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Cited by 33Abdominal vascular conditions and treatmentsAppendicitis Diagnosis and ManagementIntestinal and Peritoneal Adhesions

Hospital-based delays to revascularization increase risk of postoperative mortality and short bowel syndrome in acute mesenteric ischemia

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Tran, Lillian M., Andraska, Elizabeth, Haga, Lindsey, Sridharan, Natalie, Chaer, Rabih A., Eslami, Mohammad H.·2022·Journal of Vascular Surgery
DOI 10.1016/j.jvs.2021.09.033PMC PMC8991435
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Abstract

Objective Acute mesenteric ischemia (AMI) is a surgical emergency for which delays in treatment have been closely associated with high morbidity and mortality. Although the duration of ischemia as a determinant of outcomes for AMI is well known, the objective of this study was to identify hospital-based determinants of delayed revascularization and their effects on postoperative morbidity and mortality in AMI.Methods All patients who underwent any surgery for AMI from a multi-center hospital system between 2010 and 2020 were divided into two groups based on timeliness of mesenteric revascularization after presentation. Early revascularization (ER) was defined as having both vascular consultation ≤12 hours of presentation and vascular surgery performed at the patient's initial operation. Delayed revascularization (DR) was defined as having either delays to vascular consultation or vascular surgery. A retrospective review of demographic and postoperative data was performed. The effect of DR on major postoperative outcomes, including 30-day and 2-year mortality, total length of bowel resection, and development of short bowel syndrome, were analyzed. Effects of delayed vascular consultation alone, delayed vascular surgery alone, no revascularization during admission, and admitting service on outcomes were also examined on subgroup analyses.Results A total of 212 patients were analyzed. Ninety-nine patients received ER, whereas the remaining 113 patients experienced a DR after hospital presentation. Among the DR group, 55 patients (25.9%) had delayed vascular consultation, whereas vascular surgery was deferred until after the initial operation in 37 patients (17.4%). Fifty-one patients (24.0%) were never revascularized during admission. DR was a significant predictor of 30-day (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.4-4.9; P = .03) and 2-year mortality (hazard ratio, 1.55, 95% CI, 1.0-2.3; P = .04). DR was also independently associated with increased bowel resection length (OR, 7.47; P < .01) and postoperative short bowel syndrome (OR, 2.4; P = .03) on multivariate analyses. When examined separately on subgroup analysis, both delayed vascular consultation (OR, 3.38; P = .03) and vascular surgery (OR, 4.31; P < .01) independently increased risk of 30-day mortality. Hospital discharge after AMI without mesenteric revascularization was associated with increased risk of short bowel syndrome (OR, 2.94; P < .01) and late mortality (hazard ratio, 1.60; P = .04).Conclusions Delayed vascular consultation and vascular surgery are both significant hospital-based determinants of postoperative mortality and short bowel syndrome in patients with AMI. Timing-based management protocols that emphasize routine evaluation by a vascular surgeon and early, definitive mesenteric revascularization should be established and widely adopted for all patients with clinically suspected AMI at presentation.

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  • Introducing a clinical pathway and centers of excellence results in higher awareness of AMI, more appropriate imaging, less delays, increased number of revascularizations, and lower mortality.

    “Introducing a clinical pathway and centers of excellence results in higher awareness of AMI, more appropriate imaging, less delays, increased number of revascularizations, and, therefore, lower mortality [18, 19].”

    From Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. (2022) · cites this paper as [19]

    The Discussion (page not provided) recommends a timing-based AMI protocol with routine CTA and early vascular consultation, and postulates that it would reduce delays and improve survival. It also reports favorable mortality from another center’s pilot study. But this paper did not introduce or test such a pathway or center, and it does not establish increased AMI awareness or an increased number of revascularizations as results. (LLM, conf=0.87)

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Authors
Tran, L. M., Andraska, E., Haga, L., Sridharan, N., Chaer, R. A., & Eslami, M. H.
Affiliations
University of Pittsburgh (US)
Corresponding author
Eslami, Mohammad H.
ORCID
Venue
Journal of Vascular Surgery
Publisher
Elsevier BV
Published
2022-04
Volume
75
Issue
4
Pages
1323-1333.e3
ISSN
0741-5214 (ISSN-L)
DOI
10.1016/j.jvs.2021.09.033
PMC
PMC8991435
OpenAlex
W3206453343
Cited by
33
References
26
Citations by year
2026: 10 · 2025: 9 · 2024: 5 · 2023: 3 · 2022: 6
FWCI
3.29
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Vascular Surgery (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (5T32AI074490, 5T32HL0098036)
  • Burroughs Wellcome Fund
  • University of Pittsburgh
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, delayed revascularization, mesenteric revascularization, postoperative mortality, short bowel syndrome, length of hospital stay, timing of surgery, vascular surgery, emergency surgery, postoperative complications, mortality risk factors
MeSH terms
Hospitals, Humans, Ischemia, Mesenteric Vascular Occlusion, Retrospective Studies, Risk Factors, Short Bowel Syndrome, Time Factors, Vascular Surgical Procedures, Treatment Outcome, Mesenteric Ischemia

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