Latest / European Society for Vascular Surgery / ESVS 2025 Mesenteric Ischaemia Guidelines Q&A - Pt 1 - with Guidelines Writing Committee

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ESVS 2025 Mesenteric Ischaemia Guidelines Q&A - Pt 1 - with Guidelines Writing Committee · European Society for Vascular Surgery

0:10
Hello and welcome to the ESVS podcast. This is
0:13
Suzanne Stockmans and you are listening to part
0:15
one of the Q &A series of the 2025 ESVS Clinical
0:19
Practice Guidelines on the Management of Diseases
0:21
of the Mesenteric and Renal Arteries and Veins.
0:23
In this podcast, we will highlight the new, complex,
0:26
and most controversial recommendations in this
0:28
guideline. Today, for the first episode of this
0:31
three -part series, we will specifically talk
0:33
about chronic mesenteric ischemia. In the other
0:36
episodes, median arcuate ligament syndrome, acute
0:39
mesenteric ischemia, venous mesenteric ischemia,
0:42
renal disease, visceral artery aneurysms, and
0:45
dissections will be covered. I am happy to introduce
0:49
to you the chair and co -chairs of the Guideline
0:51
Writing Committee, who are with me today, Dr.
0:53
Mark Koelemay, Professor Bob Geelkerken, and
0:56
Dr. Nicola Leone. Dr. Koelemay is a vascular
0:59
surgeon at the Amsterdam University Medical Center
1:01
and chaired the writing committee for the 2025
1:04
Mesenteric Ischemia Guidelines that we are discussing
1:06
today. Professor Geelkerke is a vascular surgeon
1:09
at the Medispectrum Twente in Enschede and professor
1:12
at the TechMed Center, University of Twente in
1:15
Enschede, the Netherlands. Dr. Leone is a vascular
1:18
surgeon at the University Hospital of Modena
1:20
in Italy and assistant editor of the European
1:23
Journal of Vascular and Endovascular Surgery,
1:25
Vascular Forum. Congratulations on the new Mesenteric
1:29
Ischaemia Guidelines and thank you for making time
1:30
today to discuss it. Hello. Thank you. Hello.
1:33
Hi. Thank you. This guideline is an update of
1:36
the 2017 guideline. The 2025 guidelines have
1:40
102 recommendations, of which 60 are new, 21
1:44
have been regraded or significantly rephrased,
1:46
with the changed meaning to some extent, and
1:49
21 have not been changed. Importantly, only 2
1:53
out of 102 recommendations are based on level
1:55
A evidence, 12 by level B evidence, and 88 by
1:59
level C evidence or consensus. This highlights
2:02
the rarity of mesenteric and renal vascular diseases,
2:05
hindering the collection and synthesis of high
2:08
-quality data. So, the 36 class 1 recommendations
2:11
and 5 class 3 recommendations are merely based
2:14
on consensus between the members of the Guideline
2:16
Writing and Reviewing Committee. Let's start
2:19
by diving deeper in the symptoms, signs, and
2:21
diagnosis of chronic mesenteric ischemia. Recommendation
2:24
1, class 1, level C, states that chronic mesenteric
2:27
ischemia, or CMI, is recommended to be considered
2:30
present in patients with chronic abdominal symptoms
2:33
and more than 50 % stenosis of the superior mesenteric
2:36
artery and more than 50 % stenosis in another
2:39
mesenteric artery. Recommendation 2, class 2B,
2:43
level C, states that chronic mesenteric ischemia
2:46
may be considered to be present in patients with
2:48
chronic abdominal symptoms and more than 70 %
2:52
isolated superior mastic artery stenosis. Could
2:55
you summarize the typical chronic abdominal symptoms
2:57
that should raise suspicion for CMI and explain
3:01
the rationale behind these specific stenosis
3:03
thresholds? Why 50 % in multiple vessel and 70
3:07
% in an isolated SMA lesion? Well, let's start
3:10
off with the easy one. I think that chronic mesenteric
3:13
ischemia should be suspected in patients who
3:16
have pain after eating, weight loss, and because
3:20
of the pain, they have fear of eating, whereas
3:23
there may be some less specific symptoms like
3:26
nausea, diarrhea, or abdominal discomfort. I
3:30
think when patients have these symptoms, it should
3:32
be suspected, and this is why we made this. recommendation
3:36
one, because this is not always picked up by
3:39
treating physicians. So we wanted to raise awareness
3:42
of these symptoms to be indicative of chronic
3:45
mesenteric ischemia. I congratulate you on the
3:48
second observation that why is it 50 % in one
3:52
case and why is it 70 % in the isolated superior
3:56
mesenteric artery stenosis? This, of course,
4:00
is based on evidences, and what we know from
4:04
the evidences is that when you have a multivessel
4:09
atherosclerotic disease of the mesenteric arteries,
4:14
it is much more common that you can have symptoms.
