Superior Mesenteric Artery Stenosis Research Articles

A rare cause of chronic mesenteric ischemia from fibromuscular dysplasia: a case report

IntroductionChronic mesenteric ischemia is a condition that is classically associated with significant atherosclerosis of the abdominal arteries, causing postprandial abdominal pain out of proportion to physical examination. The abdominal pain is exacerbated after meals due to the shunting of blood away from the intestines to the stomach, causing relative ischemia. More than 95% of chronic mesenteric ischemia cases are due to atherosclerosis. We report the first known case of chronic mesenteric ischemia from fibromuscular dysplasia. To the best of our knowledge, this is also the first known case in the literature where postprandial abdominal pain was the presenting symptom of fibromuscular dysplasia.Case presentationA 44-year-old Caucasian woman with a history of hypertension and preeclampsia, who had taken oral contraceptive pills for 15 years, presented with an intractable, colicky abdominal pain of two weeks duration. This abdominal pain worsened with oral intake. It was also associated with diarrhea and vomiting. Physical examination revealed stage III hypertension out of proportion to her risk factors and diffuse abdominal pain without peritoneal signs. An abdominal computed tomography scan, completed in the emergency room, revealed nonspecific colitis. Laboratory work revealed leukocytosis with a left shift, an erythrocyte sedimentation rate of 79 and a C-reactive protein level of 100. She was started on intravenous flagyl and intravenous ciprofloxacin. However, all microbial cultures were negative including three cultures for clostridium difficile. Urine analysis revealed nephritic range proteinuria. The laboratory profile was within normal limits for perinuclear-anti-neutrophil cytoplasmic antibody, cytoplasmic-anti-neutrophil cytoplasmic antibody, anti-saccharomyces cerevisiae antibody, antinuclear antibody test, celiac profile, lactate, carbohydrate antigen-125 and thyroid stimulating hormone. A colonoscopy was completed, which revealed diffuse colonic lymphoid reactive hyperplasia. A small bowel series was negative for any inflammation. An indium scan, pan-computed tomography scan and transvaginal ultrasound were also negative. Magnetic resonance angiography of her abdomen revealed proximal superior mesenteric artery stenosis, which was confirmed by computed tomography angiogram findings of severe proximal and distal superior mesenteric artery stenosis, consistent with the appearance of fibromuscular dysplasia on angiography in the absence of vasculitis or atherosclerotic disease. The patient's superior mesenteric artery stenosis was subsequently angioplastied suboptimally and had to be stented with an Angioplus stent. One month after she was admitted, her abdominal pain and tolerance to oral feeds improved tremendously.ConclusionFibromuscular dysplasia most commonly presents with renal artery stenosis, which rarely causes abdominal pain. This case illustrates how fibromuscular dysplasia can present as a rare cause of chronic mesenteric ischemia, similar to chronic mesenteric ischemia from atherosclerosis.

Outcomes of planned celiac artery coverage during TEVAR

Successful thoracic endovascular aneurysm repair (TEVAR) requires adequate proximal and distal fixation and seal. We report our experience of planned celiac artery coverage during endovascular repair of complex thoracic aortic aneurysms (TAA). Since 2004, 228 patients underwent TEVAR under elective (n=162, 71%) and emergent circumstances (66, 29%). Patients with inadequate distal stent grafts landing zones during TEVAR underwent detailed evaluation of the gastroduodenal arcade with communicating collaterals between the celiac and superior mesenteric artery (SMA) by computed tomography angiography and intraoperative arteriogram. If needed, in presence of a patent SMA and demonstration of collaterals to the celiac artery, the stent grafts were extended to the SMA with celiac artery coverage. Furthermore, instances when further lengthening of distal thoracic stent graft landing zone was needed to obtain an adequate seal, the SMA was partially covered with the endograft, and a balloon expandable stent was routinely deployed in proximal SMA to maintain patency. Outcome data were prospectively collected and analyzed retrospectively. Thirty-one of 228 (14%) patients with TEVAR required celiac artery interruption; 24 (77%) had demonstrable collaterals to the SMA. Twelve (39%) of 31 patients underwent additional partial SMA coverage by stent graft, and proximal SMA stent. The majority of patients were females (n=20, 65%), the mean age was 74 years (range 55-87 years), and the mean TAA size was 6.5 cm. Postoperative complications included visceral ischemia in 2 (6%) patients, paraplegia in 2 (6%) patients, and death in 2 (6%) patients. All type 1b endoleaks (n=2, 6%) and type 2 endoleaks vial retrograde flow from the celiac artery (n=3, 10%) were successfully treated by transfemoral coil embolization. Over a mean follow-up of 15 months, there have been no other complications of mesenteric ischemia, spinal cord ischemia, SMA in-stent stenosis, or conversion to open surgical repair. Our findings suggest that celiac artery coverage to facilitate adequate distal sealing during TEVAR with complex TAA is relatively safe in the presence of SMA-celiac collaterals. Pre-existing SMA stenosis can be successfully treated by balloon expandable stents during TEVAR, and endoleaks arising from distal stent grafts attachment site or via retrograde flow from the celiac artery can be successfully managed by transfemoral coil embolization. Although early results are encouraging, long-term efficacy of these procedures remains to be determined and vigilant follow-up is needed.

