# Acute mesenteric ischemia: do specialized centres show the way forward?

Inès Lakbar, Louis Delamarre, Annika Reintam Blaser

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Inès Lakbar, Louis Delamarre, Annika Reintam Blaser. Acute mesenteric ischemia: do specialized centres show the way forward?. Anaesthesia Critical Care & Pain Medicine, 2025, 45 (1), pp.101710. 10.1016/j.accpm.2025.101710. hal-05389079

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# Acute mesenteric ischemia: do specialized centres show the way forward?

Inès Lakbar<fnref n="1" />, Louis Delamarre<fnref n="2" />, Annika Reintam-Blaser<fnref n="3" />

<footnote n="1">¹ Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, CEDEX 5, Montpellier, France. Electronic address: ines.lakbar@chu-montpellier.fr.</footnote>

<footnote n="2">² Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Gui De Chauliac, CEDEX 5, Montpellier, France.</footnote>

<footnote n="3">³ Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care, Lucerne Cantonal Hospital, Lucerne, Switzerland.</footnote>

<footnote>*Corresponding author E-mail address:</footnote>

<footnote>ines.lakbar@chu-montpellier.fr</footnote>

<footnote>(I. Lakbar)</footnote>
Acute mesenteric ischemia (AMI) remains one of the most challenging emergencies in critical care medicine [1]. Short-term mortality rates (intensive care unit (ICU) or 30-day timepoints) consistently exceed 40% in most series [2–4], and remain high, especially in the case of non-occlusive mesenteric ischemia (NOMI) [5]. These concerning figures have persisted despite advances in diagnostic imaging and therapeutic interventions [6]. However, some centres specialized and dedicated to AMI have developed a pioneering approach to manage this condition, and they may now offer the opportunity to transform these outcomes.

**The SURVI Model: a paradigm for excellence**

The 5-year experience reported by Tran-Dinh et al. in this issue of Anaesthesia Critical Care & Pain Medicine demonstrates that patients with arterial occlusive AMI may achieve reasonably high survival rates [7]. Their cohort of 133 patients with occlusive arterial AMI had mortality rates of 33.1% at 28 days and 46.6% at one year. These figures represent real improvements over historical milestones and challenge the traditionally pessimistic prognosis associated with AMI.

The SURVI (Structure d'URgences Vasculaires Intestinales) model operates through several key components that work together. The program features a 24/7 gastroenterologist-led coordination that ensures immediate specialist involvement from the moment of diagnosis, as “time is gut” [8,9]. Multidisciplinary team protocols and checklists facilitate decision-making across surgical, radiological, and critical care specialties and involve team members [10,11]. Most importantly, their aggressive revascularization strategies achieve success rates of 78.9%, far exceeding those reported in non-specialized centres [2] (Fig. 1).
<figure><img src="image_2.png" /></figure>

Similar outcomes when comparing equivalent cohorts
Range: 33.1% - 36.0%

<table><thead><tr><td>Cohort</td><td>Source</td><td>Mortality (%)</td></tr></thead><tbody><tr><td>Meta-analysis Revascularized</td><td>(Tamme et al.)</td><td>33.94%</td></tr><tr><td>AMESI Multicentre</td><td>(Kase et al.)</td><td>36.0%</td></tr><tr><td>SURVI Specialized Center</td><td>(Tran-Dinh et al.)</td><td>33.1%</td></tr></tbody></table>

<figure><img src="image_3.png" /></figure>

SURVI demonstrates superior revascularization success
13.1% improvement over multicentre approach

<table><caption>Fig. 1. SURVI model outcomes versus outcomes from the literature in patients with occlusive arterial AMI.
Note: only patients allocated to any active treatment attempt (including explorative surgery) are included in these cohorts.</caption><thead><tr><td>Cohort</td><td>Source</td><td>Revascularization Rate (%)</td></tr></thead><tbody><tr><td>AMESI Multicentre</td><td>(Kase et al.)</td><td>65.8%</td></tr><tr><td>SURVI Specialized Center</td><td>(Tran-Dinh et al.)</td><td>78.9%</td></tr></tbody></table>

## Early recognition or selection bias: examining the evidence

The SURVI results raise questions about the mechanisms underlying their success. Patient characteristics at presentation suggest relatively lower disease severity compared to typical AMI cohorts [2]. Only 37.6% required vasopressor support, and 8.3% experienced respiratory dysfunction at ICU admission. The risk stratification model revealed that patients with no identifiable risk factors experienced merely 8% mortality at 28 days.

The optimistic view is that specialized centres allow earlier recognition and faster treatment. This could prevent progression to organ failure, thanks to structured diagnostic protocols and greater clinical suspicion among referring teams. The alternative explanation is selection bias [12]. Less severe patients may be more likely to be referred or treated in specialized centres.

