Review

Vascular and Endovascular Surgery

1-10
Management of Acute Mesenteric ª The Author(s) 2016
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Ischemia: A Critical Review and DOI: 10.1177/1538574416639151
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Treatment Algorithm

Yang Zhao, MD1, Henghui Yin, MD, PHD1, Chen Yao, MD, PHD1,
Jiong Deng, BS1, Mian Wang, MD, PHD1, Zilun Li, MD, PHD1,
and Guangqi Chang, MD1

Abstract
Background: Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery
represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear
recommendation based on a higher level of evidence. Methods: A systematic review of articles published between 2000 and
2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT)
groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary
patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all
retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided w2 test or Fisher
exact test where appropriate. Results: Twenty-eight articles with a total of 1110 patients were included for the review. The ET
group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The
primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every
patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the
lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other
groups was not possible due to the limited number of cases available for review. Conclusion: Endovascular treatment may
serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be
reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach
for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

Keywords
acute mesenteric ischemia, endovascular treatment, opening surgery, hybrid technique

Introduction Notably, a hybrid technique (HT), retrograde open mesen-

Acute mesenteric ischemia (AMI) is an uncommon but
highly lethal vascular emergency, in which acute intestinal
ischemia or even infarction may occur if effective treatment
is not provided promptly. High mortality rates of 30% to
65% have been reported in several large clinical series in
the past decades.1-3 Although open surgery (OS) remains the
treatment of choice for the majority of AMI, endovascular
treatment (ET; ie, percutaneous transluminal angioplasty
[PTA] and stent placement) has emerged as a promising
alternative.4-6 Endovascular treatment may restore bowel
perfusion faster than open revascularization, such as surgical
embolectomy or bypass grafting. In addition, the morbidity
and mortality of ET during short-term follow-up seem to be
lower than OS, as suggested by case reports and small
series.7-10 However, more conclusive data from larger scale
or multicenter randomized controlled trials are not available.
teric stenting has gained increasing attention since it was first
reported in 2004.11 A combination of OS and ET, HT, allows
for primary resection of nonviable bowel as well as rapid reca-
nalization of occluded vessels in a single stage. However, rel-
evant articles are lacking and its outcome remains unclear.
Thus, the aim of this study was to summarize all available data
of different management of AMI and to propose an evidence-
based treatment algorithm.
1
Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen Uni-
versity, Guangzhou, China
Corresponding Authors:
Zilun Li and Guangqi Chang, The First Affiliated Hospital, Sun Yat-sen Uni-
versity, 58 Zhongshan Two Road, Guangzhou 510000, China.
Emails: lizilun@mail.sysu.edu.cn; changvascular@126.com; 13922231628@
163.com