Interventions for mesenteric vasculitis

This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV). We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease. There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9). Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.

Combined Endovascular and Surgical Treatment in Takayasu's Arteritis-Induced Renal Artery Stenosis (TARAS) Complicated with Vein–Graft Aneurysm of the Aorto-Renal By-pass

IntroductionWe report a case of combined endovascular and surgical treatment in a patient with Takayasu's arteritis-induced bilateral renal artery occlusion. ReportA 38-year-old women suffering from Takayasu's arteritis-induced renal artery stenosis (TARAS) was referred to our centre. The patient also complained of claudication and of symptoms related to ostial stenosis of superior mesenteric artery. She was treated with a sequence of open and endovascular procedures and is now on a 3-year uneventful follow-up. DiscussionTo our knowledge, this is the first case of combined endovascular and surgical treatment of TARAS performed simultaneously in one operative procedure that has ever been reported in the literature.

Combined Endovascular and Surgical Treatment in Takayasu's Arteritis-Induced Renal Artery Stenosis (TARAS) Complicated with Vein–Graft Aneurysm of the Aorto-Renal By-pass

Introduction: We report a case of combined endovascular and surgical treatment in a patient with Takayasu's arteritis-induced bilateral renal artery occlusion. Report: A 38-year-old women suffering from Takayasu's arteritis-induced renal artery stenosis (TARAS) was referred to our centre. The patient also complained of claudication and of symptoms related to ostial stenosis of superior mesenteric artery. She was treated with a sequence of open and endovascular procedures and is now on a 3-year uneventful follow-up. Discussion: To our knowledge, this is the first case of combined endovascular and surgical treatment of TARAS performed simultaneously in one operative procedure that has ever been reported in the literature. Combined Endovascular and Surgical Treatment in Takayasu's Arteritis-Induced Renal Artery Stenosis (TARAS) Complicated with Vein–Graft Aneurysm of the Aorto-Renal By-passEJVES ExtraVol. 19Issue 1PreviewWe report a case of combined endovascular and surgical treatment in a patient with Takayasu's arteritis-induced bilateral renal artery occlusion. Full-Text PDF Open Access

Management of isolated spontaneous dissection of superior mesenteric artery

Our objectives were to clarify the management of isolated spontaneous dissection of the superior mesenteric artery (DSMA). We reviewed seven patients diagnosed as having DSMA from 2002 to 2007 (group A). Simultaneously, we analyzed 50 cases of DSMA previously reported in the literature between 2000 and 2008 (group B). In each group, clinical presentation, Sakamoto's classification, imaging appearances, need for emergent surgery, failure of medical management, and long-term outcome were analyzed. In group A, according to Sakamoto's classification, there were two type I, two type II, and three type III. Two patients needed surgery (one type II, one type III). In group B, according to Sakamoto's classification, there were seven type I, five type II, 14 type III, and six type IV. Intestinal revascularization was necessary for 21 patients, especially for types II and III, while medical management was more frequent for types I and IV. We identified four indications for intestinal revascularization: acute mesenteric ischemia with mesenteric thrombosis, arterial rupture, chronic mesenteric ischemia with superior mesenteric artery (SMA) stenosis, and SMA dissecting aneurysm of at least 2 cm in diameter. If abdominal pain lasts for more than 1 week, types I and IV were able to be medically managed, whereas intestinal revascularization has to be considered in types II and III. Patients with symptoms lasting for more than 1 week, aneurysmal dilatation more than 2 cm in diameter, and SMA stenosis are suitable candidates for surgical management.

