Duodenal Obstruction From Mesenteric Stents Mimicking SMA Syndrome

Abstract

Superior mesenteric artery (SMA) syndrome is a rare condition, which results in compression of the third portion of the duodenum by a narrow-angled SMA against the aorta. We report a case of a patient treated for chronic mesenteric ischemia, who developed an SMA-like syndrome as a result of the compression of the duodenum between an SMA stent and an inferior mesenteric artery (IMA) stent. A 44-year-old woman with chronic mesenteric ischemia had previously been treated with multiple endovascular stents. She re-presented with persistent abdominal pain and weight loss. Findings from the angiogram performed revealed an occluded celiac artery and an SMA. Mesenteric perfusion was maintained by the IMA with poor collateralization to the celiac circulation. At the time of surgical exploration, there were no suitable target sites for a traditional aortomesenteric bypass because of the extensive length of prior stenting. A renohepatic bypass with reversed saphenous vein was performed to improve the celiac circulation. Postoperatively, she continued to have persistent abdominal pain associated with nausea and vomiting. An upper gastrointestinal study was performed that revealed severe partial obstruction of the third portion of her duodenum. On re-reviewing her preoperative computed tomography scan of the abdomen, it was more apparent that the duodenum was constricted between the SMA and IMA stents that had been previously placed. She underwent re-exploration, and a side-to-side duodenojejunostomy was performed. Subsequent study of the upper gastrointestinal showed resolution of the obstruction. To our knowledge, this is the first report of duodenal obstruction caused as a result of the complications caused by multiple stent placements, which gave an impression of SMA-like syndrome.