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2 Vascular and Endovascular Surgery
Methods
Search and Selection Process
A comprehensive search of the English-language published
literature, using the terms ‘‘acute’’ and ‘‘mesenteric’’ or
‘‘mesentery,’’ was performed to identify all articles reporting
AMI treated by ET, OS, or HT between January 2000 and
September 2013. A multistage assessment was used to identify
qualified articles. At the first stage, only titles and abstracts
were reviewed to select articles focusing on surgical treatment
of AMI for further evaluation. Articles reporting on the mole-
cular biology, pathology, pathophysiology, diagnostic tech-
nique, and serology were excluded. Case report and literature
review were also excluded, and a minimum series of 3 patients
with AMI treated with ET, OS, or HT were required for inclu-
sion. At the second stage, all articles selected were reviewed in
full-text version. Studies were excluded if (1) reporting only on
chronic mesenteric ischemia or on both AMI and chronic
mesenteric ischemia where a clear distinction of patients was
not evident; (2) mesenteric vein thrombosis was included as
etiology of AMI; (3) the data were based on autopsy reports; (4)
conservative treatment could not be distinguished from patients
treated by surgery; and/or (5) AMI occurred after cardiac sur-
gery or aortic dissection. For multiple reports of previously
listed patients, only the articles with the most recent number
of patients or with most information were included.
Data Extraction
Data were extracted by 2 authors independently, and consen-
sus was achieved by further discussion when discrepancies
occurred. Predefined variables including clinical characteris-
tics, procedural data, in-hospital data, and follow-up data
were extracted. Clinical outcomes included perioperative
mortality and morbidity, technical success, rates of primary
patency, primary intestinal resection, and second-look lapar-
otomy rate. Information not mentioned was classified as not
available (NA).
Data Synthesis and Analysis
Patients were designated into OS, ET, and HT groups accord-
ing to the treatment option for outcome analysis. Rates of
events were calculated as the number of events divided by the
number of treated patients with available data. Statistical soft-
ware SPSS 13.0 was used for all statistical analysis. Mean (M)
and standard deviations (SDs) are reported for parametric vari-
able, whereas absolute values (n) and range (95% confidence
interval [CI]) are reported for nonparametric variable in order
to infer the condition of these variables in population. Two-
sided Student t test for continuous parametric variables and
2-sided w2 test or Fisher exact test for categorical variables
were used to make comparison between OS and ET where
appropriate. Statistical significance was defined as P < .05. The
95% CI or Forest plot was built using Review Manager 5.3.
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Results
Study Selection
Among 1382 citations initially identified, 28 papers 12-39
describing 1110 patients met the inclusion criteria and were
included for the review (Figure 1). The general information for
studies is presented in Table 1 and Supplementary Table 1.
Patients’ Characteristics and Procedural Information
Patient characteristics and perioperative risk factors are shown
in Table 2. Although HT group was excluded from the com-
parison because of limited cases, an additional description and
analysis of HT is provided at the end of this section.
The M age of the population was 66.2 years old, 54.8% +
2.9% of them are female, and the most common symptom was
abdominal pain followed by nausea and vomiting, while nausea
and peritonitis were the only 2 presentations that were signif-
icantly different between ET and OS. The most frequent risk
factors were hypertension, followed by ex-/active smoker,
atrial fibrillation, and ischemia heart disease. Hyperlipidemia,
renal dysfunction, peripheral arterial disease, and ischemia