Percutaneous Intervention of Superior Mesenteric Artery Stenosis in Elderly Patients

This review article focuses on stent placement in mesenteric arteries in older patients with an increasingly common diagnosis of chronic mesenteric ischemia (CMI). We reviewed the articles that focused on the treatment of this gastrointestinal disorder by stenting/open surgical revascularization to avoid further ischemic episodes and bowel infarction and necrosis. The advantages of stent placement in mesenteric arteries are discussed in comparison to open surgical revascularization. In summary, the low morbidity and high technical success rate of catheter-based techniques have made this approach the first line of therapy for CMI due to superior mesenteric artery stenosis for many elderly patients especially high-risk operative candidates.

Duplex criteria for native superior mesenteric artery stenosis overestimate stenosis in stented superior mesenteric arteries

Superior mesenteric artery (SMA) duplex scanning is utilized to screen for high-grade (>or=70%) SMA stenosis (peak systolic velocity [PSV] >or=275 cm/second) and for follow-up of SMA bypass grafts and stents. Expected duplex scan findings in SMA bypass grafts have been recently reported. There is, however, little information correlating duplex scans from stented SMAs to procedural angiograms in patients treated for high-grade (>or=70%) SMA stenosis. We report validation of duplex scan criteria for high-grade native artery SMA stenosis, and also duplex scan examined results after SMA stent placement correlated with angiograms and angiographic measured pressure gradients pre- and post-SMA stent placement. Thirty-five patients with symptoms consistent with mesenteric ischemia were treated with SMA stents. Pre-intervention angiography demonstrated >70% SMA stenosis or SMA occlusion in all but 3 patients. Pre-intervention pressure gradients were obtained in 20 stenotic but patent SMAs and averaged 57 +/- 38 mm Hg; range, 15 to 187 mm Hg. Eighteen of the patients had SMA duplex scan prior to angiography, and 17 demonstrated an SMA PSV >or=275 cm/second or no flow, (mean 450 +/- 152 cm/second in patent arteries; range, 256 to 770 cm/second). Post-stent placement angiography demonstrated <30% SMA stenosis in all 35 patients. Post-stent pressure gradients were obtained in 22 patients and averaged 11 +/- 13 mm Hg; range, 0 to 45 mm Hg, (P < .001 compared to pre-stent pressure gradients in a paired test) and were elevated in patients with >or=60% celiac artery stenosis compared with those with <60% celiac artery stenosis (P < .006). Mean early post-stent duplex PSV scans obtained in 13 patients, were 336 +/- 45 cm/second; range, 279 to 416 cm/second (P = .011 compared to pre-stent PSVs). SMA stenting provides good anatomic results and significantly reduces measured pressure gradients. Duplex scans measured SMA PSVs are reduced post-stent placement but despite good angiographic results remain above criteria predicting high-grade native artery SMA stenosis. Duplex scan criteria developed to identify high-grade native artery SMA stenosis accurately predict high-grade native artery SMA stenosis but overestimate stenosis in stented SMAs. New duplex scan criteria are required to predict high-grade stenosis in stented SMAs.

Ischemic Complications After Pancreaticoduodenectomy

To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD). Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging. From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed. Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy. Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.

37 SPLANCNIC VESSELS ATHEROSCLEROSIS AND ITS RELATIONSHIP WITH CORONARY AND NON-CORONARY ATHEROSCLEROSIS IN A HEART SURGERY GROUP OF PATIENTS

