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Cited by 51Abdominal vascular conditions and treatmentsAppendicitis Diagnosis and ManagementIntestinal and Peritoneal Adhesions

Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia

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Chou, Elizabeth L., Wang, Linda J., McLellan, Rachel M., Feldman, Zach M., Latz, Christopher A., LaMuraglia, Glenn M., Clouse, W. Darrin, Eagleton, Matthew J. +1 more·2021·Annals of Vascular Surgery
DOI 10.1016/j.avsg.2021.01.116PMC PMC8349780
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Abstract

Objectives Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades.Methods AMI patients presenting at a single institution were reviewed (1993-2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis.Results 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04).Conclusions Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.

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  • Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30 days compared to 36 out of 85 (42%) patients who were re-vascularized (p = 0.01).

    “As an example, among the 104 patients who did not undergo revascularization, 64 (62%) died within 30 days compared to 36 out of 85 (42%) patients who were re-vascularized (p = 0.01) [86].”

    From Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. (2022) · cites this paper as [86]

  • The group from the Massachusetts General Hospital observed a decrease in the percentage of patients who underwent operative management of AMI over the last 25 years, correlated with an increase in documented increased rates of "comfort measures only" status prior to surgical intervention from 50 to 70%.

    “The group from the Massachusetts General Hospital observed a decrease in the percentage of patients who underwent operative management of AMI over the last 25 years. This was correlated with an increase in the number of documented increased rates of “comfort measures only” status prior to surgical intervention from 50 to 70% [86].”

    From Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. (2022) · cites this paper as [86]

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  1. [9]Rutherford RB. Vascular surgery. Philadelphia: Saunders; 2005.

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Authors
Chou, E. L., Wang, L. J., McLellan, R. M., Feldman, Z. M., Latz, C. A., LaMuraglia, G. M., Clouse, W. D., Eagleton, M. J., & Conrad, M. F.
Affiliations
  • Massachusetts General Hospital (US)
  • University of Virginia (US)
Corresponding author
Chou, Elizabeth L.
ORCID
Venue
Annals of Vascular Surgery
Publisher
Elsevier BV
Published
2021-07
Volume
74
Pages
53-62
ISSN
0890-5096 (ISSN-L)
DOI
10.1016/j.avsg.2021.01.116
PMC
PMC8349780
OpenAlex
W2969619292
Cited by
51
References
27
Citations by year
2026: 8 · 2025: 13 · 2024: 9 · 2023: 11 · 2022: 10
FWCI
7.04
Type
journal article
Language
en
Open access
Licence
Locations
  • Annals of Vascular Surgery (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health (T32HL007208)
Topics
  • Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
  • Health Sciences › Medicine › Emergency Medicine › Appendicitis Diagnosis and Management
  • Health Sciences › Medicine › Surgery › Intestinal and Peritoneal Adhesions
Keywords
acute mesenteric ischemia, 30-day mortality, nonocclusive mesenteric ischemia, mesenteric revascularization, comfort measures only, intestinal necrosis, anticoagulation, atrial fibrillation, treatment trends, mortality risk factors, endovascular treatment
MeSH terms
Acute Disease, Adult, Aged, Aged, 80 and over, Female, Humans, Intestines, Male, Middle Aged, Postoperative Complications, Prognosis, Retrospective Studies, Logistic Models, Treatment Outcome, Mesenteric Ischemia

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