Division of Vascular and Endovascular Surgery Massachusetts General Hospital and Harvard Medical School, Boston, Mass 02114, USA.
J Vasc Surg. 2010 Jan;51(1):140-7.e1-2. doi: 10.1016/j.jvs.2009.06.064. Epub 2009 Oct 17.
Endovascular therapy for chronic mesenteric ischemia (CMI) has been increasingly utilized. Early outcomes compare favorably with open mesenteric bypass--the current gold standard. The goal of this study is documentation of intermediate-term anatomic and functional outcomes of endovascular mesenteric revascularization for symptomatic CMI.
This is a retrospective review of all patients undergoing endovascular treatment of symptomatic CMI from July 2002 to March 2008. Study endpoints included periprocedural mortality, major morbidity, patency, symptomatic recurrence, and survival. Endpoints were analyzed using actuarial methods.
Sixty-six mesenteric arteries (78.8% stenotic/21.2% occluded) were treated in 49 patients. One or more vessels were treated in each case; however, four mesenteric artery total occlusions (3 SMAs/1 IMA) could not be crossed. Initial symptom relief was noted in 89.8% (n = 44) with no change in 5 patients. Single-vessel treatments were performed in 32 patients (65.3%) and two-vessel interventions in 17 (34.7%). The 30-day mortality rate was 2.0% (n = 1). Major complications occurred in 8 patients (16.3%). The mean follow-up duration was 37.4 +/- 2.98 months (range, 0-66). Restenosis on follow-up imaging occurred in 64.9% (n = 24) of the 37 patients who had radiographic surveillance at a mean follow-up interval of 8.5 +/- 1.9 months and was diagnosed most often by Duplex scan or computed tomographic angiography (CTA). Fourteen patients (28.6%) developed recurrent symptoms with 13 requiring a reintervention. Actuarial 36-month freedom from symptomatic recurrence was 60.9% +/- 9.4%. Two-vessel treatment was protective against symptom recurrence (P = .0014) and reintervention (P = .0060) by univariate analysis. A total of 19 reinterventions were required in 14 patients (28.6%) at a mean of 17 months from the original treatment. Primary patency at 36 months was 63.9 +/- 8.5%. Actuarial survival at 48 months was 81.1% +/- 6.1% with no CMI-related deaths in the study cohort.
Intermediate (3-year) follow-up indicates that significant restenosis and symptom recurrence are common following the endovascular treatment of symptomatic CMI. Thirty percent of the cohort required a reintervention, one-third of which were conversions to surgical reconstruction. Similar to the surgical paradigm of two-vessel revascularization, endovascular treatment of multiple mesenteric arteries produced better outcomes. A first-line endovascular approach to patients with CMI is a reasonable clinical strategy, but close follow-up is mandatory.
慢性肠系膜缺血（CMI）的血管内治疗已经越来越多地被采用。早期结果与开放肠系膜旁路术（目前的金标准）相比具有优势。本研究的目的是记录有症状 CMI 的血管内肠系膜再血管化的中期解剖和功能结果。
这是一项对 2002 年 7 月至 2008 年 3 月期间接受有症状 CMI 血管内治疗的所有患者进行的回顾性研究。研究终点包括围手术期死亡率、主要发病率、通畅性、症状复发和生存率。终点采用生存分析方法进行分析。
49 例患者的 66 条肠系膜动脉（78.8%狭窄/21.2%闭塞）接受了治疗。每种情况下都治疗了一条或多条血管；然而，有四条肠系膜总动脉完全闭塞（3 条 SMA/1 条 IMA）无法通过。89.8%（n=44）的患者最初症状缓解，5 例患者无变化。32 例（65.3%）进行了单血管治疗，17 例（34.7%）进行了双血管介入治疗。30 天死亡率为 2.0%（n=1）。8 例（16.3%）发生重大并发症。平均随访时间为 37.4+/-2.98 个月（范围，0-66）。在平均随访间隔为 8.5+/-1.9 个月的 37 名有影像学监测的患者中，有 64.9%（n=24）出现随访影像学再狭窄，并最常通过双功能超声扫描或计算机断层血管造影（CTA）诊断。14 例患者（28.6%）出现症状复发，其中 13 例需要再次介入治疗。无症状复发的 36 个月生存率为 60.9%+/-9.4%。单因素分析显示，双血管治疗可预防症状复发（P=0.0014）和再次介入治疗（P=0.0060）。14 例患者（28.6%）在最初治疗后 17 个月平均需要 19 次再次介入治疗。36 个月时的原发性通畅率为 63.9%+/-8.5%。48 个月时的生存率为 81.1%+/-6.1%，研究队列中无与 CMI 相关的死亡。
中期（3 年）随访表明，有症状 CMI 的血管内治疗后，明显的再狭窄和症状复发很常见。该队列中有 30%的患者需要再次介入治疗，其中三分之一是转为手术重建。与手术两血管重建的模式相似，多发性肠系膜动脉的血管内治疗产生了更好的结果。对 CMI 患者采用一线血管内方法是一种合理的临床策略，但必须密切随访。