Backgrounds: the improvement in heart surgery and anaesthesiology techniques in last decades have improved morbility and mortality ratio also in high surgical risk patients. Enteral ischemia after heart surgery is a rare complication (0.2 2%), but carries significant mortality (70 100%): its incidence has not been changed in these years and cases reported in literature are even increased. Pathogenesis has not been clearly understood, being complex and multifactorial: the principal cause seems to be the reduction in cardiac outflow during operation. Splancnic atherosclerosis could be also implicated in worsening or favouring enteral ischemia. Actually no relevant articles have been yet published concerning splancnic vessels screening before heart surgery. Atherosclerosis extension is only assessed with carotid duplex ultrasound and anamnestic data about previous cardiovascular events. Scope: aims of the study were to evaluate duplex scanning utility and accuracy to identify atherosclerotic lesions in splancnic vessels and to relate them with other arterial districts involvement. Methods: we studied 91 patients previously subjected to coronary angiography before heart surgery (coronary by-pass, valvular prothesis or both) at “Centro Gallucci” of “Azienda Ospedaliera di Padova”. They were all investigated with echocolordoppler of carotid arteries, aorta and its principal branches, and lower limbs arteries: if some haemodinamic stenosis were found a second level (Angio-CT or Angio-NMR) exam was performed to confirm the previous one. Chi-square test was employed in statistical analysis comparing atherosclerotic lesions distribution. Results: prevalence of carotid lesions and peripheral arterial disease was major among patients with at least one coronary artery critical stenosis; this data was not related with the number of vessels involved. Superior mesenteric artery (SMA) plaques were four times more frequent in patients with critical coronaropaty: no patients without critical lesions in coronary arteries had a >70% SMA stenosis. Carotid plaques (>1.5mm thickness), in particular those >50%, were more frequently associated with critical lesions at coronary angiography, even more than intima-medial thickening (95% vs 45%). Among patients with any degree peripheral arterial disease (PAD), 72% had coronary critical stenosis versus 30% in patients without PAD; if haemodinamic stenosis were found in lower limb arteries the prevalence of coronary critical plaques were 95%. Patients with any carotid plaque had a 44% prevalence of SMA stenosis (whatever degree), while in patients without carotid lesions it was 12.5%. No one with unaffected lower limb arterial wall had atherosclerotic SMA involvement, while if PAD was present, there was a 40% prevalence of SMA plaques (any degree). From this study also stand out that in patients with carotid stenosis >50%, and mainly among those with PAD, splancnic vessels were involved more frequently then in people without them. Both carotid plaques and PAD had a 100% sensitivity to predict a critical stenosis at SMA, even if specificity was below 50%. Conclusions: abdominal vessels duplex scanning is indicated before heart surgery only when atherosclerotic plaques are found in carotid and lower limbs arteries. Finding that kind ok lesions in pre-surgery evaluation should suggest the operator to put to use all devices useful for preventing vascular complications in the splancnic district. Echocolordoppler, if performed by an export operator, could be useful to detect the presence of atherosclerotic plaques or abdominal aortic aneurisms in abdominal vessels.

39 POLYMORPHISM OF PROINFLAMMATORY AND ANTI-INFLAMMATORY GENES IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Backgrounds: the improvement in heart surgery and anaesthesiology techniques in last decades have improved morbility and mortality ratio also in high surgical risk patients. Enteral ischemia after heart surgery is a rare complication (0.2 2%), but carries significant mortality (70 100%): its incidence has not been changed in these years and cases reported in literature are even increased. Pathogenesis has not been clearly understood, being complex and multifactorial: the principal cause seems to be the reduction in cardiac outflow during operation. Splancnic atherosclerosis could be also implicated in worsening or favouring enteral ischemia. Actually no relevant articles have been yet published concerning splancnic vessels screening before heart surgery. Atherosclerosis extension is only assessed with carotid duplex ultrasound and anamnestic data about previous cardiovascular events. Scope: aims of the study were to evaluate duplex scanning utility and accuracy to identify atherosclerotic lesions in splancnic vessels and to relate them with other arterial districts involvement. Methods: we studied 91 patients previously subjected to coronary angiography before heart surgery (coronary by-pass, valvular prothesis or both) at “Centro Gallucci” of “Azienda Ospedaliera di Padova”. They were all investigated with echocolordoppler of carotid arteries, aorta and its principal branches, and lower limbs arteries: if some haemodinamic stenosis were found a second level (Angio-CT or Angio-NMR) exam was performed to confirm the previous one. Chi-square test was employed in statistical analysis comparing atherosclerotic lesions distribution. Results: prevalence of carotid lesions and peripheral arterial disease was major among patients with at least one coronary artery critical stenosis; this data was not related with the number of vessels involved. Superior mesenteric artery (SMA) plaques were four times more frequent in patients with critical coronaropaty: no patients without critical lesions in coronary arteries had a >70% SMA stenosis. Carotid plaques (>1.5mm thickness), in particular those >50%, were more frequently associated with critical lesions at coronary angiography, even more than intima-medial thickening (95% vs 45%). Among patients with any degree peripheral arterial disease (PAD), 72% had coronary critical stenosis versus 30% in patients without PAD; if haemodinamic stenosis were found in lower limb arteries the prevalence of coronary critical plaques were 95%. Patients with any carotid plaque had a 44% prevalence of SMA stenosis (whatever degree), while in patients without carotid lesions it was 12.5%. No one with unaffected lower limb arterial wall had atherosclerotic SMA involvement, while if PAD was present, there was a 40% prevalence of SMA plaques (any degree). From this study also stand out that in patients with carotid stenosis >50%, and mainly among those with PAD, splancnic vessels were involved more frequently then in people without them. Both carotid plaques and PAD had a 100% sensitivity to predict a critical stenosis at SMA, even if specificity was below 50%. Conclusions: abdominal vessels duplex scanning is indicated before heart surgery only when atherosclerotic plaques are found in carotid and lower limbs arteries. Finding that kind ok lesions in pre-surgery evaluation should suggest the operator to put to use all devices useful for preventing vascular complications in the splancnic district. Echocolordoppler, if performed by an export operator, could be useful to detect the presence of atherosclerotic plaques or abdominal aortic aneurisms in abdominal vessels.

