岁（范围36至87岁）。95例患者（97%）有腹痛，92例患者（94%）有体重减轻。90例患者（92%）肠系膜上动脉严重病变（狭窄或闭塞70%至99%），81例患者（83%）腹腔动脉严重病变，76例患者（78%）两支动脉均严重病变。91例患者（93%）进行了旁路移植，77例顺行和14例逆行。其他7例患者中，5例行内膜切除术，1例行再植术，1例行补片血管成形术。79例患者（81%）进行了多支血管重建，19例患者（19%）进行了单支血管重建。12例患者同时进行了主动脉重建。观察到3例早期移植物血栓形成。发生5例医院死亡（5.1%）；1例同时进行了主动脉重建（1/12对4/86；P=无显著性差异）。死亡的5例患者均年龄大于70岁（5/41对0/57；P=0.011）。中位随访期为1.9年（范围0至9.6年）。所有幸存者均完成随访。1年、5年和8年生存率分别为83%、63%和55%。这些比率低于年龄匹配/性别匹配的对照受试者（P<0.001）。70岁以上患者的生存率较差（P=0.0013）。生存率不受血管重建数量的影响。逆行移植患者的中位生存率降低（4.0对5.7年；P=0.026），但他们年龄更大（75对65岁；P=0.0013）。1年和5年无症状生存率分别为95%和92%。6例患者（6%）症状复发：4例有复发性狭窄/闭塞，2例移植物通畅。无症状生存率不受血管重建数量或移植物方向的影响。
CMI手术对大多数患者成功，手术死亡率低，长期症状缓解良好。选择性同期主动脉手术未增加死亡率。单支血管与多支血管重建或顺行与逆行移植的症状复发率无差异。70岁以上患者手术死亡率增加，生存率降低。血管内治疗可能适用于这部分患者。
