Balloon Angioplasty Of The Superior Mesenteric Artery In The Treatment Of Chronic Intestinal Ischemia: A Case Report
Running head: Mesenteric angioplasty
Dragan Sagić, Miodrag Perić, Božina Radević, Mirjana Perišić*,
Zoran Popović, Milovan Bojić
Institute of Cardiovascular Diseases Dedinje, Beograd
*Institute of Digestive Diseases, Clinical Centre of Serbia, Beograd
Address correspondence to:
Dragan Sagić
Cardiovascular Institute Dedinje
M. Tepića 1,11000, Beograd
Yugoslavia
Tel:(38111)669-425,500-866
Email: sagicd@Eunet.yu
ABSTRACT
Endovascular techniques may be attempted prior to surgery in cases of stenosis or short occlusive lesions in patients with chronic mesenteric ischemia. To determine the safety and efficacy of percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia and/or stenosis of mesenteric arteries, we have performed this procedure in a 45-year old woman with chronic mesenteric ischemia.
Key words: Mesenteric artery, ischemia, percutaneous transluminal angioplasty.
Mesenteric arterial ischemia is an uncommon condition associated with a high morbidity and mortality. Acute ischemia has a reported mortality rate of at least 50%, while the chronic form may eventually lead to death from intestinal infarction or starvation, if left untreated (1,2).
Until recently, surgical revascularization and resection of an infarcted bowel have been the treatment of choice for all cases of chronic mesenteric ischemia (CMI). While surgery remains the method of choice in the acute setting, especially if signs indicating bowel infarction are present (1), in cases of CMI, however, percutaneous transluminal angioplasty (PTA) of stenotic mesenteric arteries has become an option recently (3-13).
CASE REPORT
A 45-year old woman with a history of smoking, hyperlipidemia, diffuse peripheral vascular disease and previous vascular procedures, presented with postprandial pain, diarrhea and weight loss over the previous 5 months. Following a transfemoral approach, biplane abdominal aorto-arteriography was carried out, demonstrating an eccentric stenosis of the superior mesenteric artery (SMA).
PTA was performed under the local anesthesia with addition of intravenous sedation and analgesia when indicated. Procedural medications included 100 IU/kg of intraarterially administered heparin and multiple intraarterial bolus injections of 100 mg of nitroglycerin to prevent spasm. Catheterization of SMA and the balloon-catheter placement was carried out via the transaxillary route, because of the angulation between the aorta and SMA. Powerflex (Cordis) balloon catheters (7x20 mm) were used for dilatation. The diameter of the balloon was chosen to allow for slight overdilatation of the artery but not more than 1 mm, compared to the corrected diameter of the vessel. Balloon angioplasty of the SMA stenosis reduced the mean pressure gradient from 75 mmHg to 15 mmHg (Fig.1-3).
Two days after the procedure the patient was discharged from the hospital with the mdeication of aspirin (indefinitely) and ticlopdiine (for 6 weeks). During the two-year follow-up period, she was asymptomatic and gained 4 kg in weight.
DISCUSSION
Symptomatic CMI is rarely encountered, because of the abundant collateral circulation to the intestines. The annual incidence of mesenteric ischemia has been estimated to be 1 in 100.000 in the general population (14). Usually, at least two out of three mesenteric arteries must be significantly compromised before symptoms occur (14). CMI is most commonly caused by atherosclerotic occlusive disease. Other less common causes of CMI are arteritis, dissection, fibromuscular dysplasia and neurofibromatosis (14).
Patients with symptomatic CMI may suffer posptrandial or atypical pain, nausea, vomiting, diarrhea and symptoms of malabsorbtion. Therefore, standard treatment in symptomatic patients has been surgical revascularization of one or two mesenteric arteries, using a variety of techniques (14). Primary patency rates average 80-84% among survivors, during a mean follow-up varying between 24 and 69 months (15,16,17). However, it is important to emphasize that most reports on mesenteric endovascular or open surgical revascularizations in patients with CMI lack an objective measure for evaluating long-term vascular patency, since they relay only on symptomatic follow-up.
