A decade's experience with retrograde open mesenteric stenting for acute mesenteric ischemia.

OBJECTIVE: Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach among patients presenting with AMI. METHODS: We reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary end points were in-hospital, 30-day, and 1-year mortality. Kaplan-Meier estimate for 1-year mortality and primary patency loss were generated. Secondary end points included postoperative 30-day complications. RESULTS: Between 2011 and 2022, ROMS was attempted on a total of 42 patients. The median age was 70 ± 15 years and the majority of patients were female. Pain out of proportion to the physical examination was the most common presenting symptom (n = 18, 42.9%) followed by peritonitis (n = 14, 33.4%). All patients underwent preoperative intravenous contrast computed tomography imaging. In situ thrombosis was identified as the etiology of AMI in 36 patients (85.7%). Technical success was achieved in 40 patients (95.2%). Conventional, non-hybrid operating rooms were used for the majority of cases. Revascularization of all 40 patients involved angioplasty and stenting of superior mesenteric artery. A single stent was placed in 35 patients (87.5%) and the reminder had more than one stent. Eighty percent of patients required bowel resection. A second-look laparotomy was required in 34 patients (85.0%). The mean operative time, including both the general surgery and vascular surgery portions of the index procedure, was 192 ± 57 minutes. Sepsis was the most common complication observed within 30 days, occurring in 8 patients (20.0%). In terms of mortality, 13 patients (32.5%) died during their index hospitalization, and 9 died (22.5%) within 30 days. On Kaplan-Meier analysis, the 1-year overall patient survival rate was 58.6%, and the primary patency rate for stents was 51.4%. CONCLUSIONS: ROMS has an excellent technical success rate in management of AMI with lower than traditionally reported mortality rates for AMI. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality an alternative approach for treatment of AMI.

Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis.

OBJECTIVE: This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI). METHODS: This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence. RESULTS: A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031). CONCLUSIONS: Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.

Association between PAI-1 4G/5G genotype and residual thrombus in acute mesenteric venous thrombosis.

OBJECTIVE: Plasminogen activator inhibitor-1 (PAI-1) is the most important inhibitor of plasminogen activator. The functional 4G/5G polymorphism of the gene coding for PAI-1 may affect PAI-1 plasmatic activity, influencing the imbalance between coagulation and fibrinolysis cascades. In this study, we investigated the association between the PAI-1 4G/5G genotype and the development and residual thrombus of acute primary mesenteric venous thrombosis (MVT). METHODS: The clinical data of 34 patients who underwent acute primary MVT were retrospectively reviewed. Fluorescence in situ hybridization was used to determine if patients had the 4G/5G polymorphism in the promoter of the PAI-1 gene. Patients were stratified according to the genotype of PAI-1. RESULTS: 11 patients (32.3%) were homozygous for the 4G genotype, 23 patients (67.6%) were non-homozygous for the 4G genotype (5G/5G). The extent of thrombosis was not correlated with the PAI-4G/5G polymorphism. After a mean follow-up of 16.6 ± 10.4 months, the 4G/4G genotype had a significantly larger thrombus burden (p < 0.05). 54% of patients in the 4G/4G genotype group had no lessening in the degree of mesenteric venous thrombosis, significantly higher than other patients (4G/5G + 5G/5G genotypes) (p < 0.05). CONCLUSION: The PAI-1 4G/4G predicts residual thrombus of mesenteric veins after the acute phase.

Retrograde open mesenteric stenting and outcomes for acute mesenteric ischemia.