heart disease were significantly higher in the ET group than
the OS group (P < .05). There were more cases of embolic
occlusion in the OS group than in the ET group (P < .05),
whereas the cases with nonocclusive AMI were significantly
less common in the ET group (P < .05). The most commonly
affected vessel was the superior mesenteric artery (SMA). A
significantly larger number of SMA and SMA plus celiac artery
were treated by OS (P < .05).
Procedural Details
Thrombolysis infusion was performed as primary treatment
method in 43.8% + 7.2% of patients treated by ET; nearly
27.2% + 9.7% of them received mechanical thromboembo-
lectomy as an adjunctive procedure, whereas 19.8% + 8.7%
required provisional PTA or stenting (Table 3). Mechanical
thromboembolectomy was performed in 12.9% + 4.8% of the
population treated by ET; of these patients, 25.0% were treated
with adjunctive infusion because of suboptimal outcome fol-
lowing initial management, whereas 12.5% were treated with
adjunctive PTA or stenting. Up to 36.2% + 6.9% of patients in
the ET group received primary PTA or stent placement. Addi-
tionally, ET had significantly lower rates of intestinal resection
and open revascularization.
The Main Clinical Outcomes
The overall complication rate in the ET group was significantly
lower than that in the OS group (Table 4). Endovascular treat-
ment had lower rates of wound infection, multiple organ dys-
function disease, pulmonary failure/infection, and myocardial
infarction. The incidence of ET-specific complications such as
SMA dissection, perforation or bleeding, and access site bleed-
ing was relatively low.
Zhao et al
Figure 1. The PRISMA flow diagram. AMI indicates acute mesenteric ischemia; CMI, chronic mesenteric ischemia; PRISMA, Preferred Reporting
Items for Systematic Reviews and Meta-Analyses.
Regarding the initial procedure of ET, the failure rate was
11.1% + 4.0%. Reasons for failures included failure to cross
the occlusion site and revascularize after compromised initial
procedure. The in-hospital mortality was 26.9% + 5.7% in the
ET group versus 40.3% + 3.3% in the OS group (P < .05).
Respective mortality and secondary operation data of OS or ET
treatment groups were available in 6 studies. Based on these
studies, the odds ratio for mortality of OS versus ET was 1.63
(95% CI: 0.94-2.84, P ¼ .08; Figure 2). Similarly, the odds
ratio for secondary-look operation rate was 1.85 favoring ET
(95% CI: 1.13-3.03, P ¼ .01; Figure 3). Progressive intestinal
ischemia or infarction was responsible for most of the second-
look laparotomies. Furthermore, ET group appeared to have a
higher rate of primary patency (ET: 94.4% + 4.8% vs OS:
52.5% + 7.3%, P < .05).
Follow-Up
The follow-up ranged from 1 to 60 months. A clear descrip-
tion of survival data was reported in 414 patients (ET: 150,
OS: 264; Figure 4). The cumulative survival rates of the
ET group were 93.3% + 2.0% during in-hospital period,
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3
89.7% + 2.5% at 1 year, 55.9% + 4.6% at 2 years, 48.3%
+ 4.9% at 3 years, 27.2% + 5.1% at 4 years, and 16.0% +
4.4% at 5 years, whereas the respective data of the OS group
were 89.4% + 1.9%, 49.1% + 3.1%, 44.9% + 3.1%, 41.4%
+ 3.0%, 33.8% + 2.9%, and 26.9% + 2.7%. In the overall
comparison, 3 methods were used to compare the 2 groups,
but none of them showed any significant differences (log
rank, P ¼ .91; Breslow, P ¼ .11; Tarone-Ware, P ¼ .32).
Additionally, the main procedure-related complications dur-
ing follow-up were short bowel syndrome and recurrent pain
caused by the residual partially occlusive mesenteric
ischemia.
Data of HT
The data of the HT group are shown in Supplementary Tables
2 and 3. For these 16 patients, the M age was 68.5 years, and
9 of them were female. The most common risk factors were
hypertension, smoker/ex-smoker, and ischemia heart dis-
eases. All of the patients had abdominal pain. Thirteen
(81.3%) patients had thrombotic occlusion of SMA, and the
overall complication rate was 75.0%. Endovascular
4 Vascular and Endovascular Surgery