4:18
So, to paraphrase, if you have more than one
4:22
artery involved, it is much more frequent that
4:26
you can have symptoms. And this is the reason
4:31
behind these recommendations. And when you have
4:35
one single artery, basically the evidence shows
4:39
that we need to be much more aware that that's
4:44
the true cause of the symptoms. While the recommendations
4:49
on diagnostic imaging themselves haven't changed,
4:52
the practical aspects remain highly relevant
4:54
in daily practice. Recommendation 4, class 1,
4:57
level B, states that duplex ultrasound of the
4:59
mesenteric arteries after a minimum of four hours
5:02
fasting is recommended as the first -line examination
5:05
in patients suspected of chronic mesenteric ischemia.
5:08
The guideline also states that duplex ultrasound
5:10
is technically challenging. This is partly due
5:13
to the fact that the interpretation of flow velocities
5:15
in the mesenteric arteries should consider both
5:18
the presence of stenosis in the remaining mesenteric
5:20
vessels and the respiratory cycle. Could you
5:23
elaborate on why duplex ultrasound can be so
5:25
technically complex in this context and what
5:28
practical steps or infrastructure are needed
5:31
to build a successful mesenteric duplex program
5:33
in an individual center? To be honest, all your
5:36
questions are valid and we could discuss them
5:39
for hours. So our answers, especially my answers,
5:42
will be based on my personal... experience, my
5:46
personal view about myceliac ischemia and also
5:49
driven by my clinical experience. Why duplex?
5:53
Can you use it in the outpatient setting? It's
5:56
cheap, but it's relatively difficult. Presence
6:00
of stenosis in the other myceliac arteries can
6:03
influence your measurement in the first myceliac
6:07
artery. That means if you have a stenosis in
6:09
the ciliac artery due to the collateral circulation
6:12
and to the decreased outflow resistance due to
6:16
the increased collaterals, the piectostolic velocity
6:18
and endostolic velocity in the SMA can be increased
6:21
with a completely normal SMA. The second one
6:24
is indeed, as you mentioned, the respiratory
6:26
cycle during expiration in most patients, especially
6:29
in the celiac artery, the velocities will increase.
6:33
If you treated such kind of patients with a stent,
6:35
then the duplex parameters are not valid anymore.
6:39
We don't know yet. the real duplex parameters
6:41
in standard arteries. And the last one, if you
6:45
are very experienced and you have the optimal
6:47
conditions prepared, at most only 90 % of the
6:51
patients, you can accurately assess the duplex.
6:55
You're going to see the celiac artery or the
6:57
SMA. So even in experienced centers, in one out
7:01
of 10, you can't do anything with a duplex. So
7:04
these things together highlight that mesodic
7:07
doppler ultrasound is a complex procedure requiring
7:09
highly skilled. and also very reflective practitioners,
7:13
because you have to learn from your own mistakes.
