Covered Stents Versus Bare-Metal Stents

Symptomatic chronic atherosclerotic gastrointestinal ischemia (CGI) is an uncommon, potentially underdiagnosed condition caused by fixed stenosis or occlusion of in most conditions at least one of the three gastrointestinal arteries. Atherosclerosis is a predisposing factor for CGI. Clinical symptoms can vary widely. Typical symptoms are postprandial abdominal pain, unintended weight loss and food avoidance. But atypical abdominal pain such as exercise related pain, diarrhoea and nausea can also indicate CGI. The use of endovascular techniques for revascularization of chronic stenosis and occlusions of the gastrointestinal arteries has rapidly increased and endovascular therapy with stenting has become the most common method chosen for revascularization, having replaced open surgery with its associated morbidity and mortality. Nowadays standard care in significant chronic gastrointestinal ischemia is the use of bare metal stents although the patency of these stents is not very high. According retrospective data the patency of covered stents is significantly higher compared to bare metal stents. One likely explanation for these lower restenosis and re-intervention rates observed with covered stents is the established barrier to tissue ingrowth. Only recent retrospective data about this topic is available but the expectancy in this prospective study is that the patency of covered stents is indeed higher compared to metal stents.

• Covered stent (Atrium Type V12) (Device): An endovascular treatment that consists of inserting a covered stent into the stenosed vessels.
• Bare stent (Brand Cordis Type Palmaz Blue) (Device), also known as Brand Cordis Type Palmaz Blue: An endovascular treatment that consists of inserting a stent into the stenosed vessels.

Primary outcomes

• The difference of primary and secondary patency rates of covered stents versus bare-metal stents to treat atherosclerotic CGI disease. [12 to 24 months]

Secondary outcomes

• The freedom from restenosis after 6-, 12- and 24- months after stent implantation [6 to 24 month]: Restenosis is defined as >50% intra-stent stenosis regardless of whether the patient has clinical symptoms
• The freedom from symptom recurrence after 6-, 12- and 24- months after stent implantation [6 to 24 month]: Symptom recurrence is defined as occurrence of clinical symptoms typical for CGI regardless of stent patency
• The freedom from reintervention after 6-, 12- and 24- months after stent implantation [6 to 24 month]: Re-intervention is defined as intervention due to symptom occurrence in the presence of >50% intra -stenosis, either a reimplantation of stent or a surgical procedure.
• The clinical outcome in terms of quality of life and therapeutic and total costs after 6-, 12- and 24- months after stent implantation [6 to 24 month]
• The clinical outcome in terms therapeutic and total costs after 6-, 12- and 24- months after stent implantation [6 to 24 month]

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Patients with consensus diagnostic of CGI based on a clinical meeting with a gastroenterologist, a vascular surgeon and an interventional radiologist.
* Diagnostic consensus of CGI is based on.
* Presence of postprandial pain
* Unexplained weight loss (>5% of normal body weight).
* Significant stenosis of >50% of at least one of the gastrointestinal arteries on a recent CTA (Computer Tomographic Angiography) not older than one year, with maximum slice thickness 1 mm and enhancement in aorta of 300HU (Hounsfields Units)
* Mucosal ischemia detected by VLS (Visible Light Spectroscopy) or tonometry
* Patients over the age of 18 years.
* Patients who gave informed consent.
* Patients have sustained atherosclerosis.

Exclusion Criteria:

* Patients who don't give informed consent.
* Age < 18 years
* No stenosis detected during arteriography.
* Renal insufficiency (GFR below 30 ml/min or GFR below 60 ml/min when comorbidities relevant to kidney function present).
* Previous stent placement in the to be treated gastrointestinal artery.
* Pregnancy
* Celiac artery compression syndrome.
* Vasculitis

• Results publication: Terlouw LG, van Dijk LJD, van Noord D, Bakker OJ, Bijdevaate DC, Erler NS, Fioole B, Harki J, van den Heuvel DAF, Hinnen JW, Kolkman JJ, Nikkessen S, van Petersen AS, Smits HFM, Verhagen HJM, de Vries AC, de Vries JPM, Vroegindeweij D, Geelkerken RH, Bruno MJ, Moelker A; Dutch Mesenteric Ischemia Study Group. Covered versus bare-metal stenting of the mesenteric arteries in patients with chronic mesenteric ischaemia (CoBaGI): a multicentre, patient-blinded and investigator-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol. 2024 Apr;9(4):299-309. doi: 10.1016/S2468-1253(23)00402-8. Epub 2024 Jan 29. PMID 38301673
• Results publication: van Dijk LJD, Harki J, van Noord D, Verhagen HJM, Kolkman JJ, Geelkerken RH, Bruno MJ, Moelker A; Dutch Mesenteric Ischemia Study group (DMIS). Covered stents versus Bare-metal stents in chronic atherosclerotic Gastrointestinal Ischemia (CoBaGI): study protocol for a randomized controlled trial. Trials. 2019 Aug 20;20(1):519. doi: 10.1186/s13063-019-3609-8. PMID 31429792

• Adriaan Moelker, dr, Principal investigator, Erasmus Medical Center