Table 1. Overview of 28 Included Studies. Clinical presentation of AMI is heterogeneous. Gener-

ally, the emergency department physicians must suspect
Authors Year OS þ ET þ HT OS ET HT
AMI42 if patients present with (1) sudden onset of abdom-
Zhu et al13 2013 4 0 0 4 inal pain; (2) pain-free interval approximately 6 to 12 hours
Pang et al39 2013 9 0 9 0 after symptom onset; and (3) subsequent gangrene of the
Dong et al37 2013 10 1 9 0 intestine with peritonitis. In our study, most of these pre-
Jia et al25 2013 5 0 5 0 senting symptoms are similar in both the ET and the OT
Alhan et al14 2012 107 107 0 0
treatment groups, although the incidence of peritonitis and
Ozturk et al15 2012 26 26 0 0
Ryer et al32 2012 93 82 11 0 unclear diagnosis was significantly higher in the OS group;
Gagniere et al16 2011 8 0 8 0 this is not surprising as an urgent exploratory laparotomy
Arthurs et al12 2011 70 14 56 0 would be performed in the presence of peritonitis, even if
Newton et al27 2011 142 142 0 0 clear diagnosis was not confirmed.
Hawkins et al24 2011 8 0 8 0 Anatomical suitability is one of the most important factors
Bjornsson et al36 2011 34 0 34 0 for determining choice of intervention. Generally, ET is
Heiss et al29 2010 15 0 15 0
preferred when (1) the main trunk of SMA is not angular or
Block et al21 2010 163 121 42 0
Stout et al31 2010 3 0 0 3 tortuous; (2) the proximal and distal landing zones are 10
Acosta et al22 2009 21 0 21 0 mm; (3) no main branches located within the section of
Kassahun et al38 2008 39 39 0 0 proximal or distal landing zone; and (4) no presence of
Kougias et al19 2007 72 72 0 0 peritonitis or no suspicions of intestinal necrosis. So, there is
Yanar et al28 2007 14 14 0 0 a risk that most ET patients were somehow selected. It can
Wyers et al30 2007 13 5 2 6 explain the low mortality or secondary operation rate of ET.
Freeman and Graham18 2005 18 14 1 3
Several risk factors including renal dysfunction, peripheral
Kaminsky et al20 2005 41 41 0 0
Lim et al23 2005 3 0 3 0 arterial disease, and ischemia heart disease were significantly
Bingol et al35 2004 24 24 0 0 more frequent in the ET group than in the OS group, suggesting
Park et al17 2002 58 50 8 0 that perhaps these patients were at higher operative risk. In
Barakate et al26 2002 8 7 1 0 addition to preoperative comorbidity, nutritional status is criti-
Bjorck et al33 2002 60 58 2 0 cally important when deciding on choice of intervention and is
Endean et al34 2001 42 42 0 0 recognized as an independent risk factor for surgical mortality
Overall 1110 859 235 16
and morbidity.43,44 Finally, life expectancy influences the
Abbreviations: ET, endovascular treatment; HT, hybrid technique; OS, opening selection of treatment.45-47 Although nutritional status and life
surgery. expectancy were not mentioned in most of the included articles,
these indexes should always be assessed. Endovascular treat-
procedures were successful in all patients, with an in-hospital ment should be considered as the treatment of choice for
mortality of 6.3% + 11.9% and a secondary laparotomy rate patients with poor preoperative condition and low life expec-
of 46.2% + 27.1%. The primary patency rate was 68.8% + tancy (<5 years), providing intestinal ischemia and necrosis can
11.6% according to postoperative computed tomography be excluded.
angiography or digital subtraction angiography during 5 With respect to the mortality and morbidity, overall com-
years of follow-up. plication rate was lower in the ET group compared with the
OS group, and the same trend was observed for in-hospital
mortality and primary patency rate. Survival rates at 1 to 5
Discussion years showed no significant difference between the 2 groups,
Our review of pertinent literature found that the traditional though they tended to be higher in the ET group during the
management of AMI was OS, especially for those presenting first 3 years, with the trend reversed at 4 and 5 years. Although
emergently with an acute abdomen. However, the mortality we confirmed that ET was associated with reduced periopera-
and intestinal resection rate of OS remains high, despite tive mortality and morbidity rate of AMI,12,21 most of the
improvements in diagnosis and surgical technique. Endo- patients treated by ET were selected. Indeed, selection bias
vascular treatment appears to have a higher rate of bowel is the principal limitation in our study since, by definition, OT
preservation as well as increased survival and lower compli- was likely reserved for patients who were sicker and had
cation rate compared with OS, and as such is a good alterna- impending intestinal infarction. Notably, we were unable to
tive for treating AMI. However, this presumption was only identify objective criteria for intestinal infarction such as ele-
based on case reports or small case series,7,11,40,41 whereas vated lactate or academia, which would have allowed us to
large clinical trials and systematic comparison of both thera- match treatment groups more evenly. This selection bias
pies are not yet available. The object of our study was to could also explain the result that the ET group had signifi-
summarize all available data of different surgical strategies cantly fewer secondary-look operation rate compared to the
and make comparison between them, thus proposing an OS from comparative studies. Nonetheless, planned second-
evidence-based treatment algorithm. look laparotomy or laparoscopy was proposed recently by

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Zhao et al 5

Table 2. Patients’ Characteristics.

ToT (n ¼ 1110) ET (n ¼ 234) OS (n ¼ 856)