7:16
You must recognize your own mistakes. And you
7:19
have learned if you do that, it's a very valid
7:22
and reliable tool. What struck me when revising
7:25
this guideline is that there was no new evidence
7:28
since the previous guideline on duplex validation
7:31
studies. When I wanted to get the clear cutoff
7:34
for significant stenosis, I just looked it up
7:37
again. It ranges between peak systolic velocities
7:40
between 200 and 400 centimeters per second. So
7:43
we don't know actually the actual cutoff value.
7:47
We have one in our vesicle lab, which is set
7:50
at 275. But it's interesting that since, well,
7:53
15 years ago, there have been no new studies
7:55
evaluating duplex scanning versus a reference
7:59
standard. Let's continue with recommendation
8:04
5, class 1, level C, that states that CTA is
8:08
recommended as the preferred imaging modality
8:10
for diagnosis, treatment planning, and for excluding
8:13
other intra -abdominal pathology in patients
8:15
suspected of chronic masturac ischemia, given
8:17
that a CTA is ultimately required for treatment
8:20
planning. In which clinical scenarios would you
8:23
consider skipping the initial duplex ultrasound?
8:25
And when it comes to follow -up after endovascular
8:27
revascularization of the mesenteric arteries,
8:30
which imaging modality is the most reliable for
8:32
assessing stent patency and detecting restenosis?
8:35
We already heard that duplex ultrasound is often
8:38
the first line in CMI workup. In my opinion,
8:42
there are at least three main scenarios where
8:44
we save time and proceed and go straight to CTA.
8:49
The first one is is high clinical suspicion,
8:52
acquiring fusion. intervention. And the second
8:55
one is when we suspect a non -vascular pathology.
8:59
Probably this is a patient with symptoms that
9:03
strongly suggest another serious intra -abdominal
9:06
problem like malignancy, complicated inflammatory
9:09
bowel disease or bowel obstruction. Of course,
9:13
in these cases, the multidisciplinary team and
9:16
the opinion of gastroenterology colleagues, it
9:20
is mandatory in my mind. The last one, it is
9:24
in those cases in which duplex ultrasound is
9:28
technically challenging. Of course, this might
9:31
be the case of obese patients, because it happened
9:35
to me that I've been asked to evaluate a patient
9:39
for CMI symptoms, but still the patient, it is
9:42
obese. I don't know if you had this experience.
9:46
And also the issue of bowel gas is important.
9:51
Even if you advise the patients for fasting before
9:55
the ultrasound evaluation, this might be an issue.
9:59
So I think still the duplex ultrasound, it is
10:04
the first line, even in follow -up of treated
10:09
patients. But in some selected cases, it might
10:14
be better to go straight to the CTA. If you have
10:17
a patient who is repeated. symptoms fitting to
10:21
CMI. It wasn't too fast of a disease. There's
10:23
a stent in the celiac artery and a stent in the
10:25
SMA. In my experience, it's sometimes very difficult,
10:27
and especially if there are more than one stent
10:29
inside the SMA of the celiac artery and there's
10:31
an overlapping between the stents, to see if
10:34
there's intramyoplasia inside the stent. So I
10:37
agree, with CT scanning, you can exclude or you
10:41
can diagnose. Many other diseases in the abdomen,
10:43
I completely agree with that. You can see the
10:46
outflow after the stent, but to see if there's
10:48
something inside the stent, that's very difficult.
10:51
And in my opinion, repeated duplex ultrasound
10:54
is more reliable for assessing instant stenosis
10:58
than CT scanning. What's your comment on that?
11:01
I agree with you that stented patients are not
11:05
easily evaluated by CTA. But let me also say
11:10
that sometimes I still stuck with the old paradigm
11:17
that I, in really suspicious patients, I re -enjoy
11:24
these patients. We discussed the definition of
11:27
chronic mesenteric ischemia. We now move on to
11:30
treatment strategies. Before addressing symptomatic
11:33
patients, it's important to highlight two new
11:35
recommendations for asymptomatic patients. Recommendation
11:38
7, class 1, level C, advises assessing the cardiovascular
11:42
risk profile in patients with asymptomatic atherosclerotic
11:45
mesenteric artery disease and providing appropriate
11:48
secondary prevention. Recommendation 8, class
11:51
1, level C, recommends... counseling patients
11:54
with asymptomatic multivessal mesenteric artery
11:57
occlusive disease about potential abdominal symptoms
11:59
related to mesenteric ischemia. In clinical practice,
12:03
which patients might be considered for prophylactic
12:05
mesenteric revascularization and is there a rationale
12:09
for routine follow -up in asymptomatic cases?