Endovascular treatment for thoracoabdominal aneurysms: outcomes and results☆

Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) in combination with selective open surgical revascularization may be an alternative to conventional surgical repair. We analyzed our patient outcomes after elective and emergent endovascular TAAA repair. Mortality and outcome data from 21 consecutive patients treated with endovascular TAAA repair between 2000 and 2006 were reviewed. An integrated neuroprotective approach was used on all patients. Mortality risk estimates for open surgery (OS) were calculated using the published risk assessment models and compared to our outcomes. Of the 21 patients, 9 had acute presentation: acute pain (9), rupture (6), and malperfusion (1). The celiac axis was overstented in 15. Nine hybrid open surgical procedures were performed: visceral/renal arteries (5), infrarenal aorta (3) and complete arch revascularization (1). Eleven patients had previous aortic surgery. Thirty-day mortality rate was 4.8% (1/21, predicted OS value 8.3%), 1-, 2- and 3-year survival was 80%. One hospital death occurred due to ischemic colitis after inferior mesenteric artery overstenting. No patient with acute presentation died during the initial hospital admission. There was no paraplegia (predicted OS rate 11.46%) and one event of delayed temporary paraparesis 3 weeks after hospital discharge corrected with raising the blood pressure. Other neurologic complications included one minor left pontine stroke with complete resolution, postoperative confusion (1) and saphenous nerve injury (1). No new late endoleaks occurred after initial complete aneurysm exclusion. Five patients underwent early (<30 days) and four patients underwent late endovascular reinterventions for persistent endoleak. An additional reintervention included percutaneous stenting of a superior mesenteric artery stenosis. Actual freedom from late reintervention was 81%, and 76% at 1-, 2 and 3-year follow-up. Late major adverse events included one stent infection leading to multi-organ failure and death. Endovascular treatment of thoracoabdominal aneurysms with selective visceral and renal revascularization is associated with low mortality and can only be effectively performed by a surgeon. High-risk patients and those with acute presentation appear to benefit most from this therapy. Early results up to three years of this therapy are encouraging, but further follow up to validate long-term results is required.

Imaging in Intestinal Ischemic Disorders

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel and/or colon. The incidence of bowel ischemia is increasing for a number of reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have contributed greatly to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this review, advances in multidetector computerized tomography, magnetic resonance, and ultrasound in the detection of intestinal ischemia are highlighted and placed in the context of expeditious patient management.

Endovascular versus open revascularization for chronic mesenteric ischemia: a comparative study

The aim of our study was to evaluate and compare short- and long-term outcomes of percutaneous angioplasty and open revascularization for chronic intestinal ischemia. Twenty-nine consecutive patients undergoing percutaneous angioplasty (n = 14) or open revascularization (n = 15) for chronic intestinal ischemia were prospectively studied from 2000 to 2006. All patients were symptomatic with at least thrombosis or 80% stenosis of superior mesenteric artery. No patient was lost to follow-up. Patients were older in percutaneous angioplasty than in the open revascularization group (p = 0.0009). Open revascularization allowed to revascularize more vessels (1.4 versus 1, p = 0.01). There was no difference between groups regarding major complications, mortality, hospital length of stay, and symptomatic recurrence. Primary re-stenosis was only observed in three patients (21.4%) in the percutaneous angioplasty group. Survival at 2 years estimated by the Kaplan-Meier method was 58% in the percutaneous angioplasty group and 70% in the open revascularization group (p = NS). Percutaneous angioplasty should be preferentially offered to older patients and those unable to undergo open revascularization.

