Endovascular Therapy for Acute Mesenteric Ischemia: An NSQIP Analysis

2015 ◽  
Vol 81 (11) ◽  
pp. 1170-1176 ◽  
Author(s):  
Bernardino C. Branco ◽  
Miguel F. Montero-Baker ◽  
Hassan Aziz ◽  
Zachary Taylor ◽  
Joseph L. Mills
Keyword(s):  
Endovascular Therapy ◽  
Mesenteric Ischemia ◽  
Acute Mesenteric Ischemia ◽  
Morbidity And Mortality ◽  
High Morbidity ◽  
Improvement Program ◽  
Risk Of Death ◽  
Transfusion Requirements ◽  
Emergency Surgical Intervention ◽  
The Impact

Acute mesenteric ischemia (AMI) continues to carry high morbidity and mortality. Endovascular strategies have been increasingly used in the management of AMI. The purpose of this study was to evaluate the impact of endovascular therapy on outcomes of patients with AMI. The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency surgical intervention for AMI. Demographics, clinical data, interventions, and outcomes were extracted. Patients were compared according to treatment (endovascular versus hybrid versus open revascularization). Over the six-year study period, a total of 439 patients were found to have AMI [27 (6.2%) endovascular, 23 (5.2%) hybrid, and 389 (88.6%) open revascularization]. A total of 16 (59.3%) patients in the endovascular group avoided laparotomy. There was a trend toward lower transfusion requirements (intraoperative transfusion: 3.7% for endovascular vs 17.4% for hybrid vs 19.3% for open, adjusted. P = 0.127) and complications in particular pneumonia (22.2% vs 39.1% vs 27.8%, respectively, Adj. P = 0.392) and sepsis (25.9% vs 21.7% vs 35.5%, adjusted P = 0.260). Endovascular therapy was associated with a 2.5-fold decrease in the risk of death [odds ratio, 95% confidence interval: 0.4 (0.2, 0.9), adjusted P = 0.018]. In this analysis of morbidity and mortality, endovascular therapy was associated with decreased need for laparotomy and a trend toward lower transfusion requirements and complications, in particular pneumonia and sepsis. Endovascular first therapy was associated with a 2.5-fold decrease in the risk of death. Further prospective evaluation of these results is warranted.

scholarly journals Contemporary Management of Acute Mesenteric Ischemia in the Endovascular Era

2018 ◽  
Vol 53 (1) ◽  
pp. 42-50 ◽  
Author(s):  
Sungho Lim ◽  
Pegge M. Halandras ◽  
Carlos Bechara ◽  
Bernadette Aulivola ◽  
Paul Crisostomo
Keyword(s):  
Mesenteric Ischemia ◽  
Retrospective Studies ◽  
Acute Mesenteric Ischemia ◽  
Morbidity And Mortality ◽  
Acute Ischemia ◽  
High Morbidity ◽  
Single Center ◽  
Necrotic Bowel ◽  
Open Laparotomy ◽  
Mesenteric Revascularization

Objective: Acute mesenteric ischemia is a rare disease entity associated with high morbidity and mortality. Disparate etiologies and nonspecific symptoms make the diagnosis challenging and often result in delayed diagnosis and intervention. Open laparotomy with mesenteric revascularization and resection of necrotic bowel has been considered the gold standard of care. With recent advances in percutaneous catheter-directed techniques, multiple retrospective studies have demonstrated the outcomes of endovascular therapy. Herein, we review the etiology, presentation, and diagnosis of acute mesenteric ischemia with contemporary outcomes associated with both open and endovascular treatments. Methods: The PubMed electronic database was queried in the English language using the search words mesenteric, acute ischemia, embolism, thromboembolism, thrombosis, revascularization, and endovascular in various combinations. Abstracts of the relevant titles were examined to confirm their relevance and the full articles then extracted. References from extracted articles were checked for any additional relevant articles. This systematic review encompassed literature for the past 5 years (between 2011 and 2016). Results: Early diagnosis and intervention improves acute mesenteric ischemia outcomes. Early restoration of mesenteric flow minimizes morbidity and mortality. In comparison to open laparotomy with mesenteric revascularization and resection of necrotic bowel, several retrospective studies using administrative data and single-center chart reviews demonstrate noninferior outcomes of an endovascular first approach in acute arterial mesenteric occlusion. Conclusions: For acute mesenteric arterial occlusive disease, both endovascular and open revascularization techniques are viable options. Although there is lack of level 1 evidence, single-center retrospective studies and administrative database studies demonstrated that an endovascular first approach may have improved outcomes in the immediate postoperative period. However, selection and other bias in these studies necessitate the need for definitive randomized prospective studies between endovascular and open mesenteric intervention. In contrast, mesenteric venous thrombosis may be treated with systemic anticoagulation without surgical revascularization. Catheter-directed thrombectomy and thrombolysis can be considered at the discretion of the clinician.