Data from the AMESI study support this second hypothesis: patients treated in specialized units were different from those managed elsewhere [2]. The 86.5% referral rate in the study by Tran-Dinh et al. also points towards selection bias. Referral takes time and usually excludes patients needing immediate bowel resection. Patients receiving palliative care are also not referred, yet often included in observational studies reporting high mortality [2,3,5,13]. Accordingly, the selection of patients in this specialized unit is likely to play a role in results exceeding expectations based on the literature.
However, multiple lines of evidence support the hypothesis of specialized structure improving survival [14]. The SURVI team's protocol-driven approach integrates immediate diagnostic confirmation, early anticoagulation initiation, and urgent multidisciplinary decision-making. This systematic approach aims to stop the natural progression of AMI from vascular occlusion to intestinal damage. High awareness, knowledge, and expertise in a specialist centre with an appropriate case load of a rare condition allow fast and successful management as well as early detection and management of complications.

An important consideration involves the spectrum of mesenteric ischemia represented in the SURVI cohort. Only patients with occlusive arterial AMI were included, unfortunately, not specifying the occluded vessels in detail. That occlusion of the inferior (IMA) compared to the superior mesenteric artery (SMA) is associated with better survival is to be expected [15], whereas NOMI has the highest mortality [2,5,15]. Critically ill patients with hemodynamic instability, cardiac failure, or septic shock, where mesenteric hypoperfusion occurs without mechanical vessel obstruction, often present with a higher baseline mortality risk. The absence or under-representation of NOMI cases in specialized centre series partially explains the improved survival rates when compared to the overall AMI cohort. Mortality rate in occlusive arterial AMI reported in a multicentre cohort was 49% when including all arterial occlusive AMI cases and 36% when excluding patients with IMA occlusion and those receiving only palliative care [2,16]. Importantly, the specialized unit was able to identify the mechanism of occlusion (embolism vs. thrombosis) in all cases, whereas almost 30% of cases remained unspecified in a multicentre cohort [2]. This, together with the expertise in managing intestinal failure, may contribute to appropriate treatment and better outcomes in the long term.

Indication and duration of parenteral nutrition (PN) in the AMI cohort require further exploration to understand the high prevalence of PN in the study by Tran-Dinh et al., considering that only 7.4% of patients had PN at hospital discharge in a multicentre cohort [2]. Intestinal failure-free longer-term survival should probably be the ultimate goal in the management of AMI [17].

## Uncertainties in AMI management

Despite the scientific and medical advances achieved by specialized centres, basic therapeutic questions remain unsolved across the field of AMI. Recent studies continue to highlight ongoing uncertainties in both medical and surgical management approaches. These
knowledge gaps affect clinical decision-making even within specialized centres and probably represent important targets for future research.

Our team recently demonstrated that early anticoagulation improves survival outcomes in critically ill AMI patients [13]. However, optimal timing protocols remain undefined, and the balance between bleeding risks and thrombotic benefits varies significantly among patient populations. Similarly, Kase et al. found no independent mortality benefit for either endovascular or surgical revascularization approaches when controlling for patient selection factors [16]. While apparent outcome differences reflect case complexity, severity, and selection rather than variation in treatment efficacy, this study, together with the study by Tran-Dinh et al., underlines the need to identify patients who can be managed effectively with endovascular revascularization as monotherapy.

These gaps and uncertainties in AMI management explain why specialized centres are needed for advancing AMI care and research in the ICU. The complexity of medical decisions goes from diagnostic timing considerations, anticoagulation protocol selection, revascularization approach decisions, to surgical intervention timing, and is carried on to the complex management of intestinal failure. This certainly requires expertise and standard-ized protocols.

## Future research directions and clinical implications

The demonstrated success of specialized centres like SURVI establishes the foundation for the next phase of AMI research and clinical development. While randomizing patients between specialized and non-specialized centres would be challenging, randomized controlled trials addressing specific treatment strategies appear more feasible. For example, trials comparing surgery-first versus endovascular-first approaches could be considered in selected patients.

Future studies on AMI should report patient characteristics, including descriptors of severity of illness, in detail, and evaluate several outcome measures beyond mortality statistics. Important endpoints include time-to-treatment intervals, revascularization success rates, functional recovery metrics, quality of life assessments, and resource utilization. The expertise, research team, and standardized protocols available at specialized centres position them to lead these research efforts and generate the evidence needed for broader implementation of the SURVI model.
**Conclusion**

The SURVI experience demonstrates that specialized, protocol-driven AMI management can help to achieve substantial improvements in survival, and its pioneering work is contributing to improvement in other hospitals worldwide. While questions remain about the relative contributions of early intervention versus case selection effects, the accumulated evidence supports the therapeutic value of concentrated expertise. However, referral criteria need to be further refined and treatment guidance for non-specialist sites developed.

**Consent for publication**

Not applicable.

**Ethics approval and consent to participate**

Not applicable.

**Funding**

None.

**Availability of data and materials**

Not applicable.

