Invited commentary
Article Outline
Fioole et al report 51 patients treated with percutaneous angioplasty and stenting (PTAS) for chronic mesenteric ischemia (CMI), reflecting the authors' transition towards a PTAS-first approach to CMI. They report very acceptable primary patency, secondary patency, and clinical success at 2 years of 60%, 79%, and 56%, respectively. This article is important, because the transition to endovascular-first treatment for CMI is not limited to this group but has been observed in many vascular practices. This report highlights the continued tradeoff of newer, less invasive treatments, and lower morbidity at the expense of durability and higher reintervention rates compared with open surgery.
A less invasive procedure may tend to overtreat patients with unclear or minimal symptoms. The current report includes predominately multivessel disease, but seven patients with single-vessel disease and “insufficient collaterals” were included. Importantly, the authors used a multidisciplinary approach to diagnosis, with the involvement of vascular surgeons, interventional radiologists, and gastroenterologists. Also, the authors recognize the emerging role of exercise tonometry. Despite careful consideration, there were two treatment failures due to underlying infectious causes.
In the era of open surgical revascularization, the technical discussion focused on single vs multiple revascularization and antegrade vs retrograde bypass. With PTAS, the real discussion appears to be single-vessel vs multivessel revascularization. Most of the patients with multivessel disease had single-vessel revascularization, with reliance on visualized collaterals, whereas in only six patients were multiple vessels treated. Many patients with celiac and superior mesenteric artery (SMA) disease underwent celiac revascularization only. This logic flaw is demonstrated by the open revascularization procedures necessary in 14% of the patients, which all involved direct SMA revascularization. The limitation in crossing chronic occlusions in the visceral vessels needs to be addressed. This report includes only a single revascularization of a chronically occluded SMA. Until complete SMA revascularization is possible, PTAS is not anatomically equivalent to surgical revascularization for CMI.
Surgeons need to carefully view the emerging data on PTAS for CMI.1, 2, 3 The question is whether PTAS is a reasonable first-line therapy based on the data, or because surgeons now perform PTAS. From a patient perspective, however, less may be better. Major morbidity was only 4%. But what is the cost? The authors, unfortunately, do not provide this information. With a 2-year primary patency of only 60%, repeat interventions may be the norm. Within the current health care environment, this is an excellent opportunity for comparative-effectiveness research.
References
- Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. J Vasc Surg. 2008;47:485–491
- . Long-term outcomes of endoluminal therapy for chronic atherosclerotic occlusive mesenteric disease. Ann Vasc Surg. 2008;22:541–546
- . Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience. J Vasc Surg. 2007;45:1162–1171
PII: S0741-5214(09)01701-7
doi:10.1016/j.jvs.2009.08.056
© 2010 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Percutaneous transluminal angioplasty and stenting as first-choice treatment in patients with chronic mesenteric ischemia , 05 November 2009
