Long-Term Value in Open and Endovascular Repair of Chronic Mesenteric Ischemia.

OBJECTIVES: Guidelines recommend open surgical (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities.

METHODS: Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases, Ninth Revision code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for a final cohort of patients. Multiple linear regression and mixed effects linear regression were utilized to determine factors associated with 5-year value, calculated as life years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or chronic mesenteric ischemia, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival.

RESULTS: From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n=209 each group), the ER group showed higher value at 5 years post-procedure (8.04±11.42 versus 4.89±5.28 life years/$100k charges, p<0.01). More patients underwent reintervention in the ER group (37 versus 17 patients, p<0.01), with 55 reinterventions in the ER group and 19 in the OR group (p<0.01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, while ER was positively associated. Survival was 59.6 ± 3.76% versus 62.3% ± 3.49% at 5 years (p=0.91), and reintervention-free survival was 43.7 ± 3.86% versus 58.1 ± 3.53% (p=0.04), for ER and OR respectively.

CONCLUSIONS: Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value.