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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Procedure
435
Patient underwent SMA arteriogram and
attempted intervention via left brachial (percutaneous) approach using a 90cm 6F Cordis sheath
and a Magic Torque™ wire (Boston Scientic,
Marlborough, MA) (260cm long and 0.035mm
in diameter) but the SMA stent could not be
accessed. Magic Torque wire was exchanged for
a 300-cm-long 0.014 BMW wire, and using vertebral catheter as a support system, we were able
to advance the wire and catheter to the SMA stent
and the distal portion of the SMA.There was evidence of thrombus between the two overlapping
stents (Fig.95.5), and a 2mg of TPA was infused
in the SMA over 30minutes. Patient was given
5000units of heparin, and 0.014 wire was then
exchanged with a Magic Torque wire using vertebral catheter. A superior mesenteric stent angioplasty using a 7mm× 4 cm OPTA®Pro balloon
(Cordis) was performed with less than 10% residual stenosis with lysis of most of the clot burden
(Fig.95.5). There were some branches of SMA
showing residual thrombi as lling defects or
abrupt occlusion. A follow-up CTA of the abdomen on July 14, 2008, showed satisfactory lysis
of SMA stent thrombosis (Fig. 95.6). Patient
underwent duplex imaging of the SMA on a
Fig. 95.5 Aortogram, SMA arteriogram via left brachial approach with thrombolysis and balloon angioplasty
436
Fig. 95.6 Follow-up CTA (lateral view) patent SMA
stent with distal lling of the SMA and its branches
95 Management ofRadiation- Induced Superior Mesenteric Artery Stenosis withSmall Bowel Ischemia
yearly basis with last Doppler study in June 2017
showed patent superior mesenteric stent. Patient
continued to improve, with symptoms of diarrhea
(three to four bowel movements a day). She did
not experience any signicant abdominal discomfort till her death from unrelated cause in
June 2019.
Discussion
Endovascular treatment of chronic atherosclerotic mesenteric high-grade stenosis is technically successful in vast majority of patients with
satisfactory improvement of symptoms of intestinal angina with a low morbidity and mortality
[1]. However, in patients with chronic SMA
occlusion, the lesion may be difcult to cross
despite the use of support catheter. In such
circumstances, an antegrade aortic-superior mesenteric artery bypass may be the best option if
they are symptomatic and medically good risk.
The patient described in this report had an acuteon- chronic mesenteric ischemia; such patients
have higher mortality and lower technical success often related to duration of ischemia, presence of bowel infarction, and propagated
thrombus in the smaller branches of the SMA.
Retrograde mesenteric stenting should be considered in patients with acute or acute-on-chronic
mesenteric ischemia (non-embolic) particularly in
patients who are undergoing laparotomy for suspected bowel infarction. Superior mesenteric
artery is surgically exposed at the root of the mesentery after mobilizing the ligament of Treitz.
Superior mesenteric artery is located to the right
of the superior mesenteric vein. Silastic vessel
loops were passed around the SMA and its
branches. Retrograde access was obtained using a
0.018 inch micro-puncture kit and exchanged for
a 0.035 guidewire with a 6F or a 7F sheath. The
ostial stenosis is carefully traversed with a catheter/guidewire combination. Once the wire enters
the aortic lumen and conrmed by contrast injection, the access is exchanged for a stiffer wire, and
a balloon-expandable stent is deployed, aring
the stent 2–3mm into the aortic lumen. The opening in the arteries is closed with a vein patch
angioplasty.
Some authors prefer two-vessel revascularizations when both celiac and SMA are involved,
but the main focus of treatment should be the
SMA. For percutaneous interventions, either a
transfemoral or transbrachial approach can be
used; the latter offers more support and stability
in patients with chronic occlusion [2]. Predilatation with a 3–4 mm low-prole balloon
angioplasty catheter is helpful in sizing as well as
passage of the stent [2].
In this patient, possible causes of stent thrombosis were probably the use of two overlapping
stents and dehydration secondary to small bowel
obstruction caused by ischemic stricture. Use of
two overlapping stents may lead to increased
incidence of in-stent restenosis and thrombosis.
An attempt should be made to deploy a single
stent with 2–3 mm are into the aortic lumen.
