Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2018 Aug;68(2):470-480.e1. doi: 10.1016/j.jvs.2017.11.086. Epub 2018 Mar 13.
Retrograde open mesenteric stenting (ROMS) through laparotomy was introduced as an alternative to surgical bypass in patients with acute mesenteric ischemia (AMI). The purpose of this study was to evaluate the indications and outcomes of ROMS for treatment of AMI and chronic mesenteric ischemia.
We reviewed the clinical data and outcomes of all consecutive patients treated by ROMS in seven academic centers from 2001 to 2013. ROMS was performed through laparotomy with retrograde access into the target mesenteric artery and stent placement using a retrograde or antegrade approach. End points were early (<30 days) and late mortality, morbidity, patency rates, and freedom from symptom recurrence and reintervention.
There were 54 patients, 13 male and 41 female, with a mean age of 72 ± 11 years. Indications for ROMS were AMI in 44 patients (81%) and subacute-on-chronic mesenteric ischemia with flush mesenteric occlusion in 10 patients (19%). A total of 56 target mesenteric vessels were stented, including 52 superior mesenteric arteries and 4 celiac axis lesions, with a mean treatment length of 42 ± 26 mm. Retrograde mesenteric access was used in all patients, but 16 patients also required a simultaneous antegrade brachial approach. The retrograde puncture was closed primarily in 34 patients and with patch angioplasty in 17 patients; 1 patient had manual compression. Bowel resection was needed in 29 patients (66%) with AMI because of perforation or gangrene. Technical success was achieved in all (98%) except one patient for whom ROMS failed, who was treated by bypass. Early mortality was 45% (20/44) for AMI and 10% (1/10) for subacute-on-chronic mesenteric ischemia (P = .04). Early morbidity was 73% for AMI and 50% for subacute-on-chronic mesenteric ischemia (P = .27). Patient survival for the entire cohort was 43% ± 9% at 2 years. Primary patency and secondary patency at 2 years were 76% ± 8% and 90% ± 8%, respectively. Freedom from symptom recurrence and freedom from reinterventions were 72% ± 8% and 74% ± 8% at the same interval.
ROMS offers an alternative to bypass or percutaneous stenting in patients with AMI who require abdominal exploration and in those who have flush mesenteric occlusions and have failed to respond to or are considered unsuitable for stenting by a percutaneous approach. Despite high technical success, mortality remains elevated in patients with AMI. Patency rates and freedom from symptom recurrence and reinterventions are comparable to the results achieved with stenting using percutaneous technique.
通过剖腹手术进行逆行肠系膜支架置入术（ROMS）已被引入作为急性肠系膜缺血（AMI）患者旁路手术的替代方法。本研究的目的是评估 ROMS 治疗 AMI 和慢性肠系膜缺血的适应证和结果。
我们回顾了 2001 年至 2013 年期间，7 个学术中心连续接受 ROMS 治疗的所有患者的临床数据和结果。ROMS 通过剖腹手术进行，通过逆行进入目标肠系膜动脉进行逆行进入，并使用逆行或顺行方法进行支架置入。终点是早期（<30 天）和晚期死亡率、发病率、通畅率以及症状复发和再干预的无复发率。
共有 54 名患者，13 名男性和 41 名女性，平均年龄为 72±11 岁。ROMS 的适应证为 44 例（81%）AMI 和 10 例（19%）亚急性慢性肠系膜缺血伴吻合口完全闭塞。共对 56 个目标肠系膜血管进行了支架置入，包括 52 个肠系膜上动脉和 4 个腹腔动脉病变，平均治疗长度为 42±26mm。所有患者均采用逆行肠系膜入路，但 16 例患者还需要同时进行顺行肱动脉入路。34 例患者采用直接缝合封闭逆行穿刺口，17 例患者采用补片血管成形术；1 例患者采用手动压迫。29 例（66%）AMI 患者因穿孔或坏疽需要进行肠切除术。除 1 例 ROMS 失败的患者接受旁路治疗外，其余患者均获得了技术成功。AMI 的早期死亡率为 45%（20/44），亚急性慢性肠系膜缺血为 10%（1/10）（P=0.04）。AMI 的早期发病率为 73%，亚急性慢性肠系膜缺血为 50%（P=0.27）。整个队列的患者 2 年生存率为 43%±9%。2 年时的一级通畅率和二级通畅率分别为 76%±8%和 90%±8%。相同时间间隔内的症状复发和再干预无复发率分别为 72%±8%和 74%±8%。
ROMS 为需要腹部探查的 AMI 患者以及吻合口完全闭塞且经皮介入治疗失败或不适合经皮介入治疗的患者提供了旁路或经皮支架置入的替代方法。尽管技术成功率较高，但 AMI 患者的死亡率仍然较高。通畅率以及症状复发和再干预的无复发率与经皮技术支架置入的结果相当。