Ligamentum arcuatum syndrome: color doppler ultrasound diagnosis in abdominal pain of unknown origin in young patients

To assess the diagnostic potential and accuracy of CDS in the diagnosis and management of visceral artery stenosis in young patients with abdominal pain. 126 patients < 45 y with abdominal pain were examined by CDS. Other diseases were excluded before. Systolic (Vmax.sys.) and end diastolic (Vmax.diast.) peak velocities in exspiration and inspiration were measured in the celiac (CA) and superior mesenteric artery (SMA). Vmax.syst. > 1.8 m/s in exspiration and inspiration was regarded as a respiratory fixed stenosis. This was followed by intraarterial digital subtraction angiography (i.a. DSA) including visualization of the pancreaticoduodenal artery (PDA), and, if fixed stenosis was confirmed, by operation. CDS was again performed in the follow-up. CA stenosis were found in 19 patients (mean age 28.9 y). 4 were respiratory fixed, 2 combined with SMA stenoses or occlusion, all proved by i.a. DSA. The others had no evidence of fixed CA stenoses. The 4 operated patients were postoperatively immediately well. One with intermediate pain again had a stenosis in the SMA-bypass which was successfully treated by PTA. The others were treated with dietary procedures and regularly controlled by CDS. Ligamentary CA stenosis in young patients is rare, but may lead to considerable abdominal pain and weight loss. Hemodynamicly significant stenoses are proved by CDS with respiratory fixed Vmax.syst. > 1.8 m/s and Vmax.diast. > or = 1 m/s; i.a. DSA often shows a retrograde perfusion of the PDA. Such patients should be treated surgically. CDS should be performed in the follow-up.

Descending thoracic and abdominal aortic coarctation in the young: Surgical treatment after percutaneous approaches failure

Descending thoracic and abdominal aortic coarctations are characterized by a segmental narrowing that frequently involves the origin of the visceral and renal arteries. Optimal primary treatment is debated, being reported for both surgical and percutaneous complications. We describe our surgical experience with two youths presenting with failure of distal descending aortic stenting and with abdominal aortic coarctation post-balloon angioplasty, and associated thrombosis of a stented right renal artery and stenosis of the origin of the superior mesenteric artery (SMA). In both cases, a longitudinal aortoplasty was performed with a polytetrafluoroethylene (PTFE) patch, using simple aortic cross-clamping. Renal thrombosis and SMA stenosis were managed with eversion technique. In-hospital course was uneventful. Midterm follow-up showed absence of significant restenosis and better control of hypertension. In order to refrain from operating on these patients as long as possible, and also because of the very high risk of a redo-surgery, we think that an initial balloon angioplasty should be considered. Surgical management can be adopted, even after failure of percutaneous treatments, with satisfactory short- and midterm vessels patency.

A Word of Caution Before Killing Hypogastric Arteries

The clinical investigation performed by Bratby et al. [1] regarding internal iliac artery (IIA) embolization prior to endovascular aneurysm repair (EVAR) is very important because it highlights the relatively safe feasibility of EVAR in such borderline iliac anatomies. In a similar study we conducted [2] including 33 unilateral and 8 bilateral IIA embolizations, we found similar results, with five cases of buttock/hip claudication (12.2%) and no case of bowel or spinal cord ischemia. While buttock claudication is the most frequent complication [1, 2], bowel and spinal cord ischemia are the major complications of IIA embolization. Bowel ischemia has been considered a multifactorial problem in open surgery, considering embolism, long-term hypoperfusion, mesentery stretch, traction or compression due to self-retraining retractor, bowel reperfusion syndrome, and collateral circulation. While most of these situations are not present during EVAR, collateral arterial circulation is a common risk factor. Yano et al. [3] reported high rates of bowel ischemia with hypogastric exclusion after EVAR, attributed to stenosis or occlusion of the ipsilateral femoral artery. Collateral arterial vasculature seems to play an important role in bowel ischemia after EVAR [4]. Even if there is no angiographic evidence that could forecast bowel ischemia, before proceeding to bilateral IIA exclusion, patients’ collateral arterial circulation should be studied, aiming for the preoperative identification of celiac artery or superior mesenteric artery stenosis or obstruction and patency of external iliac artery and common femoral artery collaterals. Furthermore, operators should be particular accurate regarding the preservation of these circumflex collaterals during surgical preparation of the femoral arteries. Regarding spinal cord ischemia prevention when planning IIA exclusion, particular attention should be paid to the patient’s medical history. Thoracic aortic procedures, endovascular or surgical with sacrifice of intercostal arteries, and subclavian artery stenosis or occlusion are important factors that could increase the risk of spinal cord injury. In conclusion, I believe that when bilateral IIA exclusion is considered as an operative strategy prior to EVAR, preoperative imaging workup should focus also on the status of the patient’s collateral circulation.

