S. Mallick1,2, T. Coaston1,2, S. Sakowitz1,2, G. Porter1,2, E. Aguayo1,2,3, O. Kwon1,2,3, A. Vadlakonda1,2, S. Bakhtiyar4, P. Benharash1,2 1University Of California – Los Angeles, Center For Advanced Surgical & Interventional Technology (CASIT), Department Of Surgery, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Cardiovascular Outcomes Research Laboratories (CORELAB), Department Of Surgery, Los Angeles, CA, USA 3Los Angeles County Harbor-UCLA Medical Center, Department Of Surgery, Los Angeles, CA, USA 4University of Colorado Anschutz Medical Campus, Department Of Surgery, Aurora, CO, USA
Introduction:
Acute mesenteric ischemia (AMI) accounts for only 0.1% of hospital admissions but is associated with a mortality rate of 30%. Despite early reports associating endovascular repair with superior outcomes, a contemporary comparison of approaches remains lacking. Using a national cohort, we evaluated the association between revascularization approach and outcomes in patients with AMI.
Methods:
The 2016-2021 Nationwide Readmissions Database was used to identify all adult (≥18 years) hospitalizations for AMI, undergoing an open (OR) or endovascular repair (Endo). Multivariable regression models were developed to evaluate the association between surgical approach and perioperative outcomes, including in-hospital mortality, major complications, subsequent bowel resection, or infusion of total parenteral nutrition (TPN) during the same hospitalization, costs, and non-elective readmission.
Results:
Of 16,754 patients presenting with AMI, 10,128 patients underwent endovascular revascularization. During the study period, the total number of procedures increased (2,622 in 2016; 3,241 in 2021; p<0.001), however the proportion of Endo remained the same (60.7% in 2016; 60.6% in 2021; p=0.59). Compared to OR, Endo was older (70.6 ± 12.1 vs 67.1 ± 13.0 years, p<0.001) and more commonly insured by Medicare (73.2 vs 62.9%, p<0.001). Additionally, Endo and OR had similar median Elixhauser comorbidity scores (5 (4-7) vs 5 (4-7), p=0.44). Importantly, across the study period the in-hospital mortality rate rose (21.0% in 2016; 25.9% in 2021; p<0.001), with OR exhibiting significantly higher rates as compared to Endo (34.2 vs 18.1%; p<0.001).
After adjustment, Endo was associated with lower odds of in-hospital mortality (Adjusted Odds Ratio [AOR] 0.42, 95% Confidence Interval [CI] 0.37, 0.48) and all complications studied (Figure 1A, all p<0.001). Notably, endovascular repair was associated with lower risk of bowel resection (AOR 0.54, CI 0.46, 0.62) and need for TPN (AOR 0.51, CI 0.43, 0.60). Additionally, endovascular repair was associated with a decrease in both length of stay (β-3.34 days, CI -4.02, -2.66) and hospitalization costs (β+ $15,521, CI -$18,826, -$12,215; all p<0.001). While endovascular repair was associated with significantly lower odds of non-home discharge it displayed similar odds of 90-day non-elective readmission (Figure 1B).
Conclusion:
Among patients undergoing mesenteric revascularization for AMI, open approach was linked with inferior clinical and financial outcomes. With the recent increase in mortality, further work is warranted to determine if increased adoption of endovascular repair could improve outcomes among patients requiring vascular repair for AMI nationally.