Data Number of Data Available, Number of Data Number of

Available (n) Events, n (%) n (%) Events, n (%) Available (n) Events, n (%) P

Age, years 1110 66.2 214 69.6 669 68.0

Female gender 1077 590 (54.8% + 2.9%) 205 107 (52.2% + 6.8%) 644 344 (53.4% + 3.9%) .76
Symptoms and
signs
Abdominal pain 886 855 (96.5% + 1.2%) 183 175 (95.6% + 2.9%) 481 467 (97.1% + 1.5%) .37
Nausea 476 256 (53.8% + 4.5%) 89 46 (51.7% + 10.4%) 220 146 (66.4% + 6.2%) .01
Vomit 767 396 (51.6% + 3.5%) 168 75 (44.6% + 7.5%) 447 232 (51.9% + 4.6%) .11
Diarrhea 707 225 (31.8% + 3.4%) 75 16 (21.3% + 9.3%) 378 119 (31.5% + 4.7%) .19
Bloody diarrhea 698 125 (17.9% + 2.8%) 165 26 (15.8% + 5.6%) 318 65 (20.4% + 4.4%) .21
Peritonitis 1002 200 (19.9% + 2.5%) 77 11 (14.3% + 7.8%) 208 124 (59.6% + 6.7%) .0001
WBC count, 639 17.28 132 14.03 289 19.21
109/L
Comorbidity
Hypertension 1073 617 (57.5% + 2.9%) 191 88 (46.1% + 7.1%) 664 310 (46.7% + 3.8%) .88
Diabetes 1075 205 (19.1% + 2.4%) 191 38 (19.9% + 5.7%) 664 109 (16.4% + 2.8%) .26
mellitus
COPD 1070 119 (11.1% + 1.9%) 191 0 664 78 (11.8% + 2.5%) .0001
Hyperlipidemia 1079 103 (9.6% + 1.8%) 191 33 (17.3% + 5.4%) 664 29 (4.4% + 1.6%) .0001
Renal 1070 113 (10.6% + 1.8%) 191 26 (13.6% + 4.9%) 664 31 (4.7% + 1.6%) .0001
dysfunction
Peripheral 1068 205 (19.2% + 2.4%) 191 46 (24.1% + 6.1%) 664 109 (16.4% + 2.8%) .015
artery disease
Cerebral artery 1068 81 (7.6% + 1.6%) 191 12 (6.3% + 3.4%) 664 39 (5.9% + 1.8%) .83
disease
Ischemia heart 1066 294 (27.6% + 2.7%) 190 69 (36.3% + 6.8%) 661 174 (26.3% + 3.4%) .007
disease
Atrial fibrillation 1062 374 (35.2% + 2.9%) 189 64 (33.9% + 6.8%) 660 245 (37.1% + 3.7%) .41
Valvular disease 1070 33 (3.1% + 1.0%) 191 7 (3.7% + 2.7%) 664 24 (3.6% + 1.4%) .97
History of 1070 31 (2.9% + 1.0%) 191 6 (3.1% + 2.5%) 664 16 (2.4% + 1.2%) .57
thrombotic
event
Active/ex-smoking 933 384 (41.2% + 3.2%) 191 53 (27.8% + 6.4%) 664 210 (31.6% + 3.5%) .31
Previous 1070 80 (7.5% + 1.6%) 191 10 (5.2% + 3.2%) 664 31 (4.7% + 1.6%) .75
myocardial
infarction
Etiology
Embolic 1056 474 (44.9% + 2.1%) 207 82 (39.6% + 6.7%) 665 351 (52.8% + 3.8%) .001
Thrombotic 1056 495 (46.9% + 3.0%) 207 97 (46.9% + 6.8%) 665 291 (43.8% + 3.8%) .43
Nonocclusive 1056 60 (5.7% + 1.4%) 207 24 (11.6% + 4.4%) 665 18 (2.7% + 1.2%) .0001
Undeterminated 1056 31 (2.9% + 1.0%) 207 5 (2.4% + 2.1%) 665 6 (0.9% + 0.7%) .088
Vessel
SMA 615 428 (69.6% + 3.6%) 174 143 (82.2% + 5.7%) 260 189 (72.7% + 5.4%) .022
Celiac artery 615 11 (1.8% + 1.1%) 174 1 (0.6% + 1.1%) 260 10 (3.9% + 2.3%) .07
SMA þ celiac 615 44 (7.2% + 2.0%) 174 22 (12.6% + 4.9%) 260 5 (1.9% + 1.7%) .0001
artery
IMA 615 0 174 0 260 0 NA
SMA þ IMA 615 3 (0.5% + 0.6%) 174 3 (1.7% + 1.9%) 260 0 .064
Celiac þ IMA 615 1 (0.2% + 0.3%) 174 1 (0.6% + 1.1%) 260 0 .40
SMA þ IMA þ 615 3 (0.5% + 0.6%) 174 3 (1.7% + 1.9%) 260 0 .064
CA
Others 615 22 (3.6% + 1.5%) 174 0 260 10 (3.9% + 2.3%) .007
Undeterminated 615 101 (16.4% + 2.9%) 174 0 260 46 (17.7% + 4.6%) .0001
Abbreviations: CA, celiac artery; COPD, chronic obstructive pulmonary disease; ET, endovascular treatment; IMA, inferior mesenteric artery; NA, not available;
OS, open surgery; SMA, superior mesenteric artery; ToT, total data; WBC, white blood cell.

