背景:临床实践指南推荐了血管内优先方法(ENDO)用于治疗慢性肠系膜缺血(CMI)患者,而对于被认为是不良ENDO候选对象的患者,则建议采用开放式肠系膜搭桥(OMB)。然而,先前失败的血管内或开放性肠系膜重建对随后的OMB的影响尚不清楚.因此,本研究旨在研究复发性CMI患者在ENDO或原发性OMB(P-OMB)失败后进行治疗OMB(R-OMB)的结果.
方法:回顾了2002-2022年在佛罗里达大学接受OMB的所有患者。R-OMB后的结果(即,比较了失败的ENDO或P-OMB)和P-OMB的病史。主要终点是30天死亡率,而次要终点包括并发症,重新干预,和生存。Kaplan-Meier方法用于评估无再干预和全因死亡率,而多变量Cox比例风险模型确定了死亡的预测因素。
结果:总共145个OMB程序(R-OMB,n=48[33%];P-OMB,n=97[67%])进行了分析。大多数R-OMB手术是针对失败的支架进行的(先前的ENDO,n=39[81%];先前的OMB,n=9[19%])。R-OMB患者通常较年轻(66±9vs.P-OMB,69±11年;p=.09),吸烟暴露发生率较低(29%vs.P-OMB,48%;p=0.07);然而,人口统计学或合并症没有其他差异。R-OMB与术中输血减少相关(0.6vs.P-OMB,1.4个单位;p=0.01),但导管选择或旁路配置没有差异。总体30天死亡率和并发症发生率分别为7%(n=10/145)和53%(n=77/145)。分别,组间没有差异。值得注意的是,R-OMB降低了心脏(6%vs.P-OMB,21%;p<.01)和出血并发症发生率(2%vs.P-OMB,15%;p=0.01)。免于再干预(1年和5年:R-OMB-95±4%,83±9%vs.P-OMB-97±2%,93±5%,分别为;对数秩p=.21)和生存率(1年和5年:R-OMB-82±6%,68±9%vs.P-OMB-84±4%,66±7%;p=.91)相似。全因死亡率的独立预测因素包括新的术后血液透析需求(HR7.4,95CI3.1-17.3;p<.001),肺(HR2.7,95%CI1.4-5.3;p=.004)和心脏(HR2.4,95%CI1.1-5.1;p=.04)并发症,以及女性(HR2.1,95CI1.03-4.8;p=.04)。值得注意的是,R-OMB不是死亡的预测因子。
结论:在管腔内支架失败或先前的开放旁路后,治疗性OMB的围手术期和长期结局似乎与P-OMB相当。这些发现支持了最近更新的临床实践指南建议,即血管内优先治疗复发性CMI,因为OMB的围手术期并发症风险很大。然而,在肠系膜血运重建失败后认为不适合进行腔内重建的患者亚组中,R-OMB结果似乎是可接受的,并强调了该策略在选定患者中的实用性。
BACKGROUND: Clinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI.
METHODS: All patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death.
RESULTS: A total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death.
CONCLUSIONS: The perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.