Covered stent if used should be carefully sized so
that important branch or branches of the SMA are
not excluded from the circulation. Recently
Haben et al. reported 150 patients who underwent interventions on the celiac artery (56 vessels) and SMA (133), and 38 patients had
interventions on both vessels [3]. They reported
that patients older than 70 years have better
results than younger patients, and this may reect
a more malignant presentation in the younger
patients. Ostial aring was shown to the single
factor on multivariable analysis associated with
References
437
improved patency [3]. Their data supported the
continued use of bare-metal stents in the treatment of chronic mesenteric ischemia [3].
References
1. Hosn MA, Katragunta N, Sharafuddin
MJ. Endovascular intervention for mesenteric ischemia. In: Hans SS, Shephard AD, Weaver MR, Bove
PG, Long GW, editors. Endovascular and open vascular reconstruction: a practical approach. Boca Raton:
CRC Press; 2018. p.15–8.
2. Oedrich GS, Macedo R, Stone DH, Woo EY, et al.
Multicenter study of retrograde open mesenteric
artery stenting through laparotomy for treatment of
acute and chronic mesenteric ischemia. J Vasc Surg.
2018;68:470–80.
3. Haben C, Park WM, Bena JF, Parodi FE, et al.
Improving mid-term results justify the continued use of
bare-metal stents for endovascular therapy for chronic
mesenteric ischemia. J Vasc Surg. 2020;71(1):111–20.
Superior Mesenteric Artery In-stent Restenosis
96
Physical Examination
A 71-year-old female was seen in the outpatient
clinic in March 2013 with complaints of postprandial pain and weight loss but without any
history of diarrhea. Following a negative GI
endoscopy (upper and lower), she underwent
CTA of the abdomen and pelvis which showed
celiac artery occlusion, high-grade stenosis superior mesenteric artery (SMA), and occlusion of
inferior mesenteric artery (IMA).
Procedure
Patient was taken to the interventional radiology
suite on March 20, 2013, and using a left brachial access with a micropuncture technique, a
5 F sheath was inserted. An angle stiff
GLIDEWIRE
Omniush catheter (AngioDynamics, Latham,
NY) was advanced at the level of T12. Abdominal
aortogram in AP and steep RAO position was
obtained. There was evidence of celiac artery
occlusion, high-grade stenosis of SMA, nonvisualization of IMA, and presence of meandering mesenteric artery (Fig.96.1). 5 F sheath in
the left brachial artery was exchanged for a
90-cm-long 6 F narrow sheath. Using angled
vertebral catheter and 035260 cm Magic
Torque™ wire (Boston Scientic, Marlborough,
MA), SMA stenosis was traversed (Fig.96.2),
®
(Terumo, Tokyo, Japan) with
and pre-angioplasty was performed with a
5 mm × 2-cm-long angioplasty balloon. This
was followed by deployment of 7×19mm balloon-expandable stent (Omnilink, Abbott,
Abbott Park, Il) raised to 14 atmospheric pressure so that the nal diameter of the stent was
7.4mm. Completion run showed less than 20%
residual stenosis (Fig.96.3).
Following SMA stenting, patient had com-
plete relief of her GI symptoms. Superior mesenteric artery duplex imaging in March 2015
showed a peak systolic velocity (PSV) of 268cm/
sec with an end diastolic velocity (EDV) of
48 cm/sec. Patient developed recurrent symptoms of abdominal pain following meals associated with weight loss. She underwent duplex
study of the SMA on August 2016 which showed
PSV of SMA (stent) 462cm/sec with an EDV of
198cm/sec. Patient underwent CTA of the abdomen which showed severe in-stent restenosis of
the SMA on September 1, 2016 (Fig.96.4). She
underwent balloon angioplasty of the SMA stent
in-stent restenosis using a 7mm×4cm Armada®
(Abbott) balloon raised to 16 atmospheric pressure via left brachial access using 6F 90-cm-long
sheath with satisfactory completion run showing
less than 10% residual stenosis (Fig. 96.5).
Patient was relieved of her GI symptoms.
Follow-up duplex imaging had shown in (last
study) May 21, 2019, PSV 410 cm/sec and an
ESV of 53cm/sec which is consistent with less
than 70% in-stent restenosis.
