Chronic visceral ischemia: symptom-free survival after open surgical repair.
A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p < 0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7-21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8-21.9; p <0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.
English
William P
WP
Division of Surgical Sciences, Section on Vascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
Pearce
Jeffrey D
JD
Craven
Timothy E
TE
Edwards
Matthew S
MS
Geary
Randolph L
RL
Plonk
George W
GW
Hansen
Kimberley J
KJ
D000368:Aged; D001157:Arterial Occlusive Diseases / Q000453:epidemiology / Q000601:surgery*; D002908:Chronic Disease; D015897:Comorbidity; D005260:Female; D006801:Humans; D007511:Ischemia / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery*; D008297:Male; D017537:Mesenteric Artery, Inferior; D017538:Mesenteric Artery, Superior; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D014654:Vascular Patency; D014781:Viscera / Q000098:blood supply*