12:12
At first, if it's an arthroscopic disease, as
12:14
you say, assessing cardiovascular risk profile
12:16
and trying to decrease risk profile as far as
12:21
possible is important. That's one. But that's
12:24
for the whole spectrum of osteoarthritis diseases.
12:26
The second part of the question is more difficult.
12:29
Does it make sense to follow up these patients?
12:31
In elderly patients, stenosis of myceliac artery
12:34
is very common. And that means you have to follow
12:37
up many, many, many patients. So what we do is,
12:40
if you have a two -factor disease patient, we
12:42
discuss with him, if you experience any abdominal
12:46
symptoms, doesn't matter what, please contact
12:48
us. And if you have acute abdominal symptoms,
12:52
please say to your general physician or to the
12:54
hospital where you'll go to, they know that I
12:57
have two federal myceliac disease. And in that
13:00
moment, you have a higher chance of developing
13:02
acute mycelial ischemia. That's the way how we
13:04
deal with this kind of patient. So no routine
13:07
follow -up. Personalize it for every individual
13:10
patient. I have one follow -up question about
13:12
cardiovascular risk management in these patients,
13:14
because in asymptomatic patients with peripheral
13:17
artery disease, it's not recommended to start
13:19
a thrombocyte aggregation inhibitor. But do you
13:22
think in these patients with asymptomatic mesenteric
13:25
atherosclerosis, we should start? a thrombocyte
13:29
aggregation inhibitor? I personally balance the
13:32
risk against the benefit because most of the
13:35
time I'm seeing these kind of patients that are
13:39
elder than maybe 20 years ago. When it comes
13:42
to be a young patient with atherosclerotic disease
13:47
in several districts and so on, I usually prescribe
13:51
antiplatelet therapy. The other end, if it is
13:53
an 80 years old patient with low life expectancy.
14:00
or even low comorbidities, I slow down the pace.
14:04
So now let's move on to symptomatic patients.
14:07
The guideline recommends revascularization for
14:09
patients with multivessel mesenteric artery occlusive
14:12
disease and chronic mesenteric ischemia. Recommendation
14:15
9, class 1, level B. And specify that at least
14:18
the superior mesenteric artery should be treated.
14:20
Recommendation 10, class 1, level C. Historically,
14:23
the SMA has been the primary target for revascularization
14:26
with the ciliic and inferior mesenteric arteries
14:29
as... secondary options. In patients with multivessel
14:32
symptomatic disease, would you focus solely on
14:35
revascularizing the SMA or is there a rationale
14:37
for restoring flow to as many mesenteric vessels
14:40
as possible? This is a key point of clinical
14:43
debate. Of course, current practice and guidelines
14:46
generally favor slow restoration of the most
14:49
critical vessel, which is the SMA, because the
14:52
goal is to relieve the symptoms and avoiding
14:56
unnecessary interventions. My personal rationale
15:00
for focusing on the SMA is symptoms relief, and
15:04
this comes from the anatomy, and reduce risk.
15:07
Because every time we manage to do an intervention,
15:11
we should be aware that there are possible complications.
15:14
And so focusing on a single vessel, necessary
15:17
revascularization reduces the complexity and
15:20
the duration of the procedure. However, revascularizing
15:24
a second or third vessel, it might be justified
15:27
in specific situations, such as collateral dependence
15:31
in case of severe multivessel diseases with impaired.
15:35
collateral network in case of technical failure
15:39
and personally I rather choose to go for a multivascular
15:44
revascularization with an endovascular approach.
