What is the treatment for a patient with mesenteric artery stenosis?

Treatment of Mesenteric Artery Stenosis

For chronic mesenteric ischemia (CMI) with symptomatic multivessel disease, endovascular revascularization with angioplasty and stenting is the first-line treatment, offering lower perioperative mortality compared to open surgery, though open surgical bypass provides superior long-term patency and should be considered in younger, low-risk patients. 1, 2

Clinical Context and Treatment Indication

• Revascularization is only indicated for symptomatic patients with multivessel disease (typically involving at least two of the three mesenteric vessels: celiac artery, superior mesenteric artery [SMA], or inferior mesenteric artery [IMA]). 1
• Prophylactic revascularization in asymptomatic patients is not recommended, even when significant stenosis is detected on imaging. 1
• Do not delay revascularization to improve nutritional status, as this approach has been associated with clinical deterioration, bowel infarction, and sepsis. 1

Endovascular-First Strategy

Primary Approach

• Percutaneous transluminal angioplasty with stent placement (PTA/S) has become the preferred initial treatment in most centers, with technical success rates of 85-100%. 2, 3
• Endovascular therapy demonstrates significantly lower postoperative mortality (OR 0.20,95% CI 0.17-0.24) compared to open surgery. 1
• Lower perioperative morbidity and shorter hospital stays favor endovascular approaches as first-line therapy. 2

Technical Considerations

• Primary stenting is preferred over balloon angioplasty alone in most contemporary practice. 1
• Covered stents are associated with lower restenosis rates (10% vs. 50%), fewer symptom recurrences, and reduced reintervention rates compared to bare-metal stents for SMA stenosis. 1
• Balloon-expandable stents should be used for ostial lesions due to their superior precision and higher radial force against calcified lesions. 1

Number of Vessels to Treat

• The decision to treat one versus two vessels remains controversial, though there is a non-significant trend toward lower recurrence rates with two-vessel stenting. 1
• Treatment should target vessels with hemodynamically significant stenosis contributing to symptoms. 1

Open Surgical Revascularization

Indications for Surgery

Open surgery should be considered in the following specific situations: 1

• Failed endovascular therapy without possibility for repeat endovascular intervention
• Extensive occlusion, severe calcifications, or other technical difficulties precluding endovascular access
• Young patients with non-atherosclerotic lesions (vasculitis, mid-aortic syndrome, fibromuscular dysplasia)
• Patients fit for surgery who prioritize long-term durability over lower perioperative risk

Surgical Advantages

• Open mesenteric bypass offers superior long-term patency, lower reintervention rates, and better freedom from recurrent symptoms compared to endovascular therapy. 1, 4
• Overall 5-year survival is higher with open repair, even in high-risk patients. 2

Long-Term Outcomes and Limitations

Endovascular Therapy

• One-year primary patency is approximately 65%, with primary-assisted patency of 97% and secondary patency of 99%. 3
• Higher rates of restenosis and recurrent symptoms necessitate closer surveillance and potential reintervention. 2
• One- and 3-year survival estimates are 85% and 74%, respectively, following endovascular repair. 2

Factors Affecting Patency

• Chronic obstructive pulmonary disease is associated with worse 1-year primary patency (OR 3.2,95% CI 1.4-7.7). 3
• Femoral access (versus brachial) correlates with higher reintervention rates (OR 3.0,95% CI 1.1-7.9). 3
• Treatment of occluded vessels yields similar outcomes to stenotic vessels when using endovascular techniques. 3

Secondary Prevention

• Lifelong antiplatelet therapy is indicated following treatment of chronic mesenteric ischemia. 1
• Best medical therapy for atherosclerosis should be implemented, including lifestyle modifications, statin therapy, blood pressure control, and diabetes management. 1
• The benefit of dual antiplatelet therapy (DAPT) remains unknown in this population. 1

Multidisciplinary Decision-Making

Both endovascular and open surgical options should be discussed case-by-case by a multidisciplinary team including vascular surgeons, interventional radiologists, and gastroenterologists, weighing patient age, comorbidities, anatomic factors, and treatment goals. 1

Common Pitfalls

• Avoid treating single-vessel disease in isolation, as occlusive disease of only one mesenteric artery makes CMI unlikely; search for alternative diagnoses. 1
• Do not confuse chronic mesenteric stenosis with acute mesenteric ischemia, which requires urgent/emergent intervention with different treatment algorithms. 1
• Recognize that endovascular therapy requires ongoing surveillance for restenosis, with patients needing regular follow-up imaging. 2