Reviewed by Reza Lankarani MD

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World Journal of Emergency Surgery

https:/doi.org/10.1186/s13017-025-00616-4

This prospective observational substudy of the AMESI cohort provides valuable insights into the complex management of acute arterial occlusive mesenteric ischemia (AMI), specifically superior mesenteric artery (SMA) occlusion. Crucially, the authors rigorously account for baseline severity of illness (APACHE II, SOFA, lactate, vasopressor/ventilator needs), a major confounder often inadequately addressed in prior literature.

Their sophisticated statistical approach, including multivariable logistic regression adjusted for key severity markers, robustly demonstrates that the apparent mortality benefit of endovascular therapy in unadjusted analysis (15.7% vs. 45.8%) is largely attributable to patient selection favoring less severely ill patients for endovascular intervention.

The finding that neither initial treatment modality (endovascular vs. surgical) nor the performance of revascularization itself was an independent predictor of mortality after adjustment challenges simplistic interpretations of previous retrospective data and guideline recommendations.

The subgroup analysis of endovascular monotherapy effectiveness (66.6% success rate) and its stark mortality difference (2.9% effective vs. 41.2% insufficient) provides clinically relevant granularity, highlighting the critical importance of patient selection for this approach.

The explicit inability to identify reliable time thresholds or lactate cut-offs (beyond normal ranges) for predicting endovascular success underscores the complexity of AMI pathophysiology and the limitations of isolated biomarkers or symptom duration in guiding therapy.

The study's significant strengths are its prospective nature, adjustment for illness severity, multicenter representation, and transparent reporting of limitations.

However, key limitations acknowledged by the authors must be considered: inherent selection bias in treatment assignment within an observational design, relatively small subgroup sizes (especially for failed endovascular monotherapy, n=17), potential heterogeneity in treatment protocols across centers, and missing data for severity scores in some patients.

Despite these limitations, the study makes a substantial contribution by shifting the paradigm: it compellingly argues that the choice between endovascular and surgical intervention should prioritize the patient's overall physiological condition and the etiology of occlusion (embolism vs. thrombosis) over rigid adherence to symptom duration thresholds. It sets a crucial precedent for future studies by emphasizing the absolute necessity of detailed reporting and adjustment for baseline severity, symptom duration, and AMI subtype to generate truly evidence-based management guidelines.

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Reza Lankarani M.D

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