15:49
It is very difficult in my personal practice
15:52
that I choose for a multivascular revascularization
15:55
in an open fashion. There are evidence in all
15:58
the literature, and they are comparing apples
16:00
and oranges, to be honest, that not for durable
16:03
technical success for an individual artery, it
16:05
doesn't differ. But if your endpoint is clinical
16:07
success, that means in patients without symptoms,
16:10
then two -facil revascularization, especially
16:13
in endovascular repair, is better than one -facil.
16:16
And I think the reason for that is that we know
16:18
that the patency, the primary patency of reconization
16:21
of one vessel in the ideal situation, 80, 85
16:24
% at two years. If you have two vessels and you
16:26
have enough collaterals, one of the reconstruction
16:28
can occlude, but the other one is enough to stay
16:31
free of symptoms. So if it's relatively easy
16:34
to do through two vessels, if it's difficult
16:36
or it increased the risk, like in an open repair,
16:39
you really must have good arguments to do a two
16:42
vessel approach. In an open repair, we perform
16:44
a two vessel reconstruction. young patients,
16:46
because then we really have a long -term follow
16:49
-up. But if you have a 75 years old patient,
16:52
an endovascular approach is not possible anymore
16:55
to perform a retrograde SMA bypass, and that's
16:58
doing very, very well. That was a great discussion.
17:01
Recommendation 13, class 3b, level C, remains
17:03
unchanged and advises against delaying urgent
17:06
revascularization to improve nutritional status
17:09
in patients with severe chronic mensteric ischemia,
17:12
those with significant weight loss, diarrhea,
17:14
or constant abdominal pain. Could you explain
17:16
the reasoning behind this recommendation and
17:18
why early revascularization is prioritized over
17:21
attempts at nutritional optimization in these
17:23
patients? The poor prognosis of patients with,
17:27
as we call in the guideline, ischemic rest pain,
17:31
but then in the belly, is from a very old study.
17:33
And in this study, if I remember well, some four
17:36
patients died because the intervention was delayed.
17:40
And this scared us about waiting too long. So
17:42
in fact, we do not know exactly whether it's
17:45
dangerous to wait. But on the other hand, if
17:47
you have found the culprit, so why would you
17:49
delay intervention and wait for the patient to
17:52
be exhausted much more as a worse condition at
17:55
the time of the procedure? So if you have a diagnosis
17:58
and a patient has severe ischemia, it's... only
18:02
logical to go on to treat them. And in this old
18:04
study, there was a signal that feeding would
18:07
provoke mesenteric ischemia. I'm not particularly
18:10
convinced that this is actually the case, that
18:12
feeding provokes ischemia. Maybe the others have
18:14
some more strong opinions about that. Not strong
18:17
opinions, if you mean that I really give you
18:20
some evidence. No, not at all. But when we started
18:23
our expert center, we performed some angiographies
18:26
in patients with severe three -feather disease.
18:29
And where you injected contrasting... these patients,
18:31
you see a lot of tone tests in the SMA going
18:34
to the collaterals, going to the hepatic artery,
18:36
and not going to the either colic artery. So
18:39
not to the small bowel, but to the liver. And
18:41
the liver is a low resistance organ. So if you
18:43
feed the patient the resistance, because all
18:46
the feeding is metabolized in the liver, the
18:48
hypothesis is that the resistance in the liver
18:50
will decrease. And at that moment, the intramuscularic
18:54
steel, blood. which was go to the small bowel,
18:57
is going to the liver, is increasing. And the
18:59
inflow is not enough. That means you can pass
19:01
the critical level and you created end -stage
19:04
acute mystic ischemia. And we experienced that
19:07
several times, even in patients where we started
19:09
with parenteral feeding. Also, that should be
19:12
metabolized by the liver. So then we think we
19:14
do something good for the patients and we wait
19:16
14 days or something like that, starting parenteral
19:18
feeding. In these 14 days, the patient had an
19:21
either -circle infarction. I agree with you.
