Based on review of single-center reports and a systematic review, endovascular revascularization has been associated with decreased morbidity, length of stay and convalescence time [17]. Morbidity and length of stay averages 11 % and 3 days with endovascular, compared to 33 % and 14 days with open surgery [17]. Mortality rates are similar based in a recent systematic review, which indicates average 30-day mortality of 6 % (0–15 %) for open and 5 % (0–21 %) for endovascular revascularization [17]. Open surgical bypass can be performed with low mortality in good risk patients operated on institutions with large experience in these types of reconstructions [1, 23]. A recent review of 229 patients treated for CMI using clinical risk stratification showed similar mortality for open (2.7 %) and endovascular (2.4 %) revascularization [2]. Mortality was 1 % for low-risk and 6.7 % for high-risk patients treated by open bypass, with the highest mortality rate (8.9 %) in those patients who had concomitant aortic reconstructions. Nonetheless, despite the excellent results reported in large volume centers, these operations carry high mortality in the community, reaching 20 % in the State of New York and 13 % in the United States [1, 23].

Poor prognostic indicators for long-term patient survival after mesenteric revascularization include advanced age and presence of severe cardiac, pulmonary or renal disease [2, 63]. The type of revascularization has not been shown to affect survival, but comparative analysis is limited by selection bias favoring open bypass for good risk and endovascular revascularization for higher risk patients. Tallarita et al. reported long-term survival in a cohort of 343 patients treated for CMI, and showed nearly identical 5-year survival rates using propensity matched scores for patients treated by open (57 %) or endovascular (60 %) revascularization [63]. Five-year patient survival averaged 71 % for low-risk, 49 % for intermediate-risk, and 38 % for high-risk patients. Freedom from mesenteric-related death was 91 % after open and 93 % after endovascular revascularization at 5 years. Independent predictors of any cause mortality were age >80 years, chronic kidney disease stage IV or V, diabetes and home oxygen therapy. Chronic kidney disease stage stage IV or V and diabetes were independently associated with mesenteric related death. The most common causes of late death were cardiac events, followed by cancer, respiratory complications and mesenteric-related complications. The combined rate of early and late mesenteric-related death was 8 % for patients treated by open and 6 % for those who had endovascular revascularization.

Both methods of revascularization are highly effective with average symptom improvement in 88 % of patients treated by endovascular and 93 % of those treated by open revascularization [17]. A pooled review of the literature suggests that angioplasty alone may be associated with lower rates of technical success (78 %) compared to stenting (94 and 93 %) [23]. Symptom improvement is noted immediately after revascularization, but it is not uncommon for patients to complain of modest bloating and worsening diarrhea. The presence of persistent abdominal pain suggests other diagnosis (e.g. motility disorder, irritable bowel syndrome) or inadequate revascularization.

Most single-center reports and a systematic review indicate that open reconstructions are more durable. Bypass is associated with lower rates of restenosis, better patency, and higher freedom from recurrent symptoms or re-interventions compared to mesenteric angioplasty and stenting. Primary patency of open bypass averaged 89 % at 5 years in a recent review of the pooled literature (57–92 %) with freedom from re-interventions of 93 % [23]. A recent contemporary report by Ryer et al. indicated that open bypass has been increasingly performed in patients with more comorbidities and worse anatomy, but maintained excellent primary patency of 76 % at 5 years [6]. In the systematic review of van Petersen et al. [17], endovascular treatment was associated with increased restenosis (37 % versus 15 %), symptom recurrences (30 % versus 13 %) and re-interventions (20 % versus 9 %) when compared to open revascularization. Primary patency was lower for mesenteric stenting (51 % versus 86 %), with similar secondary patency rates (83 % versus 87 %), respectively.

Overall, endovascular treatment has been plagued by higher rates of restenosis when compared to patency rates reported for open reconstructions (Tables 20.3 and 20.4) [2, 5, 19, 20, 26, 27, 40, 41, 64–71]. There are currently no reporting standards or consensus on the definition of in-stent restenosis, which is largely based on surveillance duplex ultrasound imaging [72–74]. Most reports have included a large number of patients treated by angioplasty alone and had inconsistent reporting standards. Review of large clinical experiences have shown that primary stenting is associated with less restenosis and re-interventions [29]. The average 3-year primary patency rate for bare metal stents is 52 % (range, 30–81 %) calculated from pooled literature [23]. Clinical data on re-interventions for in-stent restenosis remains scarce. Options include balloon angioplasty with cutting or cryoplasty balloons, redo stenting with bare metal, drug-eluting or covered stents and atherectomy [75, 76].