OBJECTIVES: Data regarding retrograde open mesenteric stenting (ROMS) for urgent mesenteric ischemia is limited to small single center and case series, with variable utilization across patient populations and ill-defined outcomes. We aimed to evaluate characteristics and outcomes of patients with acute mesenteric ischemia requiring urgent surgical intervention. METHODS: Retrospective cohort study of patients with mesenteric ischemia requiring urgent surgical intervention from 2018 to 2020 was queried from the National Inpatient Sample (NIS) database. Study groups were defined as those requiring an open bypass (BYPASS), an open superior mesenteric artery embolectomy (OPEN), or ROMS. Descriptive statistics were used to report variables. Comparisons were mad using t test, chi-squares tests, and multivariate regression reported as odds ratio (OR), 95% confidence interval (CI) where appropriate. RESULTS: 898 patients with mesenteric ischemia requiring urgent surgical intervention were included: Bypass: 284, OPEN: 363, ROMS: 251. There was no difference in gender or race between groups. Patients requiring ROMS were more likely to be older 70.2 + 11.3versus Bypass 66.81 + 11.6 and OPEN 67.17 + 14.5, p = 0.0035. ROMS patients had the highest Charlson Comorbidity Index (CCI) 2.9 versus 2.5 Bypass and 2.6 OPEN, p = 0.0292 with the most frequent comorbidities: Diabetes 37% (p = 0.01), renal disease 24.3% (p = 0.5), and previous preoperative myocardial infarction 9.2%, p = 0.05; however, the lowest mortality rate was seen within this Group 15.9% versus bypass 19.7%, OPEN 34.5%, p < 0.0001. Patients requiring bypass were more likely to have chronic pulmonary disease 34.5% versus OPEN 24.2% and ROMS 31.5%, p = 0.013, peripheral vascular disease (PVD) 38% versus OPEN 16%, and ROMS 29.9%, p < 0.0001. On multivariate regression, ROMS was associated with 50% decreased incidence of mortality (OR 0.45, 95% CI 0.27-0.75). Open SMA embolectomy was associated with nearly 2x mortality rate compared to bypass procedures OR 2.0, 95% CI 1.3-3.0, p < 0.001. Previous MI was also associated with nearly 2x incidence of mortality (OR 1.9, 95% CI 1.01-3.6), while pre-existing PVD conferred a protective effect (OR 0.56, 95% CI 0.36-0.89). Higher CCI and age were associated with slightly increased risk for mortality OR 1.2 and 1.03, p < 0.05 for both. CONCLUSIONS: In patients with acute mesenteric ischemia, ROMS demonstrated a significant mortality benefit compared to traditional open procedures. Advanced age, history of MI, and open SMA embolectomy were associated with increased mortality. Little data exists regarding ROMS in a real-world population evaluating ROMS, which is a newer technique. These data suggest that ROMS may be a superior alternative to restore mesenteric flow in the acute setting and further prospective studies evaluating ROMS to other procedural types in urgent and elective settings are needed.

Factors that may affect the outcome of acute occlusive mesenteric ischemia. A single-center study.

BACKGROUND: Acute mesenteric ischemia is a rare but lethal disease. Acute occlusive mesenteric ischemia consists of mesenteric artery embolism, mesenteric artery thrombosis, and mesenteric vein thrombosis. This study aimed to investigate the factors that may affect the outcome of acute occlusive mesenteric ischemia. METHODS: Data from acute occlusive mesenteric ischemia patients admitted between May 2016 and May 2022 were reviewed retrospectively. Patients were divided into 2 groups according to whether complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission. Demographics, symptoms, signs, laboratory results, computed tomography angiography features, management and outcomes were analyzed. RESULTS: 59 patients were enrolled in this study. Complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission in 17 patients. Transmural intestinal necrosis, peritonitis, white blood cell count, percentage of neutrophils, percentage of lymphocytes, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, creatine kinase isoenzyme, cardiac troponin I, laparoscopic exploration rate, open embolectomy rate, enterostomy rate, length of necrotic small bowel, length of healthy small bowel, surgical time and intraoperative blood loss differed significantly between groups. Creatine kinase isoenzyme (OR = 1.415, 95% CI: 1.060-1.888) and surgical time (OR = 1.014, 95% CI: 1.001-1.026) were independent risk factors associated with complications(Clavien‒Dindo ≥ 2). CONCLUSIONS: Our analysis suggests that acute occlusive mesenteric ischemia patients with a creatine kinase isoenzyme level greater than 2.22 ng/mL or a surgical time longer than 156 min are more likely to experience complications'(Clavien‒Dindo ≥ 2) occurrence within 6 months of the first admission.

Dual-energy CT late arterial phase iodine maps for the diagnosis of acute non-occlusive mesenteric ischemia.