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6 Vascular and Endovascular Surgery

Table 3. Procedural Details.

ET (n ¼ 234) OS (n ¼ 856)

Data Number of Data Number of

Available (n) Events, n (%) Available (n) Events, n (%) P

Endovascular treatment
Thrombolysis infusion 185 81 (43.8% + 7.2%)
Adjunctive Mechanical thrombectomy/aspiration 81 22 (27.2% + 9.7%)
Adjunctive PTA/stent 81 16 (19.8% + 8.7%)
Mechanical embolus/thrombectomy/aspiration 185 24 (12.9% + 4.8%)
Adjunction thrombolysis 24 6 (25.0% + 17.3%)
Adjunctive PTA/stent 24 3 (12.5% + 13.2%)
Primary PTA/stent 185 67 (36.2% + 6.9%)
Initial failures 235 26 (11.1% + 4.0%)
Stent used
Stent 1 72 43 (59.7% + 11.3%)
Stent 2 72 22 (30.6% + 10.6%)
Stent >3 72 7 (9.7% + 6.8%)
Second-look laparotomy 232 99 (42.7% + 6.4%) 837 302 (36.1% + 3.3%) .067
Ischemic bowel requiring resection 235 89 (37.9% + 6.2%) 853 521 (61.1% + 3.3%) .0001
Open revascularization 235 20 (8.5% + 3.6%) 859 568 (66.1% + 3.2%) .0001
Thromboembolectomy, 15 12 (80.0% + 20.2%) 433 234 (54.0% + 4.7%) .085
Bypass 15 2 (13.3% + 17.2%) 433 167 (38.6% + 4.6%) .087
Other 15 1 (6.7% + 12.6%) 433 58 (13.4% + 3.2%) .71
Abbreviations: ET, endovascular treatment; OS, opening surgery; PTA, percutaneous transluminal angioplasty.

Table 4. Primary Outcome.

ET (n ¼ 234) OS (n ¼ 856)

Data Available (n) Number of Events, n (%) Data Available (n) Number of Events, n (%) P

Overall complications 209 100 (47.9% + 6.8%) 644 400 (62.1% + 3.8%) .0001
Wound infection 209 0 284 11 (3.9% + 2.2%) .003
MODS 188 3 (1.6% + 1.8%) 323 56 (17.3% + 4.1%) .0001
Reocclusion of SMA 188 1 (0.5% + 1.0%) 284 8 (2.8% + 1.9%) .15
SMA dissection 209 4 (1.9% + 1.9%) 405 0 .013
SMA perforation/bleeding 188 2 (1.1% + 1.5%) 405 0 .1
Emboli in distal branches 199 2 (1.0% + 1.4%) 405 0 .11
Short bowel syndrome 209 11 (5.3% + 3.0%) 405 37 (9.1% + 2.8%) .09
Septicemia 188 7 (3.7% + 2.7%) 405 25 (6.2% + 2.3%) .22
Acute renal failure 188 16 (8.5% + 3.9%) 284 18 (6.3% + 2.8%) .371
Pulmonary infection 188 16 (8.5% + 3.9%) 323 49 (15.2% + 3.9%) .029
Myocardial infarction 188 1 (0.5% + 1.0%) 284 19 (6.7% + 2.9%) .003
Anastomotic leakage 188 0 284 10 (3.5% + 2.1%) .007
Urinary infection 188 0 284 7 (2.5% + 1.8%) .045
Access site bleeding 199 11 (5.5% + 3.2%) 405 0 .0001
Bowel ischemia/infarction 188 19 (10.1% + 4.3%) 337 36 (10.7% + 3.3%) .84
Stroke 188 2 (1.1% + 1.5%) 284 3 (1.1% + 1.2%) 1
In-hospital mortality 234 63 (26.9% + 5.7%) 859 346 (40.3% + 3.3%) .0001
Primary patency 89 84 (94.4% + 4.8%) 181 95 (52.5% + 7.3%) .0001
Abbreviations: ET, endovascular treatment; MODS, multiple organ dysfunction disease; OS, opening surgery; SMA, superior mesenteric artery.