19:23
Nowadays, if you have an end... stage acute and
19:26
chronic or end stage chronic multivascular disease,
19:28
revascularize the patient and not start to train
19:32
the abdomen. All right, so we covered when to
19:35
revascularize, but the next crucial question
19:37
is how. Recommendation 14, class 1, level B,
19:41
advises an endovascular first approach for patients
19:43
with chronic mesenteric ischemia who have suitable
19:46
anatomy. While endovascular therapy carries lower
19:49
perioperative risk, open surgery appears to offer
19:51
lower long -term recurrence rates. How do you
19:54
communicate these differences to patients when
19:56
discussing treatment options? I hope it's no
19:59
debate that in such difficult patients with symptoms
20:02
which... can be attributed to many diseases.
20:05
It's crucial to discuss them in multidisciplinary
20:08
teams. No physician in the world is really competent
20:11
for all these different diseases. And starting
20:13
such a discussion, you really get a balanced
20:16
discussion and you create a good advice. And
20:19
afterwards, you should share this advice with
20:22
the positive and negative points with the patient
20:24
and explain in detail the various options and
20:27
short and long -term outcome. And that's the
20:29
principles of shared decision -making. Yes, personally
20:32
at my institution, I grew up with this idea of
20:35
discussing every single patient. And I want to
20:38
thank Bob also for bringing up the shared decision
20:41
making, because I think that's key for a good
20:44
doctor and patient relationship. And it's key
20:46
also for modern clinical practice. If we discuss
20:49
the patients and we chose for endovascular revascularization,
20:53
routine mesoteric artery stenting is recommended,
20:55
as says in recommendation 15, class 1, level
20:58
C. There has long been debate over the choice
21:01
between covered and bare metal stents. Recommendation
21:03
16, class 2A, level B, advises considering covered
21:07
stenting for lesions shorter than 25 millimeters,
21:10
provided no significant side branches are covered.
21:13
The new recommendation 17, class 2B, level C,
21:16
suggests bare metal stents may... be appropriate
21:19
for lesions longer than 25 millimeters or when
21:22
landing beyond important side branches. These
21:24
recommendations are supported by 2024 RCT by
21:28
Terlau et al., which compared covert 47 stents
21:31
versus bare metal stents 47 stents in the celiac
21:34
artery or SMA for patients with atherosclerotic
21:37
chronic mesenteric ischemia. Only lesions shorter
21:40
than 2 .5 cm were included and patients requiring
21:44
coverage of a significant side branch or with
21:47
previous stenting were excluded. At 24 months,
21:49
primary patency was 80 .8 % for covered stents
21:53
versus 49 .1 % for bare metal stents with a p
21:57
-value of below 0 .001. Covered stents also had
22:02
lower re -intervention and stent fracture rates,
22:04
while safety and technical success were comparable.