PURPOSE: To evaluate the diagnostic accuracy of dual-energy CT (DECT) iodine maps in comparison to conventional CT series for the assessment of non-occlusive mesenteric ischemia (NOMI). MATERIAL AND METHODS: We evaluated data from 142 patients (72 men; 50.7%) who underwent DECT between 2018 and 2022, with surgically confirmed diagnosis of NOMI. One board-certified radiologist performed region of interest (ROI) measurements in bowel segments on late arterial (LA) and portal venous (PV) phase DECT iodine maps as well as LA conventional series, in both ischemic and non-ischemic bowel loops, using surgical reports as reference standard, and in a control group of 97 patients. Intra- and inter-reader agreement with a second board-certified radiologist was also evaluated. Receiver operating characteristic (ROC) curve analysis was performed to calculate the optimal threshold for discriminating ischemic from non-ischemic bowel segments. Subjective image rating of LA and PV iodine maps was performed. RESULTS: DECT-based iodine concentration (IC) measurements showed significant differences in LA phase iodine maps between ischemic (median:0.72; IQR 0.52-0.91 mg/mL) and non-ischemic bowel loops (5.16; IQR 3.45-6.31 mg/ml) (P <.0001). IC quantification on LA phase revealed an AUC of 0.966 for the assessment of acute bowel ischemia, significantly higher compared to both IC quantification based on PV phase (0.951) and attenuation values evaluated on LA conventional CT series (0.828). Excellent intra-observer and strong inter-observer agreements were observed for the quantification of iodine concentration. Conversely, weak inter-observer agreement was noted for conventional HU assessments. The optimal LA phase-based IC threshold for assessing bowel ischemia was 1.34 mg/mL, yielding a sensitivity of 100% and specificity of 96.48%. CONCLUSION: Iodine maps based on LA phase significantly improve the diagnostic accuracy for the assessment of NOMI compared to conventional CT series and PV phase iodine maps.

[Modern biochemical markers of acute mesenteric ischemia]. / Sovremennye biokhimicheskie markery ostroi mezenterial'noi ishemii.

OBJECTIVE: To analyze modern literature data on biochemical markers of critical mesenteric ischemia. MATERIAL AND METHODS: We analyzed the most promising, highly specific and sensitive biochemical markers of total and segmental intestinal damage following acute mesenteric ischemia. Analysis included domestic and foreign literature data between 2015 and 2023. RESULTS: We identified the most easy-to-use for any hospitals biochemical markers with at least 90% sensitivity and specificity for further practical research. CONCLUSION: Further prospective research will provide a new step in solving the problem of timely diagnosis of acute mesenteric circulatory disorders.

Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia.

OBJECTIVE: To evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients' discharge to home vs nursing facility a decade after an episode of AMI. METHODS: The retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR-). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI. RESULTS: The mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR- group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR- group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR- patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up. CONCLUSIONS: In this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.

Exploring Outcomes Related to Residential Determinants in Acute Mesenteric Ischemia Patients.

INTRODUCTION: To access the relationship between residential status and outcomes in surgical acute mesenteric ischemia (AMI) patients. METHODS: Retrospective chart review of 153 AMI patients admitted to our institution between 2007 and 2021. Residential median income and Rural-Urban Commuting Area (RUCA) code were used as residential proxies. RESULTS: Being of the female sex (odds ratio [OR] = 3.116 [1.276-7.609] P = 0.013) and having a vascular intervention performed (OR = 2.927 [1.087-7.883] P = 0.034) were both associated with a threefold increase in the risk of mortality. Increased age (OR = 1.037 [1.002-1.073] P = 0.039), elevated blood urea nitrogen (OR = 1.032 [1.012-1.051] P = 0.001), and living in higher residential income area (OR = 1.049 [1.009-1.091] P = 0.017) had a small, but statistically significant, increased risk of mortality. Patients in higher median income areas were less likely to undergo colonic resection (OR = 0.953 [0.911-0.997] P = 0.038) and tended to have a lower likelihood of receiving an ostomy (OR = 0.963 [0.927-1] P = 0.051). Being from urban or rural areas was not associated with mortality (OR = 1.565 [0.647-3.790] P = 0.321, although rural patients were more likely to undergo colon resection (OR = 2.183 [0.938-5.079] P = 0.070). Furthermore, rural patients were much more likely to be readmitted than urban dwellers (OR = 4.700 [1.022-21.618] P = 0.047). CONCLUSIONS: AMI patients living in rural or small-town areas were more likely to be readmitted and tended to undergo colonic resection. Patients residing in higher income areas had a slightly higher risk of mortality but tended to be less likely to require ostomy or colonic resection. These findings suggest a potential need for postoperative care initiatives focused on AMI patients living in rural and lower income areas.

Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia.

INTRODUCTION: Although stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction. METHODS: From January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis. RESULTS: Although the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients' groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test). CONCLUSIONS: In patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.

