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A new study, published in the February 2007 issue of the Journal of Vascular Surgery has found that retrograde open mesenteric stenting (ROMS) has a high technical success rate for treating mesenteric ischemia (AMI) due to atherosclerotic occlusive disease.

“Retrograde open mesenteric stenting is a hybrid technique in which the superior mesenteric artery (SMA) is exposed at the base of the transverse mesocolon for retrograde cannulation following local patch angioplasty at the intended puncture site,” said Mark C. Wyers, MD, assistant professor of vascular surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. 

Dr. Wyers said that like traditional surgical bypass, ROMS allows for an accurate assessment and treatment of any non-viable bowel during laparotomy. At the same time, he said, SMA recanalization and stenting is performed to revascularize the viscera. Cannulation via the infra-colic SMA offers the potential advantage of a more direct approach to lesions that might otherwise require arm or prolonged femoral access.”

Study researchers noted that acute AMI has a traditionally been treated with emergent operative bypass, often combined with segmental resection of non-viable small bowel. Endovascular treatment has not generally been used for patients with AMI who need emergent revascularization and potential resection of non-viable bowel because percutaneous procedure does not allow for an assessment of bowel viability. Additionally, the procedure requires advanced endovascular skills, which can take substantial time and might delay revascularization.

During a four-year period, 13 patients with occlusive AMI who required emergency revascularization were studied. Retrospectively, treatments included: traditional open surgical bypass, five; antegrade, percutaneous SMA stenting, two; ROMS, six. Despite the small numbers, in-hospital mortality was lower in this ROMS group (17 percent) compared to the bypass (80 percent) and percutaneous stent (100 percent) groups.  

Results for six patients with SMA occlusions were technically successful. In five of these patients, a prior attempt at antegrade SMA stenting via a brachial approach had been unsuccessful (three during this index procedure and two previously during a separate attempt at SMA stenting). Researchers said this high technical success rate is due to superior pushability and torquability achieved by direct SMA access close to the point of obstruction.

The main limitation with mesenteric stenting is the high rate of recurrent stenosis, according to researchers. They revealed that restenosis rates may be higher because of the longer lesion length associated with complete occlusions. 

“Frequent duplex surveillance is required to judge the need for re-intervention,” said Dr. Wyers. “Recurrent stenosis seems to happen relatively early after mesenteric stenting, so we recommend surveillance within the first month and every three months thereafter.

Dr. Wyers added that this is an initial study and although ROMS is an equally efficacious procedure with less associated physiologic stress, researchers cannot be certain that improved survival is a result of this technique. “The improved survival may be the result of earlier diagnosis and better preoperative imaging with multidetector CTA. Larger numbers of patients, followed prospectively would be necessary to determine the potential impact of this technique on morbidity and mortality rates. However, based on my experience with this technique, in this select patient group, I consider ROMS to be my first choice of revascularization techniques.”