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• W3138196974 abstract "In this era of modern imaging the issue of how to handle asymptomatic lesions is a common discussion at hospital rounds worldwide. When I was a young surgical trainee in the 1970s, the most common abdominal surgical procedure was diagnostic laparotomy, imagine! Fortunately, that was a long time ago, but the present situation, in which we are exposed to multiple asymptomatic lesions, creates a new challenge. In this issue of European Journal of Vascular and Endovascular Surgery, Dr. Marine Bordet and colleagues present a follow up study of patients with superior mesenteric artery (SMA) stenoses.1Bordet M. Tresson P. Huvelle U. Long A. Passot G. Bergoin C. et al.Natural history of asymptomatic superior mesenteric arterial stenosis depends on celiac and inferior mesenteric artery status.Eur J Vasc Endovasc Surg. 2021; 61: 810-818Abstract Full Text Full Text PDF Scopus (1) Google Scholar They identified the patients in a CT database, and followed 77 of them for a median of 39 months. They were divided into two groups. Group A had an isolated > 70% stenosis of the SMA (n = 24), and Group B had > 70% concurrent stenosis of the coeliac and/or the inferior mesenteric artery (n = 53). Group B tended to develop symptomatic disease (acute or chronic mesenteric ischaemia [AMI/CMI]) more often (0% vs. 15%, p = .05), the significance of which is difficult to appraise as the study was at risk of a type II statistical error because of small sample size and few events. It is questionable to mix the development of AMI and CMI as the consequences are so different. The strength of this paper however, is that it is novel. Very few previous studies have reported long term follow up of patents with asymptomatic SMA stenosis. Another important finding was the low five year survival rate of only 45%, worse than after surgery for colorectal cancer. The authors claim that “The latest European Society for Vascular Surgery (ESVS) guidelines2Björck M. Koelemay M. Acosta S. Bastos Goncalves F. Kölbel T. Kolkman J.J. et al.Editor’s choice - Management of the diseases of the mesenteric arteries and veins. Clinical practice guidelines of the European Society of Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2017; 53: 460-510Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar remain unclear given the lack of data in the literature”. I agree that there is a lack of data, but actually the ESVS mesenteric guidelines are quite clear on this issue. In Chapter 3.2.3. (Treatment of chronic mesenteric ischaemia) the very first sentence reads: “Revascularisation is indicated in patients who develop symptoms of CMI”.2Björck M. Koelemay M. Acosta S. Bastos Goncalves F. Kölbel T. Kolkman J.J. et al.Editor’s choice - Management of the diseases of the mesenteric arteries and veins. Clinical practice guidelines of the European Society of Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2017; 53: 460-510Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar In other words, there is no indication to treat patients with asymptomatic CMI. The second paragraph reads: “Prophylactic revascularisation in patients with asymptomatic disease is controversial and is rarely performed,” and “Mesenteric revascularisation during other concomitant aortic reconstructions also remains controversial because combined reconstructions have higher morbidity and mortality rates”. The reason why the guideline writing group did not elaborate further on this issue was the 100% consensus that no such indication existed. In hindsight, perhaps an explicit negative recommendation against such practice should have been issued. The recently published North American SVS Guidelines on CMI,3Huber T.S. Bjorck M. Chandra A. Clouse W.D. Dalsing M.C. Oderich G.S. et al.Chronic Mesenteric Ischemia Clinical Practice Guideline from the Society for Vascular Surgery.J Vasc Surg. 2021; 73: 87S-115SAbstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar however, have a more liberal or active approach, which is expected given the healthcare system in the USA: “In select asymptomatic patients with severe mesenteric artery occlusive disease, we suggest a shared decision-making approach between the patient and provider to discuss revascularization as a treatment option. Grade: Weak, Quality of Evidence: Low”. They are also open to revascularisation when undergoing aortic reconstruction, as well as when treating mesenteric aneurysms. This is actually the most important difference between the two guidelines,2Björck M. Koelemay M. Acosta S. Bastos Goncalves F. Kölbel T. Kolkman J.J. et al.Editor’s choice - Management of the diseases of the mesenteric arteries and veins. Clinical practice guidelines of the European Society of Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2017; 53: 460-510Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar,3Huber T.S. Bjorck M. Chandra A. Clouse W.D. Dalsing M.C. Oderich G.S. et al.Chronic Mesenteric Ischemia Clinical Practice Guideline from the Society for Vascular Surgery.J Vasc Surg. 2021; 73: 87S-115SAbstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar and the background was elaborated on in a recent joint editorial in this journal.4Björck M. Huber T.S. Chronic mesenteric ischaemia, the transatlantic perspective.Eur J Vasc Endovasc Surg. 2021; 61: 177-178Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The main reason why clinicians and researchers may reach different conclusions is how they estimate the risk that a patient with an asymptomatic SMA stenosis develops AMI, and when that happens, what the outcome is. In a recent interesting paper from Finland, the importance of the first contact in the emergency department was identified. If the patient was evaluated in the surgical emergency room, time to operation was shorter and survival was better (90 day mortality was 50.0% vs. 74.5%, p = .025).5Lemma A.N. Tolonen M. Vikatmaa P. Mentula P. Vikatmaa L. Kantonen I. et al.Choice of first emergency room affects the fate of patients with acute mesenteric ischaemia: the importance of referral patterns and triage.Eur J Vasc Endovasc Surg. 2019; 57: 842-849Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Primum non nocere. First, do no harm. This was an early teaching in medical school and is important from practicing surgery for > 40 years. Many more patients die with asymptomatic arterial lesions than as a result of them. Modern medical therapy is no longer conservative, it may even be aggressive, and although not without side effects, it is quite effective. When we performed long term follow up on patients screened for carotid artery stenosis at the time of abdominal aortic aneurysm screening, we were surprised that secondary prevention often was not durable.6Högberg D. Björck M. Mani K. Svensjö S. Wanhainen A. Five year outcomes in men screened for carotid artery stenosis at 65 years of age: a population based cohort study.Eur J Vasc Endovasc Surg. 2019; 67: 759-766Abstract Full Text Full Text PDF Scopus (15) Google Scholar A multidisciplinary collaboration, including primary healthcare, is necessary to maintain effective medical therapy over time. The challenge of organising such effective healthcare should not be underestimated. Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery StatusEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 5PreviewThe benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. Full-Text PDF" @default.
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• W3138196974 title "Asymptomatic Superior Mesenteric Arterial Stenosis: Primum non nocere" @default.
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