some surgeons.20,28 In a study by Ward et al, 80% of patients
underwent second-look procedure and nearly half had posi-
tive findings of bowel necrosis requiring additional resec-
tion.48 Of interest, outcome in those patients undergoing
second-look operation was not worse than a similar group
who did not return for a second-look operation.20 Based on
our review and analysis of the existing literature, we propose a
treatment algorithm for AMI (Figure 5).Ultimately, however,
treatment strategy for AMI, including surgical approach and
second-look operation, should be tailored according to each
patient, clinical presentation, comorbidities, nutritional sta-
tus, and life expectancy.

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Zhao et al 7

Figure 2. In-hospital mortality for patients treated with OS versus ET. CI indicates confidence interval; ET, endovascular therapy; OS, opening
surgery therapy.

Figure 3. Secondary operation for patients treated with OS versus ET. CI indicates confidence interval; ET, endovascular therapy; OS, opening
surgery therapy.

Furthermore, HT, intraoperative retrograde SMA revascu-

Figure 4. Kaplan-Meier estimate of overall survival for patients
treated with ET (n ¼ 150) versus OS (n ¼ 264). Cum Survival indicates
cumulative survival rates; ET, endovascular therapy; HT, hybrid ther-
apy; OS, opening surgery therapy; N, number of patients.
larization, may avoid most of the disadvantages of ET and
OS. It helps confirm the viability of the bowel, followed by
prompt endovascular procedure via puncturing the main
trunk of SMA, thus limiting the length of operation as well
as many of its associated risks (ie, infection, fluid shifts,
etc).49 Indeed, in our review, HT appeared to have a satisfac-
tory mortality rate and primary patency rate. Comparison
between HT and the other groups was not made because of
the small number of cases.
Our study has a number of important limitations. Most nota-
bly, as mentioned, is the inherent selection bias favoring ET
over OT, which likely results in better outcomes for the former.
Moreover, none of the included articles are especially well
designed. There were no randomized, blinded, or controlled
studies available for review. In addition, some studies lacked
clear definitions or specific details, especially with regard to
presenting symptoms or indication for surgery, further limiting
the statistical analysis. Specific guidelines do not exist for the
selection of AMI therapies, resulting in significant heterogene-
ity for treatment strategies in the literature. Nevertheless, our
study represents a review of the literature and an attempt at

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8 Vascular and Endovascular Surgery
Figure 5. Treatment algorithm. ET indicates endovascular therapy;
OS, opening surgery therapy; HT, hybrid therapy.
producing some organization to the management of AMI,
including a proposed treatment algorithm.
Conclusion
In conclusion, the decision between ET and OS in patients with
AMI should be based on clinical presentation, anatomy, pre-
operative comorbidity, nutritional status, and life expectancy.
Although endovascular procedure appears to have lower mor-
bidity and mortality and may be considered as a first-line
therapy in selected patients who are not at risk for intestinal
ischemia, OS remains the treatment of choice for any patient
who is suspected of intestinal ischemia or necrosis. In patients
requiring emergency laparotomy, intraoperative retrograde
SMA revascularization represents an attractive alternative to
Downloaded from ves.sagepub.com at City University Library on April 9, 2016
traditional open revascularization. Larger case series and, ide-
ally, randomized controlled trial are needed to further clarify
the best treatment strategy for AMI.
Author Contribution
Yang Zhao and Henghui Yin contributed equally to this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was supported by specialized Research Fund for the Doctoral Program
of Higher Education (20130171120079).
Supplemental Material
The online supplemental figure and tables are available at http://ves.
sagepub.com/supplemental.
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