Treatment of acute mesenteric ischemia between 2010 and 2020 - a German nation-wide study.

BACKGROUND: Aim of this study was to analyze long-term trends of hospitalizations, treatment regimen and in-hospital mortality of in-patients with acute mesenteric ischemia (AMI) over the past decade and effects of the SARS-CoV2-pandemic. METHODS: We analyzed fully anonymized data from the German Federal Statistical Office of patients with AMI between 2010 and 2020. Besides descriptive analyses of age, gender, in-hospital mortality, comorbidity burden and treatment regimen, multivariable logistic regression analyses were performed to identify independent variables associated with in-hospital mortality and different treatment. RESULTS: A total of 278,121 hospitalizations (120,667 male [43.4%], mean age 72.1 years) with AMI were included in this study. The total number of hospitalizations increased from 2010 (n = 24,172) to 2019 (n = 26,684) (relative increase 10.4%). In-hospital mortality decreased over the past decade from 36.6% to 2010 to 31.1% in 2019 (rel. decrease 15.2%). Independent risk factors for in-hospital mortality were older age (OR = 1.03 per year), higher comorbidity burden (OR = 1.06 per point in van Walraven score [vWs]), male gender (OR = 1.07), AMI as a secondary diagnosis (OR = 1.44), and the need for surgical (visceral surgery: OR = 1.38, vascular surgery: OR = 3.33) and endovascular treatment (OR = 1.21). We report a decline in hospitalizations during the first wave of infection in spring 2020 (rel. decrease 9.7%). CONCLUSION: In-hospital mortality rate has declined over the past decade, but remains high at above 30%. Older age, increased comorbidity and male gender are independent factors for in-hospital mortality. Hospitalizations requiring vascular surgery are associated with high in-hospital mortality, followed by visceral surgery and endovascular approaches. The first wave of the SARS-CoV2-pandemic in spring 2020 implied a decrease in hospital admissions.

Prognostic factors after acute mesenteric ischemia: which patients require specific management?

PURPOSE: Diagnosis and treatment of AMI are a real issue for implicating physicians. In the literature, only one AMI stroke center has reported its results so far, with increasing survival rates. Our aim was to analyze acute mesenteric ischemia (AMI) related mortality and predictive factors, in a single academic center, before creating a dedicated intestinal stroke center. METHODS: All the patients with an AMI, between January 2015 and December 2020, were retrospectively included. They were divided into 2 groups according to the early mortality: death during the first 30 days and alive. The 2 groups were compared. RESULTS: 173 patients (57% of men), were included, with a mean age of 68 ± 16 years. Overall mortality rate was 61%. Mortality occurred within the first 30 days in 78% of dead cases. Dead patients were significantly older, more frequently admitted from intensive care, with more serious clinical, laboratory and radiological characteristics. We have identified 3 protective factors - history of abdominal surgery (Odd Ratio = 0.1; 95%CI = 0.01-0.8, p = 0.03), medical management with curative anticoagulation (OR = 0.09; 95%CI = 0.02-0.5, p = 0.004) and/or antiplatelets (OR = 0.04; 95%CI = 0.006-0.3, p = 0.001)-, and 2 predictive factors of mortality - age > 70 years (OR = 7; 95%CI = 1.4-37, p = 0.02) and previous history of coronaropathy (OR = 13; 95%CI = 1.7-93, p = 0.01). CONCLUSIONS: AMI is a severe disease with high morbidity and mortality rates. Even if its diagnosis is still difficult because of non-specific presentation, its therapeutic management needs to be changed in order to improve survival rates, particularly in patients older than 70 years with history of coronaropathy. Developing a dedicated organization would improve the diagnosis and the management of patients with AMI.

Computed Tomography-Defined Body Composition as Prognostic Parameter in Acute Mesenteric Ischemia.