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review

Vascular ◽  
2021 ◽  
pp. 170853812110245
Author(s):  
Li Hou ◽  
Tiehao Wang ◽  
Jiarong Wang ◽  
Jichun Zhao ◽  
Ding Yuan
Keyword(s):  
Endovascular Therapy ◽  
Open Surgery ◽  
Mesenteric Ischemia ◽  
Meta Analysis ◽  
Case Series ◽  
Acute Mesenteric Ischemia ◽  
High Morbidity ◽  
Hybrid Techniques ◽  
Open Surgical Treatment ◽  
Mortality Estimates

Objective Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years. Methods Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs). Results In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33–0.47; I2 = 84%), 26% (95% CI, 0.19–0.33; I2 = 33%), and 32% (95% CI, 0.21–0.44; I2 = 26%), respectively. Conclusions The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.

Use of indocianine green fluorescence in acute mesenteric ischemia

2020 ◽  
Vol 3 (2) ◽  
Author(s):  
Jaime Bonnín-Pascual
Keyword(s):  
Indocyanine Green ◽  
Terminal Ileum ◽  
Mesenteric Ischemia ◽  
Intestinal Anastomosis ◽  
Acute Mesenteric Ischemia ◽  
Left Colon ◽  
Infrared Light ◽  
High Morbidity ◽  
Green Fluorescence ◽  
Clinical Cases

Introduction: Acute mesenteric ischemia has a high morbidity and mortality and constitutes an intraoperative challenge in the management of ischemic areas. In this context, we analyze the use of indocyanine green fluorescence to assess intestinal vascularization through 3 clinical cases. Case presentation: we present 3 clinical cases operated for acute mesenteric ischemia. Evaluation of intestinal viability is performed under infrared light after intravenous infusion of 25 mg of indocyanine green. Case 1 is a 42-year-old male with multiple antecedents of severe vascular disease, presenting with a massive acute mesenteric ischemia involving multiple intestinal segments. Fluorescence allows two adjusted bowel resections with double intestinal anastomosis. Case 2 is a 74-year-old woman with a history of non-anticoagulated atrial fibrillation who is decided to perform an urgent surgery when an esophageal, gastric and portal system pneumatosis is observed, as indirect signs of ischemia, in urgent CT. During the surgical act there is an ischemia of the terminal ileum and right colon without clear signs of involvement at the esophageal-gastric level. The assessment after administration of ICG discriminates the clear ischemic involvement from terminal ileum to ascending colon and patched in the transverse and left colon, without esophageal or gastric involvement. Case 3 is a 49-year-old woman with aortoiliac and visceral Takayasu disease and revascularization surgery of the celiac trunk. Given the increase in abdominal pain, a new CT scan demonstrates colonic pneumatosis. Urgent laparotomy shows necrosis at the level of the left colon and hypoperfusion of the cecum. The administration of ICG finds a lack of uptake of the entire colon. A subtotal colectomy with ileostomy and mucous fistula is performed. Introduction: Acute mesenteric ischemia has a high morbidity and mortality and constitutes an intraoperative challenge in the management of ischemic areas. In this context, we analyze the use of indocyanine green fluorescence to assess intestinal vascularization through 3 clinical cases. Case presentation: we present 3 clinical cases operated for acute mesenteric ischemia. Evaluation of intestinal viability is performed under infrared light after intravenous infusion of 25 mg of indocyanine green. Case 1 is a 42-year-old male with multiple antecedents of severe vascular disease, presenting with a massive acute mesenteric ischemia involving multiple intestinal segments. Fluorescence allows two adjusted bowel resections with double intestinal anastomosis. Case 2 is a 74-year-old woman with a history of non-anticoagulated atrial fibrillation who is decided to perform an urgent surgery when an esophageal, gastric and portal system pneumatosis is observed, as indirect signs of ischemia, in urgent CT. During the surgical act there is an ischemia of the terminal ileum and right colon without clear signs of involvement at the esophageal-gastric level. The assessment after administration of ICG discriminates the clear ischemic involvement from terminal ileum to ascending colon and patched in the transverse and left colon, without esophageal or gastric involvement. Case 3 is a 49-year-old woman with aortoiliac and visceral Takayasu disease and revascularization surgery of the celiac trunk. Given the increase in abdominal pain, a new CT scan demonstrates colonic pneumatosis. Urgent laparotomy shows necrosis at the level of the left colon and hypoperfusion of the cecum. The administration of ICG finds a lack of uptake of the entire colon. A subtotal colectomy with ileostomy and mucous fistula is performed. Conclusions: The fluorescence with ICG provides a better visualization of the intestinal vascularization in the AMI, and allows to determine the limits of the affected tissue to perform adjusted resections.