22:07
Could you explain the rationale for using 25
22:09
mm as the cut -off for lesion length in this
22:12
trial? And based on your experience, how do you
22:14
think covered stents would perform in longer
22:16
or more complex mesenteric lesions? Has this
22:19
study influenced your practice and are there
22:21
still scenarios where you might prefer a bare
22:24
metal stent even for shorter lesions? I think
22:26
there are several things here on the table. The
22:30
25 mm cutoff for inclusion in the COBAGI trial
22:35
was primarily a measure to standardize the complexity
22:39
of the lesions. being compared and to optimize
22:43
the mechanical performance of the balloon expandable
22:47
cover stents used. Of course, atherosclerotic
22:50
lesions in the mesenteric arteries are overwhelmingly
22:54
osteal and focal. This led the authors limiting
22:58
the study to this lesion shorter than 25 mm,
23:02
I suppose. Also, there are some technical issues
23:06
here that could be discussed. Balloon expandable
23:09
cover stents offer high radial print and precise
23:13
deployment, are often shorter compared to self
23:17
-expanding stents, and choosing a 25 cutoff ensured
23:21
that a single balloon expandable stent reliably
23:24
covered the entire lesion, maintaining the consistency
23:28
needed for a rigorous RCT. And of course, the
23:32
idea behind the study is that probably a covert
23:37
stent creates a barrier to prevent the instant
23:41
intimal hyperplasia. Also on this topic, covert
23:45
stents are usually safer and also many of these
23:50
are provided over an O35 platform. On the other
23:55
hand, when we think about birth stents, we have
23:59
several platforms. Also, I know 14 that in my
24:03
personal experience, it is the best choice for
24:07
these patients. Lastly, I would like to discuss
24:10
the fact of many of these lesions are extremely
24:14
calcified. It is challenging to go through these
24:18
lesions in my personal experience right now i
24:21
do still choose the bare metal stance because
24:25
this is the very first evidence that we have
24:28
in this field but i do agree that this is a top
24:33
-ranked publication and i think that is going
24:37
to change my practice over the next years i'd
24:40
like to comment on this last sentence that really
24:42
practically changing nowadays. And I think with
24:45
the available steerable sheets, we use routinely
24:47
that technical failure is not a matter of concern
24:51
anymore. In the Kobachi study, we used the Atrium
24:53
P12 covered stand, and that's a really stiff
24:55
stand. All the disadvantages of a stiff covered
24:58
stand, saying that the technical success rate
25:01
was very, very high. Technical failure was not
25:04
a reason anymore not to use a covered stand.
25:06
And there are more flexible stands available
25:08
on the market, but they are also more expensive.
25:11
The cutoff point of 25 mm also in the combustion
25:13
study was for practical reasons. We wanted to
25:16
select really clear origin stenosis, because
25:19
if you have a long stenosis or long occlusions,
25:22
there are many more arguments and maybe confounders
25:25
for the study outcome. Combining stents, severe
25:27
asterosclerotic in the outflow part of the SMA,
25:29
really introduced confounders in the study. So
25:32
we created a straightforward cohort with only
25:34
origin stenosis. In my opinion, it's clear that
25:37
comfort is better than bare metal, and this also
25:40
in align with the US experience. So for the final
25:44
topic of today's podcast, we will focus on open
25:46
surgery for chronic mesenteric ischemia. Recommendation
25:49
19, class 2a, level C, advises considering open
25:53
revascularization in FIT patients, either after
25:57
a failed endovascular intervention or when endovascular
26:00
therapy is not feasible or is contraindicated.
26:03
Interestingly, the guidelines do not specify
26:05
the preferred surgical approach, type of conduit,
26:08
graft configuration, inflow source, or number
26:11
of vessels to revascularize. Instead, they emphasize
26:14
that the operation should be tailored to the
26:16
patient's anatomy and overall clinical risk.
26:19
I would love to hear your expert perspective.
26:21
What's your usual approach to open revascularization
26:24
in these patients? Well, let me say that surgery
26:27
has a long history and I think it makes use of
26:31
experience rather than evidence because there
26:33
have been no comparative trials comparing anterograde
26:37
or retrograde or short bypasses from the order.
26:40
The evidence is lacking and that's why it's quite
26:44
a wide advice what to do. In fact, you can do
26:47
anything you like and you should tailor this
26:49
exactly like it's stated to the anatomy of the
26:51
patient and your preference. I have done all
26:54
kinds of surgery. Not too many because most of
26:57
the patient will be treated endovascularly, but
26:59
I've performed end -to -grade, re -to -grade
27:01
and short bypasses. In fact, I don't have any
27:04
preference for any kind of surgery. When I was
27:07
a teenager vascular surgeon, I always say you
27:09
should do it this way and all the other things
27:12
are wrong. That's not the case, especially not
27:14
in this domain. But you should be competent on
27:17
all the techniques. Endocrine, retocrine, venous
27:20
material, but also retocrine, tenting and all
27:23
this kind of stuff. So you can really show that
27:25
you're feeling the best approach for the individual
27:28
patient. It's tailor -made in every patient.