INTRODUCTION: Body composition comprising low-skeletal muscle mass (LSMM) and subcutaneous and visceral adipose tissue (SAT and VAT) can be assessed by using cross-sectional imaging modalities. Previous analyses suggest that these parameters harbor prognostic relevance in various diseases. Aim of this study was to analyze possible associations of body composition parameters on mortality in patients with clinically suspected acute mesenteric ischemia (AMI). METHODS: All patients with clinically suspected AMI were retrospectively assessed between 2016 and 2020. Overall, 137 patients (52 female patients, 37.9%) with a median age of 71 years were included in the present analysis. For all patients, the preoperative abdominal computed tomography (CT) was used to calculate LSMM, VAT, and SAT. RESULTS: Overall, 94 patients (68.6%) of the patient cohort died within 30 days within a median of 2 days, range 1-39 days. Of these, 27 patients (19.7%) died within 24 h. According to the CT, 101 patients (73.7%) were classified as being visceral obese, 102 patients (74.5%) as being sarcopenic, and 69 patients (50.4%) as being sarcopenic obese. Skeletal muscle index (SMI) was lower in non-survivors compared to survivors (37.5 ± 12.4 cm2/m2 vs. 44.1 ± 13.9 cm2/m2, p = 0.01). There were no associations between body composition parameters with mortality in days (SMI r = 0.07, p = 0.48, SAT r = -0.03, p = 0.77, and VAT r = 0.04, p = 0.68, respectively). In Cox regression analysis, a nonsignificant trend for visceral obesity was observed (HR: 0.62, 95% CI: 0.36-1.05, p = 0.07). CONCLUSION: SMI might be a valuable CT-based parameter, which could help discriminate between survivors and non-survivors. Further studies are needed to elucidate the associations between body composition and survival in patients with AMI.

Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy.

BACKGROUND: Acute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations. METHODS: The clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis. RESULTS: In total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality. CONCLUSIONS: Morbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.

Role of spleen density in predicting postoperative complications in patients with acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is a life-threatening surgical emergency with a poor prognosis. This study assessed the association of diffuse reduction of spleen density (DROSD) with postoperative complications and identified risk factors for adverse outcomes in AMI patients after surgery. METHODS: Patients who were diagnosed with AMI and underwent surgical operations between April 2006 and July 2021 were enrolled. Spleen density was assessed using preoperative non-enhanced computed tomography. The lowest quartile of spleen density in all patients was regarded as the cutoff value for DROSD. Univariate and multivariate analyses were performed to determine the risk factors related to postoperative outcomes after surgery. RESULTS: According to the diagnostic cutoff, patients with a spleen density ≤49.07 HU were defined as DROSD. In a cohort of 97 patients, 34.0% developed complications within 30 days of surgery. The multivariate analysis illustrated that DROSD was an independent risk factor for prognostic outcomes in AMI patients after surgery. CONCLUSION: Patients with low spleen density were prone to postoperative complications. As an imaging method, preoperative assessment of spleen density is a novel predictor that can be used clinically to identify high-risk AMI patients with poor prognosis.

Association of COVID-19 Infection and Acute Mesenteric Ischemia.

COVID-19 is an infectious disease that is considered to be a thromboinflammatory disorder. The study was aimed to determine the prevalence of COVID-19 in patients with acute mesenteric ischemia (AMI) and the outcomes of surgical treatment in relation to COVID-19. A total of 140 patients were included in this multicentric study divided into two groups: the test group (n=65) consisted of cases of AMI detected during the COVID-19 pandemic and the control group (n=65) consisted of cases of AMI detected before the pandemic. Test group patients were classified as COVID-positive (COVID+), or COVID-negative (COVID-) if they tested positive, respectively negative test for COVID-19 on admission. Primary outcomes were: prevalence of COVID-19 infection among test group patients, association between COVID-19 infection and inoperability, and between COVID-19 and treatment outcome. Secondary outcomes were association between each blood parameter and inoperability and treatment outcome. There were no statistically significant differences between inoperability and COVID-19 positivity on admission, overall mortality between the control group and the test group and overall mortality between COVID+ and COVID- patients, as well as among those patients that have been surgically treated (p>0.05). There were statistically significant differences between serum amylase levels (p=0.034), and serum LDH levels (p=0.0382) and inoperability, between serum LDH levels and postoperative mortality (p=0.0151), and overall mortality (p=0.00163). High level of LDH and serum pancreatic amylase are associated with a higher rate of inoperability and a higher postoperative and overall mortality rate. COVID-19 does not seem to independently influence the treatment outcome of AMI.

Microcatheter-Directed Thrombolysis Using Recombinant Tissue Plasminogen Activator for the Treatment of Acute Superior Mesenteric Artery Embolism: A Case Report.