scholarly journals Outcomes of Revascularized Acute Mesenteric Ischemia in the American College of Surgeons National Surgical Quality Improvement Program Database

2011 ◽  
Vol 77 (7) ◽  
pp. 832-838 ◽  
Author(s):  
William B. Newton ◽  
Matthew J. Sagransky ◽  
Jeanette S. Andrews ◽  
Kimberly J. Hansen ◽  
Matthew A. Corriere ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Mesenteric Ischemia ◽  
Mortality Rates ◽  
Quality Improvement Program ◽  
Morbidity And Mortality ◽  
Definitive Treatment ◽  
Mortality Data ◽  
Improvement Program ◽  
Surgical Quality ◽  
American College Of Surgeons

This report examines outcomes of revascularization for acute arterial mesenteric ischemia (AAMI) using the American College of Surgeons National Surgical Quality Improvement Program database. Patients with International Classification of Diseases, 9th Revision and Current Procedural Terminology codes indicating AAMI with concomitant mesenteric revascularization were identified. Demographic, risk factor, procedural, morbidity, and mortality data were examined. Associations with morbidity and mortality were analyzed by logistic regression. One hundred forty-two cases of AAMI were identified. Seventy-one cases were thrombotic and 71 were embolic according to revascularization codes. Mean age was 66 years, 84 per cent of patients were white, and 54 per cent were female. Unadjusted major morbidity and mortality rates were 69 and 30 per cent, respectively. Patients with thrombotic AAMI were more likely to have a lower body mass index, greater than 10 per cent weight loss in the past 6 months, and a history of smoking. Patients with embolic AAMI were more likely to present emergently with sepsis. Unadjusted morbidity and mortality rates were 78 and 38 per cent for embolic and 61 and 23 per cent for thrombotic AAMI, respectively. Multi-variable predictors of morbidity included bowel resection at the time of revascularization, transfer admission, and involvement of a surgical resident. Multivariable predictors of mortality included impaired functional status, increased age, and postoperative sepsis. Cause of AAMI was not a significant predictor of morbidity or mortality. In a large sample of AAMI cases, AAMI remained a highly lethal and morbid condition. Predictors of morbidity and mortality included indicators of advanced presentation, treatment delay, and patient-related factors specific to AAMI, including debility and advanced age. Efforts directed at prevention and increasing the speed of diagnosis and definitive treatment appear to be necessary to improve outcomes.

scholarly journals Evaluation of The Impact of Sarcopenia in Patients With Acute Mesenteric Ischemia

2019 ◽  
Vol 58 (6) ◽  
pp. e758-e759
Author(s):  
Julien Chikande ◽  
Emmanuel Augene ◽  
Fabien Lareyre ◽  
Ali Bailith ◽  
Yann Pelletier ◽  
...  
Keyword(s):  
Mesenteric Ischemia ◽  
Acute Mesenteric Ischemia ◽  
The Impact

Role of Frailty and Comorbidity Status in Predicting Morbidity and Mortality in Patients with Acute Mesenteric Ischemia

2020 ◽  
Vol 67 ◽  
pp. 105-114 ◽  
Author(s):  
Fan-Feng Chen ◽  
Xiao-Ning Ye ◽  
Hao-Te Jiang ◽  
Guan-Xia Zhu ◽  
Shou-Liang Miao ◽  
...  
Keyword(s):  
Mesenteric Ischemia ◽  
Acute Mesenteric Ischemia ◽  
Morbidity And Mortality ◽  
Comorbidity Status

Mortality, Morbidity, and Prognostic Factors in the Surgical Resection of Brain Metastases: A Contemporary Cohort Study

2020 ◽  
Vol 81 (04) ◽  
pp. 279-289
Author(s):  
Helder Picarelli ◽  
Marcelo de Lima Oliveira ◽  
Gustavo Nader Marta ◽  
Davi J. Fontoura Solla ◽  
Manoel Jacobsen Teixeira ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
Brain Metastases ◽  
Causes Of Death ◽  
Cox Regression ◽  
Morbidity And Mortality ◽  
Carcinomatous Meningitis ◽  
Primary Tumor Site ◽  
Risk Of Death ◽  
Prognostic Indices ◽  
The Impact