27:31
And as you said, it also depends on the experience
27:34
of the team. In my practice, it is quite rare
27:38
also to revascularize in an open fashion these
27:41
patients, but usually in CMI patients, we go
27:47
for prosthetic bypasses. The first choice would
27:51
be aorto -SMA or aorto -celiac bypass. If there
27:56
are some challenging features, we would go for
28:01
retrograde from the iliac. We all are aware of
28:05
the best serial trial, where it's proven that
28:08
autogenous material is much, much better than
28:11
endothelial and prosthetic material. We can never
28:13
perform a randomized control trial in the chronic
28:16
mystic ischemia domain. Never. Not enough patients.
28:19
But why can't we translate knowledge from other
28:22
areas to CMI area and set autogenous materials
28:26
always better than prosthetic material? So in
28:28
my institute, it's a finished vein or arterial
28:31
conduits first. second third then a long time
28:35
nothing and then prosthetic material between
28:38
the bowels and i know that here we are opening
28:41
a wide discussion and this is because historically
28:46
we had some issue with kinking and occlusion
28:51
with the vein graft in the abdomen and also to
28:55
shorten the operation time go to the origin of
29:00
the SMA and there you see looped the bypass going
29:03
parallel to the SMA to your distal anastomosis,
29:07
your anastomosis site on the SMA. That's crucial.
29:10
And then you don't have a chance that he kinked.
29:13
But the difficulty of doing this is not to rotate
29:16
them. I agree. So that's how we perform for many,
29:21
many years. And kinking is not an issue in my
29:25
experience. So for the last question of today,
29:27
recommendation 20, class 2B, level C, suggests
29:30
that retrograde open mesenteric artery stenting,
29:33
or ROMs, can be considered for patients with
29:36
chronic mesenteric ischemia requiring superior
29:38
mesenteric artery revascularization when an integrate
29:41
percutaneous approach is either not feasible
29:43
or has failed. In your practice, which patients
29:47
would you choose ROMs for rather than performing
29:49
a mesenteric bypass? So the percutaneous endocrine
29:53
mysderic artery stenting is the first choice
29:55
in every patient. If this is not feasible because
29:58
you don't have any access, not from below and
30:01
not from above, then the next treatment choice
30:04
in these patients is the reticulate operative
30:06
mysderic artery stenting. And that means you
30:09
perform a small laparotomy just on the left side
30:12
of the mysderic vein, but also the horse of the
30:15
mysderic vein, you always find the mysderic artery.
30:19
And in that area, it's mostly a very good artery
30:23
from good quality. And then you have your marker
30:26
puncture set and you puncture the artery. And
30:29
then you are only five centimeters and most of
30:32
the time even smaller distance between the open
30:34
SMA and the aorta lumen. And it's relatively
30:38
easy to canalize with the normal techniques,
30:41
interluminal, extraluminal, the SMA origin. and
30:45
get entry to the orthoglumen. In very calcified
30:48
cases, it's not possible to pass the SMA. And
30:52
at that moment, we have a puncture needle. And
30:54
then we really puncture through the SMA, outside
30:57
the SMA, through the mesothelium, inside the
31:00
aorta. And then we perform the PTA. And immediately
31:03
thereafter, we place the covered stent. That
31:05
works very well. But that's really not allowed.
31:07
The trick once is the second choice if. Integrate
31:11
regurgitation is not possible in severely ill
31:15
patients, and all acute mesenteric ischemia patients
31:17
are severely ill. All right, so that wraps up
31:22
our first Q &A on the 2025 ESVS Clinical Practice
31:25
Guidelines on the Management of Diseases of the
31:28
Mesenteric and Renal Arteries and Veins. Today,
31:31
we talked extensively about chronic mesenteric
31:33
ischemia, but there's a lot more to the guideline
31:35
that will be covered in the next episode. So
31:37
please come back for part two next week. Thank
31:40
you to my guests and my listeners for being here
31:42
today. Until next week. Bye. Bye -bye. Bye -bye.