Reperfusion Hemorrhage Following Superior Mesenteric Artery Stenting

Percutaneous transluminal angioplasty and stent placement is now an established treatment option for chronic mesenteric ischemia and is associated with low mortality and morbidity rates. We present a case of reperfusion hemorrhage complicating endovascular repair of superior mesenteric artery stenosis. Although a recognized complication following repair of carotid stenosis, hemorrhage has not previously been reported following mesenteric endovascular reperfusion. We describe both spontaneous cessation of bleeding and treatment with coil embolization.

Drug-Eluting Stent for Recurrent Mesenteric Artery In-Stent Restenosis

To report the use of a drug-eluting stent (DES) for treatment of symptomatic in-stent restenosis (ISR) in the superior mesenteric artery (SMA). A 79-year-old woman suffering from chronic renal failure and needing dialysis was admitted for vomiting, postprandial abdominal pain, and weight loss for 3 months. Computed tomographic angiography (CTA) documented massive calcification of the vascular bed, mainly in the aorta, and a very tight ostial stenosis of the SMA. A 4.5-x20-mm Genesis stent was deployed at the ostium, with good angiographic result and immediate symptomatic benefit. After 3 months, symptoms recurred; angiography demonstrated ISR. Percutaneous angioplasty with a 4-x15-mm cutting balloon was performed. The patient remained asymptomatic for only 2 months; recurrent ISR at this time was treated with a 3.5-x24-mm coronary TAXUS Express paclitaxel-eluting coronary stent deployed inside the previously implanted stent. Under prolonged double antiplatelet regimen, the patient was asymptomatic at the 8-month follow-up; CTA demonstrated patency of the SMA. Considering the high rate of restenosis and the periprocedural complications described with endovascular treatment of SMA stenosis, a drug-eluting stent may be a good option not only for the treatment of restenosis but also in de novo lesions, at least when the vessel diameter is <4.5 mm.

Tratamiento endovascular como alternativa terapéutica en la isquemia mesentérica crónica

Chronic mesenteric ischemia (CMI) is an uncommon disorder. Traditional treatment consists of open surgical (OS) revascularization. We report a case of CMI treated with percutaneous angioplasty and stenting. A 77-year-old-woman reported a history of postprandial abdominal pain, weight loss, asthenia, and anorexia. On physical examination, the only relevant sign was systolic murmur. Oral panendoscopy showed chronic atrophic gastritis and patchy intestinal metaplasia with Helicobacter pylori colonization; rectal sigmoidoscopy showed colonic diverticula. Abdominal ultrasound color-flow imaging confirmed superior mesenteric artery (SMA) stenosis > 70%. Angiography confirmed proximal SMA subocclusion and celiac trunk stenosis of 50%. Percutaneous angioplasty and stenting were carried out. The patient made an immediate recovery and remains without postprandial pain. CMI due to atherosclerotic occlusive disease was first reported in 1936 and is a relatively uncommon disorder. This entity usually occurs in patients over 60 years of age with other atherosclerotic symptoms. CMI presents with postprandial abdominal pain, anorexia due to <<fear of food>>, and weight loss. Despite high perioperative morbidity and mortality rates, OS revascularization has traditionally been the treatment of choice. The most frequent indications include pain relief, improvement of nutritional status, and prevention of intestinal infarction. Endovascular therapy seems to be a valid alternative, mainly in high-risk patients, with good immediate and medium-term results.