**Declaration of competing interest**

IL received fees from presentations from Viatris and AOP Health. ARB is holding a grant from the Estonian Research Council (PRG1255). LD has no conflict of interest relevant to this article.
References

[1] Reintam Blaser A, Coopersmith CM, Acosta S. Managing acute mesenteric ischaemia. Intensive Care Med 2024;50:593-6. http://dx.doi.org/10.1007/s00134-024-07363-1.

[2] Reintam Blaser A, Mańdul M, Bjońck M, Acosta S, Bala M, Bodnar Z, et al. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational Study (AMESI Study). Crit Care 2024;28:32. http://dx.doi.org/10.1186/s13054-024-04807-4.

[3] Leone M, Bechis C, Baumstarck K, Ouattara A, Collange O, Augustin P, et al. Outcome of acute mesenteric ischemia in the intensive care unit: a retrospective, multicenter study of 780 cases. Intensive Care Med 2015;41:667-76. http://dx.doi.org/10.1007/s00134-015-3690-8.

[4] Tamme K, Reintam Blaser A, Laisaar K-T, Mańdul M, Kals J, Forbes A, et al. Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis. BMJ Open 2022;12e062846. http://dx.doi.org/10.1136/bmjopen-2022-062846.

[5] Bourcier S, Oudjit A, Goudard G, Charpentier J, Leblanc S, Coriat R, et al. Diagnosis of non-occlusive acute mesenteric ischemia in the intensive care unit. Ann Intensive Care 2016;6:112. http://dx.doi.org/10.1186/s13613-016-0213-x.

[6] Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022;17:54. http://dx.doi.org/10.1186/s13017-022-00443-x.

[7] Tran Dinh A, cordoniu A, Dubois L. Prognosis of critically ill patients with occlusive arterial acute mesenteric ischemia: the 5-year French 2 experience of a dedicated mesenteric stroke center SURVI. Anaesthesia Crit Care Pain Med 2025;29101650. http://dx.doi.org/10.1016/j.accpm.2025.101650.

[8] Nuzzo A, Maggiori L, Ronot M, Becq A, Plessier A, Gault N, et al. Predictive factors of intestinal necrosis in acute mesenteric ischemia: prospective study from an intestinal stroke center. Am J Gastroenterol 2017;112:597-605. http://dx.doi.org/10.1038/ajg.2017.38.

[9] Nuzzo A, Peoc'h K, Vaittinada Ayar P, Tran-Dinh A, Weiss E, Panis Y, et al. Improving clinical suspicion of acute mesenteric ischemia among patients with acute abdomen: a cross-sectional study from an intestinal stroke center. World J Emerg Surg 2023;18:37. http://dx.doi.org/10.1186/s13017-023-00505-8.

[10] Shiota N, Nosaka N, Nawa N, Fujiwara T, Shigemitsu H, Wakabayashi K. Enhancing early mobilization in critically ill patients through multidisciplinary rounds: a process-focused observational study. Anaesth Crit Care Pain Med 2025;44101485. http://dx.doi.org/10.1016/j.accpm.2025.101485.
[11] Bloc S, Alfonsi P, Belbachir A, Beaussier M, Bouvet L, Campard S, et al. Guidelines on perioperative optimization protocol for the adult patient 2023. Anaesth Crit Care Pain Med 2023;42101264. http://dx.doi.org/10.1016/j.accpm.2023.101264.

[12] Gonzalez FA, Santonocito C, Lamas T, Costa P, Vieira SM, Ferreira HA, et al. Is artificial intelligence prepared for the 24-h shifts in the ICU? Anaesth Crit Care Pain Med 2024;43101431. http://dx.doi.org/10.1016/j.accpm.2024.101431.

[13] Lakbar I, Delamarre L, Tamme K, De La Torre NH, Pensier J, Monet C, et al. Anticoagulation management and outcomes in critically ill patients with acute mesenteric ischemia: an international study. Intensive Care Med 2025. http://dx.doi.org/10.1007/s00134-025-07980-4.

[14] Abrard S, Savary D, Nevin D, Inaba K, David J-S. Traumatic cardiac arrest, what clinicians and researchers must know. Anaesth Crit Care Pain Med 2025;44101507. http://dx.doi.org/10.1016/j.accpm.2025.101507.

[15] Kase K, Reintam Blaser A, Tamme K, Maëndul M, Forbes A, Talving P, et al. Epidemiology of acute mesenteric ischemia: a population-based investigation. World J Surg 2023;47:173-81. http://dx.doi.org/10.1007/s00268-022-06805-5.

[16] Kase K, Blaser AR, Koitmäe M, Talving P, Tamme K, Acosta S, et al. Comparison between endovascular and surgical treatment of acute arterial occlusive mesenteric ischemia. World J Emerg Surg 2025;20:46. http://dx.doi.org/10.1186/s13017-025-00616-4.

[17] De Man AME, Gunst J, Reintam Blaser A. Nutrition in the intensive care unit: from the acute phase to beyond. Intensive Care Med 2024;50:1035-48. http://dx.doi.org/10.1007/s00134-024-07458-9.
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