Treatment strategies and predictors for acute and subacute mesenteric artery thromboembolic occlusion

This study aimed to evaluate treatment outcomes, identify predictors of mortality and intestinal ischemia, and derive a management algorithm for acute and subacute superior mesenteric artery (SMA) thromboembolic occlusion. In this single-center, retrospective cohort study, 140 patients diagnosed with acute SMA occlusion between February 2020 and October 2025 were included. Data on clinical presentation, imaging, treatment, and outcomes were collected. Predictors of 30-day mortality and intestinal ischemia requiring resection (American Association for the Surgery of Trauma [AAST] score ≥ 3) were identified using logistic regression. Subgroup analyses were performed on patients managed conservatively, surgically, or were potential candidates for surgery. A management algorithm was proposed based on the findings. The overall 30-day mortality was 48.6% (68/140). Treatment groups comprised conservative management ( n = 86, 61.4%), examination only ( n = 6, 4.3%), bowel resection ( n = 36, 25.7%, including 5 with combined revascularization), and revascularization without resection ( n = 12, 8.6%). Independent predictors of 30-day mortality included age (odds ratio [OR] = 1.093, 95% CI 1.041–1.147, p < 0.001), AAST score ≥ 3 (OR = 10.905, 95% CI 3.377–35209, p < 0.001), acidosis (OR = 0.288, 95% CI 0.120–0.692, p = 0.005), elevated D-dimer (OR = 1.374, 95% CI 1.182–1.017, p = 0.029), and elevated cardiac troponin I (OR = 1.005, 95% CI 1.000-1.009, p = 0.023). Predictors for severe intestinal ischemia were peritoneal irritation (OR = 40.905, 95% CI 7.676-217.974, p < 0.001), nausea/vomiting (OR = 6.712, 95% CI 1.826–24.673, p = 0.004), elevated lactate (OR = 1.555, 95% CI 1.093–2.212, p = 0.014), and elevated myoglobin (OR = 1.003, 95% CI 1.001–1.005, p = 0.016). Subgroup analysis revealed that vessel reconstruction was not significantly associated with improved survival after bowel resection ( p = 1.000). All conservatively managed patients with symptom onset > 2 weeks survived without surgery. Mortality in acute SMA occlusion is driven by the severity of systemic and intestinal injury. Vessel reconstruction was not demonstrated to confer a significant survival benefit after bowel resection, and in selected patients with subacute presentation (> 2 weeks) and no signs of ongoing ischemia, conservative management may be considered. The proposed algorithm emphasizes risk stratification using clinical signs and biomarkers to guide individualized treatment.