Background: Acute mesenteric ischemia (AMI) is a life-threatening condition, and in 50% of patients, AMI is caused by acute superior mesenteric artery (SMA) embolism. Endovascular treatment is increasingly being considered the primary modality in selected cases. Many studies have reported that percutaneous aspiration embolectomy using a guiding catheter and thrombolysis with recombinant tissue plasminogen activator (rtPA) are effective in treating SMA embolism. However, no reports on treating SMA embolism using rtPA administered via a microcatheter exist. Case presentation: A 64-year-old man with underlying atrial fibrillation presented with acute SMA embolism revealed using computed tomography (CT). rtPA (total 3 mg) was carefully administered into the occluded SMA through a microcatheter. No complications occurred, and complete revascularization of the SMA was revealed on follow-up CT. Conclusions: Compared with previous reports, this case report reveals that successful revascularization can be achieved using rtPA administered via a microcatheter, with a low dose of rtPA and a short duration of thrombolysis.

Acute mesenteric ischemia - a persistent problem.

Acute mesenteric ischemia is a disease with a relatively low incidence (0,02-0,9% of acute surgical hospitalizations) but a very high mortality rate which can reach up to 100% without early revascularization. Given the above, prompt and accurate diagnosis and subsequent surgical intervention is the cornerstone of treatment and essential to reduce the high mortality rate. Early revascularization can reduce overall mortality by up to 50%. Treatment of acute mesenteric ischemia requires the cooperation of gastrointestinal surgeons, vascular surgeons and interventional radiologists. Thorough clinical examination, contrast computed tomography performed at the initial stage, and the current possibilities of interventional radiology are the keys to improving the results of treatment of acute mesenteric ischemia. The purpose of this paper is to refresh knowledge in the management of acute mesenteric ischemia and summarize the most up-to-date information on the diagnosis and treatment of this disease.

[Acute mesenteric ischemia - a 15-year experience of surgical treatment in a multi-field hospital]. / Ostraya arterial'naya mezenterial'naya ishemiya ­ 15-letnii opyt khirurgicheskogo lecheniya v mnogoprofil'nom statsionare.

OBJECTIVE: To evaluate the results of surgical treatment of arterial acute mesenteric ischemia in a single hospital over a 15-year period (from 2007 to 2022). MATERIAL AND METHODS: There were 385 patients with acute occlusion of superior or inferior mesenteric artery over a 15-year period. The causes of acute mesenteric ischemia were thromboembolism of superior mesenteric artery (51%), its thrombosis (43%) and thrombosis of inferior mesenteric artery (6%). Female patients predominated (258 or 67%), while male patients comprised 33% (n=127). Age of patients ranged from 41 to 97 years (mean 74±9). The main diagnostic method for acute intestinal ischemia was contrast-enhanced computed tomography or CT angiography. Intestinal revascularization was performed in 101 patients: 10 patients - open embolectomy or thrombectomy from superior mesenteric artery, 41 patients - endovascular intervention, 50 patients - combined surgery (revascularization with resection of necrotic bowel segments). Isolated resection of necrotic intestines was performed in 176 patients. Exploratory laparotomy was performed in 108 patients with total bowel necrosis. Prevention and treatment of reperfusion and translocation syndrome after successful intestinal revascularization implied extracorporeal hemocorrection for extrarenal indications (veno-venous hemofiltration or veno-venous hemodiafiltration). RESULTS: Overall 15-year mortality rate (385 patients) for acute SMA occlusion was 71% (256 out of 360 patients), postoperative mortality excluding exploratory laparotomies for the same time period - 59%. Mortality rate for inferior mesenteric artery thrombosis was 88%. Routine CT angiography of mesenteric vessels, active and effective early intestinal revascularization (open or endovascular surgery), as well as extracorporeal hemocorrection methods for reperfusion and translocation syndrome reduced mortality rate to 49% over the past 10 years (from 2013 to 2022). Mortality in acute mesenteric ischemia in the first 5 years of this study (from 2007 to 2012) was 64% (p=0.16). The main cause of death was intestinal gangrene with multiple organ failure. Reperfusion syndrome after effective endovascular revascularization complicated by severe pulmonary edema and acute respiratory distress syndrome resulted death in 15% of patients. CONCLUSION: Acute mesenteric ischemia is followed by high mortality rates and extremely poor prognosis. Early diagnosis of acute intestinal ischemia using modern diagnostic methods (CT angiography of mesenteric vessels), effective revascularization of superior mesenteric artery (open, hybrid or endovascular), prevention and treatment of reperfusion and translocation syndrome can improve postoperative outcomes.

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

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.