PTA in the treatment of CMI was first reported in 1980 (18). The results are encouraging, with an average technical and initial clinical success rate between 85% and 87%. Primary patency rate averaged 63% and 75%, respectively, during a mean follow-up of 12-39 months (10,17) (Table 1). The results of the current series of patients with CMI further emphasize the therapeutic value of modern endovascular techniques (balloon angioplasty and stents). When we analyzed atherosclerotic nonostial and ostial lesions among the reviewed series, initial technical success rates of 95% (73 of 77 arteries) for nonostial lesions and 78% (14 of 18 arteries) for ostial lesions were found (4,6,9-14). Such a difference in the patency rate may indicate that an ostial lesion per se is not an absolute indication for primary stenting in mesenteric arteries.
The use of stents in patients with CMI also appears to be limited, according to the literature. Finch (19) primarily stented an ostial SMA stenosis with a Palmaz stent in a patient with abdominal angina who remained asymptomatic after 4 months. Ozdil et al. (20) placed stents in the SMA in a patient with Takayasu's arteritis following failed balloon angioplasty due to the immediate recoil. There is only one report of a larger series of patients with CMI treated with stents, in which 12 patients were treated with balloon-expandable Strecker stents, following failed angioplasties of stenotic lesions (16).
In above mentioned review article (14), PTA was technically unsuccessful in 17 of the 126 patients (13%). The seven cases of atherosclerotic elastic recoil and the two angioplasty-induced dissections may have been avoided by placement of stents.
Among the reviewed reports, major PTA-induced complications (intestinal embolization, occlusion of aortofemoral Y-graft, peripheral embolization, axillary haematoma, brachial artery occlusion) have occurred in 7% of patients. Two complications were fatal (1.6%) (1-14).
In conclusion, PTA of the mesenteric arteries is a valuable treatment option in patients with CMI, especially if considered to be a very high operative risks. The initial technical success rate is excellent, with the majority of patients becoming completely symptomatic at a short-term follow-up. However, using PTA in longer occlusions might impose a higher risk of intestinal infarction from embolized thrombotic material; in this setting, surgery should be preferred therapeutic option.
Table 1.
Review of the literature on percutaneous angioplasty of SMA.
| Authors | No pts | Technical success | Periprocedural complications | Clinical success | Recurrent stenosis | Late bowel infarction | Follow-up (months) |
| Allen 13 | 19 | 18/19 | 2 | 15/18 | 3 | 0 | 39 |
| Hallisey 12 | 15 | 13/15 | 0 | 14 | 4 | 3 | 28 |
| Rose 11 | 8 | 3/8 | 2 | 6/7 | 2 | 0 | 12 |
| Matsumoto 10 | 19 | 15-19 | 3 | 12 | 2 | 0 | 25 |
| Sniderman 9 | 14 | 12/14 | 0 | 12 | 5 | 1 | 14 |
| McShane 8 | 6 | 6/6 | 0 | 6 | 4 | 0 | 16 |
| Simonetti 7 | 22 | 21/22 | 0 | 20 | 2 | 0 | 14 |
| Levy 6 | 4 | 4/4 | 0 | 4 | 2 | 0 | 27 |
| Wilms 5 | 8 | 7/8 | 1 | 7 | 0 | 0 | 17 |
| Roberts 4 | 4 | 4/4 | 1 | 4 | 2 | 0 | 21 |
| Golden 3 | 7 | 6/7 | 0 | 6 | 0 | 0 | 14 |
| Total | 126 | 87% | 7% | 85% | 22% | 3% | 12-39 |
FIGURES
Figure 1. Lateral arteriogram: superior mesenteric (SMA) stenosis (85%) with a 75 mmHg mean blood pressure gradient.
Figure 2. Percutaneous balloon angioplasty of SMA.
Figure 3. No residual SMA stenosis following balloon angioplasty.
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