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Endovascular Interventions in Acute Mesenteric Ischemia: The Implication of Lactic Acidosis

Robert J. Beaulieu, Joshua C. Grimm, David T. Efron, Christopher J. Abularrage, James H Black III, Shalini Selvarajah and Mark L. Lessne

Background:

In the setting of acute mesenteric ischemia (AMI), lactic acidosis has been used as a surrogate for at-risk or necrotic bowel. The role of endovascular therapy in maximizing outcomes in AMI patients remains controversial and there are no set guidelines for using endovascular intervention as an initial treatment strategy. We sought to determine if the endovascular strategy was safe and effective in patients with AMI who develop lactic acidosis.

Methods and Findings:

The Nationwide Inpatient Sample (NIS) was examined for patients presenting with AMI (557.9) between the years 2005-2009. Patients were included if they presented as urgent/emergent and underwent endovascular therapy. Patients were divided according to the presence of lactic acidosis. The primary outcome measured was in-hospital mortality. 663 patients met inclusion criteria. Of these patients, 74 (11.2%) developed lactic acidosis. Patients with lactic acidosis were found to have an increased mortality compared to patients without lactic acidosis when undergoing endovascular treatment (47.1% vs. 20.8%, p = 0.029). The two groups did not differ in rates of bowel resection (19.8 vs. 12.4%, p = 0.41), TPN administration (23.1% vs. 14.1%, p=0.382) or length of stay (11.4 days vs. 13.6 days, p=0.54). The main limitation of this study was the use of a large database that precluded granular level data regarding patient characteristics and decisions for management strategies.

Conclusions:

Endovascular intervention should be considered cautiously as a primary therapeutic strategy in AMI patients with lactic acidosis as it was associated with increased mortality. The presence of lactic acidosis in patients with AMI was not associated with worse bowel related outcomes and thus may not be useful to determine whether open surgery is mandated as an initial approach.