Severe stenosis of the superior mesenteric artery causing an acute coronary syndrome successfully treated by percutaneous angioplasty

Abstract

Pedicled gastroepiploic artery (GEA) may be used as an arterial conduit in selected patients undergoing total arterial coronary bypass grafting [1]. Myocardial ischemia may result from spasm, occlusion, and stenosis of the graft [2]. The anastomosis site at distal right coronary artery (RCA) is reported to be the most common location for stenosis of pedicled GEA bypass graft. In this work, we describe a unique case, in which the celiac artery was totally occluded and collateralized by the superior mesenteric artery which was itself severely stenosed at its ostium. Lesions manifested as an acute coronary syndrome. The patient was treated by percutaneous angioplasty with stent placement at the ostial mesenteric artery. An 84-year-old woman was referred to our intensive care unit by the emergency department for a non ST elevation myocardial infarction; EKG showed a marked ST segment depression in the lateral and inferior leads (Fig. 1) and troponin T level was elevated at 2.4 mg/l. The patient has a known history of coronary artery bypass grafting (9 years prior to admission) with a GEA to the right coronary artery, left internal mammary artery to the left anterior descending and right mammary artery to the left circumflex. She has a severe peripheral artery disease with a known occlusion of the right internal carotid artery and a total occlusion of the lower abdominal aorta. Coronary angiogram was performed through a double radial access: all the native coronary arteries were totally occluded, both internal thoracic artery grafts were patent (Fig. 2a, b). A significant ostial stenosis of the left subclavian artery was noted (Fig. 2c). We were unable to selectively opacify the celiac artery which was totally occluded. It was completely collateralized by the superior mesenteric artery which was presenting a severe ostial stenosis (Fig. 2d). A patent GEA was observable on the late frames of the mesenteric artery sequences (Fig. 2e). Given the EKG aspect of ischemia in inferior and lateral leads, we assumed that the culprit lesion was the ostial stenosis of the mesenteric artery which was ultimately responsible for the vascular supply of all the inferior territory. Through the left radial access, a balloon-expandable stent was successfully implanted with excellent immediate angiographic results (Fig. 2f, g). Given the relative frailty of the patient and the difficulty in vascular access, we decided to treat during the same procedure the high-grade stenosis of the ostial left subclavian artery which could potentially alter the flow on the left mammary artery; hence, a self-expandable stent was successfully implanted (Fig. 2h). The immediate clinical evolution was favorable; however on day 4, the patient presented a massive stroke and unfortunately expired few hours later in the coronary care unit. The present report is the first, to our knowledge, to document an ACS caused by a severe stenosis of the mesenteric artery collateralizing totally occluded celiac and gastroepiploic arteries. Although the superiority of GEA grafts over the saphenous vein grafts has never been clearly established in the setting of surgical revascularization of the RCA [3], they have been used by some surgical teams when an allarterial bypass grafting was deemed suitable. Ischemic events related to pedicled GEA grafts have been classically linked to a disease progression in the S. Rekik (&) J. Brunet F. X. Hager G. Bayet L. Meille J. M. Quatre J. Sainsous Cardiovascular Department, Clinique Rhone Durance, Avignon, France e-mail: sofienerek@yahoo.fr