Abstract Objective Despite advances in systemic therapy and radiotherapy (RT), neurosurgical resection (NSR) remains a mainstay of the treatment of brain metastases (BMs). Although it is unequivocal in instances of diagnostic doubt, radioresistance, and risk of death due to neurologic causes, NSR may be controversial in other situations. Many aspects related to NSR have not yet been well established, and the primary prognostic indices were proposed only in the last decade. This study evaluates the survival and the morbidity, causes of death, prognostic factors, and the impact of RT in patients with BMs treated by NSR in the current era. Methods A total of 200 patients with BMs who were treated by NSR were evaluated sequentially and followed prospectively. We used logistic regression and Cox regression models to identify independent factors associated with mortality at 4 weeks and at 1 year, respectively. Clinical features, morbidity, recurrence, and causes of death were also studied. Results Lung cancer was the most prevalent cancer (36.5%); the median Karnofsky Performance Status (KPS) score was 60. Total resection was achieved in 89%, and adjuvant RT was applied in 63% of the cases. The rates of surgical mortality, morbidity, and mortality at 4 weeks were 1.5%, 17%, and 7.5%, respectively. Systemic infections were the leading cause of death in 62.5% of the cases. The median survival was 5 months, and 34.5% of patients lived > 1 year. The postoperative KPS (KPSpo) score remained unchanged or improved in 94.5% of the cases. In the multivariate analysis, a KPSpo score ≥ 80 and the application of adjuvant RT were associated with a lower risk of death at 12 weeks and at 1 year. Interestingly, the variables of primary tumor site, number of BMs, and presence of carcinomatous meningitis were not significant. Conclusion Morbidity and mortality were high, a third of the patients lived > 1 year, and the KPS score improved or remained unchanged in most cases. Prognostic indices and health conditions were important predictive factors, but the KPSpo score and adjuvant RT were independent variables for survival at 12 weeks and at 1 year. Therefore, new studies are needed to assess the influence of new therapies and specific molecular profiles.

scholarly journals Biofilm Production by Carbapenem-Resistant Klebsiella pneumoniae Significantly Increases the Risk of Death in Oncological Patients

2020 ◽  
Vol 10 ◽  
Author(s):  
Enea Gino Di Domenico ◽  
Ilaria Cavallo ◽  
Francesca Sivori ◽  
Francesco Marchesi ◽  
Grazia Prignano ◽  
...  
Keyword(s):  
High Risk ◽  
Klebsiella Pneumoniae ◽  
Univariate Analysis ◽  
Carbapenem Resistance ◽  
Morbidity And Mortality ◽  
Risk Of Death ◽  
Carbapenem Resistant ◽  
Biofilm Production ◽  
Oncological Patients ◽  
The Impact

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a prominent cause of nosocomial infections associated with high rates of morbidity and mortality, particularly in oncological patients. The hypermucoviscous (HMV) phenotype and biofilm production are key factors for CRKP colonization and persistence in the host. This study aims at exploring the impact of CRKP virulence factors on morbidity and mortality in oncological patients. A total of 86 CRKP were collected between January 2015 and December 2019. Carbapenem resistance-associated genes, antibiotic susceptibility, the HMV phenotype, and biofilm production were evaluated. The median age of the patients was 71 years (range 40–96 years). Clinically infected patients were 53 (61.6%), while CRKP colonized individuals were 33 (38.4%). The most common infectious manifestations were sepsis (43.4%) and pneumonia (18.9%), while rectal surveillance swabs were the most common site of CRKP isolation (81.8%) in colonized patients. The leading mechanism of carbapenem resistance was sustained by the KPC gene (96.5%), followed by OXA-48 (2.3%) and VIM (1.2%). Phenotypic CRKP characterization indicated that 55.8% of the isolates were strong biofilm-producers equally distributed between infected (54.2%) and colonized (45.8%) patients. The HMV phenotype was found in 22.1% of the isolates, which showed a significant (P<0.0001) decrease in biofilm production as compared to non-HMV strains. The overall mortality rate calculated on the group of infected patients was 35.8%. In univariate analysis, pneumoniae significantly correlated with death (OR 5.09; CI 95% 1.08–24.02; P=0.04). The non-HMV phenotype (OR 4.67; CI 95% 1.13–19.24; P=0.03) and strong biofilm-producing strains (OR 5.04; CI95% 1.39–18.25; P=0.01) were also associated with increased CRKP infection-related mortality. Notably, the multivariate analysis showed that infection with strong biofilm-producing CRKP was an independent predictor of mortality (OR 6.30; CI 95% 1.392–18.248; P=0.004). CRKP infection presents a high risk of death among oncological patients, particularly when pneumoniae and sepsis are present. In infected patients, the presence of strong biofilm-producing CRKP significantly increases the risk of death. Thus, the assessment of biofilm production may provide a key element in supporting the clinical management of high-risk oncological patients with CRKP infection.

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