Guidelines of the American Heart Association (AHA) (Anderson et al. 2013) present the following recommendations regarding the diagnosis of chronic intestinal ischemia (Class I):

Guidelines for therapy:

Apparent from the guidelines above, endovascular and open surgical treatment of chronic intestinal ischemia are equally recommended.

ESC guidelines refer to mesenteric artery disease. Recommendations for diagnosis of symptomatic chronic mesenteric ischemia are as follows (European Stroke Organisation et al. 2011):

Guidelines for management:

ESC guidelines do not match AHA guidelines. Here, in contrast to AHA guidelines, the endovascular approach has explicit priority over the surgical procedure.

A systematic literature review of the last 25-years was conducted by Pecoraro et al. (2013) to identify studies reporting on chronic mesenteric ischemia (CMI) treatment with more than 10 patients. Randomized studies were not available for treatment recommendations. Patients were divided into endovascular treatment (ER) or open treatment (OR) groups. Forty-three articles with 1795 patients were included. Perioperative morbidity and mortality rates were lower in the ER group. No difference in survival rate was observed. Primary and secondary patencies were superior in the OR group. A greater number of vessels were revascularized in the OR group. CMI recurrence was more frequent in the ER group. Follow-up was longer in the OR group. Technical success was superior in the OR group and in-hospital length of stay was shorter in the ER group. Considering the lower periprocedural mortality and morbidity after ER, according to the authors this approach should be considered as the first treatment option in most CMI patients, especially in those with severe malnutrition. Primary OR should be restricted to cases that do not qualify for ER or good surgical risk patients with long life expectancy.

A systematic review of 12 studies comparing ER and OR in CMI was given by Saedon et al. (2015). A total of 4255 patients were treated primarily with ER and a total of 3110 with OR. In this meta-analysis there were no differences in mortality and morbidity, but patency rates were better following OR. In a further meta-analysis, 8 studies (569 cases) were included (Cai et al. 2015). This meta-analysis showed that there was no difference in 30-day mortality and 3-year cumulative survival rate between the ER group and the OR group; compared with the OR group, the ER group resulted in significantly lower rate of in-hospital complication, while recurrence rate within 3 years after revascularization was significantly greater in the ER group.

Schermerhorn et al. (2009) identified all patients undergoing surgical (bypass, endarterectomy, or embolectomy) or PTA/S (angioplasty, with and without stenting) mesenteric revascularization from the Nationwide Inpatient Sample (NIS) from 1988 to 2006. There were 6342 PTA/S and 16,071 open surgical repairs overall (acute and chronic mesenteric ischemia included). Three thousand four-hundred and fifty-five (61.9%) patients with CMI were treated via angioplasty ± stent (ER), 2128 (38.1%) patients were treated via bypass, endarterectomy or embolectomy (OR). The vast majority of OR procedures were bypasses (93%). Endarterectomy (4%) and embolectomy (3%) did not play a decisive role. Crucial results of this analysis are summarised in Table 7.1. Patients undergoing ER were older and had higher rates of comorbidities as compared to patients of the OR group. According to this study, ER is the acceptable first-line therapy for patients with CMI due to significantly reduced hospital mortality rates and fewer complications compared to OR. This was confirmed by the presented multivariate analysis concerning predictors of hospital mortality: mortality was 5- to 6-fold higher in OR compared to ER (odds ratio 5.1). Additional predictors for increased mortality were increasing age (odds ratio 1.6 per decade, meaning that mortality relatively increased by 50% with every decade), atrial fibrillation and atrial flatter (odds ratio 2.5) and congestive heart failure (odds ratio 2.8). The NIS database was also used by Moghadamyeghaneh et al. (2015) to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Seven-thousand nine-hundred and six patients underwent surgical (62%) or endovascular treatment (38%) for CMI. Open vascular treatment had higher mortality (adjusted odds ratio, AOR: 5.07) and morbidity (AOR: 2.14).

Oderich et al. (2012) retrospectively reviewed the clinical data of 156 patients treated with 173 mesenteric artery stent placements for CMI (1998–2010). Eleven patients (7%) developed 14 mesenteric artery complications (distal embolization n = 6/branch perforation n = 3/dissection n = 2/stent dislodgement n = 2/stent thrombosis n = 1). Five patients required conversion to open surgical repair, including after failed endovascular treatment in one. There were four procedure-related deaths (2.5%). Any complications were seen in 46 (30%) patients. The same group presented follow-up data of patients with CMI and mesenteric artery angioplasty and stenting (Tallarita et al. 2011). 57/157 patients developed mesenteric artery in-stent restenosis (MAISR) after a mean follow-up of 29 months. There were 30 patients treated with reintervention for MAISR. Twenty-six patients (87%) underwent redo endovascular revascularization. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. After a mean follow-up of 29 months, 15 patients (50%) developed a second restenosis, and seven (23%) required another reintervention. In this study, mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%).