Comparison of Endovascular Therapy and Open Surgical Revascularization in Patients With Acute Superior Mesenteric Artery Occlusion: A Large-Scale Analysis Based on the JROAD-DPC Database

Abstract

Background: Acute mesenteric ischemia is rare, and few large-scale trials have evaluated endovascular therapy (EVT) and open surgical revascularization (OS). This study aimed to assess clinical outcomes after EVT or OS for acute superior mesenteric artery occlusion and identify predictors of mortality and bowel resection.

Methods and results: Data from the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC) database from April 2012 to March 2020 were retrospectively analyzed. Overall, 746 patients with acute superior mesenteric artery occlusion who underwent revascularization were classified into 2 groups: EVT (n=475) or OS (n=271). The primary clinical outcome was in-hospital mortality. The secondary outcomes were bowel resection, bleeding complications (transfusion or endoscopic hemostasis), major adverse cardiovascular events, hospitalization duration, and cost. The in-hospital death or bowel resection rate was ≈30%. In-hospital mortality (22.5% versus 21.4%, P=0.72), bowel resection (8.2% versus 8.5%, P=0.90), and major adverse cardiovascular events (11.6% versus 9.2%, P=0.32) were comparable between the EVT and OS groups. Hospitalization duration in the EVT group was 6 days shorter than that in the OS group, and total hospitalization cost was 0.88 million yen lower. Interaction analyses revealed that EVT and OS had no significant difference in terms of in-hospital death in patients with thromboembolic and atherothrombotic characteristics. Advanced age, decreased activities of daily living, chronic kidney disease, and old myocardial infarction were significant predictive factors for in-hospital mortality. Diabetes was a predictor of bowel resection after revascularization.

Conclusions: EVT was comparable to OS in terms of clinical outcomes in patients with acute superior mesenteric artery occlusion. Some predictive factors for mortality or bowel resection were obtained.

Registration: URL: www.umin.ac.jp/ctr/; Unique Identifier: UMIN000045240.

Keywords: acute superior mesenteric artery occlusion; bowel resection; endovascular therapy; in‐hospital mortality; open surgical revascularization.

Figure 1. Patient flowchart.

BMI indicates body mass index; EVT, endovascular therapy; ICD‐10, International Classification of Diseases, Tenth Revision; JROAD‐DPC, Japanese Registry of All Cardiac and Vascular Diseases‐Diagnosis Procedure Combination; OS, open surgical revascularization; and SMAO, superior mesenteric artery occlusion.

Figure 2. Revascularization trend for patients with acute superior mesenteric artery occlusion.

EVT indicates endovascular therapy; and OS, open surgical revascularization.

Figure 3. Trend in in‐hospital mortality or bowel resection rate in the revascularization group.

The straight line shows the annual in‐hospital death or bowel resection rate.

Figure 4. Interaction effect test for mortality between revascularization and covariates.

The P values of the interaction test for CVD and PE/DVT were 0.24 and 0.55, respectively. ADL indicates activities of daily living; Af, atrial fibrillation; AFL, atrial flutter; BMI, body mass index; CKD, chronic kidney disease; CVD, cerebrovascular disease; DM, diabetes mellitus; DL, dyslipidemia; EVT, endovascular therapy; HD, hemodialysis; HT, hypertension; OMI, old myocardial infarction; OR, odds ratio; OS, open surgical revascularization; PAD, peripheral arterial disease; and PE/DVT, pulmonary thromboembolism/deep vein thrombosis.