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_96
439
440
Fig. 96.1 Abdominal aortogram showing celiac artery occlusion, near occlusion at origin of SMA and IMA, large
meandering mesenteric artery
96 Superior Mesenteric Artery In-stent Restenosis
Fig. 96.2 SMA access via large sheath and angled catheter
Discussion
Several studies have demonstrated that SMA
stent for mesenteric occlusive disease is less
durable as compared with open repair with a high
rate of in-stent restenosis (20–66%). Treatment is
recommended in patients who develop recurrent
symptoms of chronic mesenteric ischemia or
have pre-occlusive in-stent restenosis. Treatment
should also be considered taking into account
comorbidities and the location of the in-stent
restenosis. Most often a secondary endovascular
procedure using angioplasty or a stent placement
is a satisfactory option. A SMA bypass should be
considered in good-risk patients with occlusions
or unfavorable anatomy for repeat endovascular
References
441
Fig. 96.5 Post-angioplasty of in-stent restenosis of SMA
Fig. 96.3 Satisfactory SMA stent placement
Fig. 96.4 CTA (lateral view) celiac artery occlusion,
SMA in-stent restenosis, and calcied aorta with IMA
occlusion
treatment. Peak systolic velocity of greater than
275cm/sec reliably predicts equal or greater than
70% stenosis in an un-stented SMA. Relative
increase in PSV of stented carotid, renal, and
SMA as compared to un-stented arteries has been
reported in the literature [1]. Stenosis of one mesenteric artery often affects the velocity of other
mesenteric vessels. High-grade stenosis or occlusion of celiac artery may affect the post-stenting
pressure gradient in the SMA [1]. Tallarita etal.
reported 30 patients treated with reintervention
for mesenteric artery in-stent restenosis with 24
patients presenting with recurrent symptoms (21
chronic, 3 acute), and six had asymptomatic preocclusive lesions [2]. Twenty-six patients underwent redo endovascular treatment with stent
placement in 17 and PTA in 9 [2]. The remaining
four patients had open bypass including one for
acute ischemia [2]. Seven patients treated with
repeat endovascular revascularization developed
complications including one death in a patient
with redo stenting [2]. Freedom from recurrent
symptoms, restenosis, and reinterventions were
70% ± 10%, 60% ± 10%, and 50% ± 10% at
2years.
References
1. Soult MC, Wuamett JC, Ahanchi SS, Stout CL.Duplex
ultrasound criteria for in-stent restenosis of mesenteric
arteries. J Vasc Surg. 2016;64:1366–72.
2. Tallarita T, Oderich GS, Macedo TA, Gloviczki P,
et al. Reinterventions for stent restenosis in patients
treated for atherosclerotic mesenteric artery disease. J
Vasc Surg. 2011;54:1422–9.
Endovascular Treatment
ofSymptomatic Celiac
andSuperior Mesenteric Artery
Occlusive Disease
97
Physical Examination andHistory
A 57-year-old female was admitted via emergency room to the hospital on November 24,
2019, with abdominal pain, nausea, and vomiting of 48hours duration. She was experiencing
worsening postprandial pain for the past 2days.
She had poor oral intake and experienced weight
loss for the past 6weeks. Medical comorbidities
included Type II diabetes mellitus, hypertension, hyperthyroidism, and hyperlipidemia.
Patient was a nonsmoker. She had absent right
axillary pulse, right brachial pulse, and right
radial pulse. Pulses were not palpable in both
lower extremities (femoral, popliteal posterior
tibial, and dorsalis pedis). Examination of the
abdomen of the showed diffuse tenderness but
without any guarding or rigidity. Lab data
showed hemoglobin 10.4 g, hematocrit 30.4,
platelet count 527,000, sodium 112, potassium
5.5, creatinine 0.9, and lactate 4.9. With medical
management (uid restriction and resuscitation), the lactate level decreased to 2mg/dL and
WBC count to 8600 from 13,000/ml. Sodium
level increased to 124 mg/L over the next
24 hours. Contrast- enhanced CT scan of the
abdomen, and pelvis showed occlusion of the
infrarenal abdominal aorta and bilateral common iliac arteries with reconstitution of external
iliac arteries and severe narrowing of both internal iliac arteries. There was 60–70% stenosis of
the celiac artery, 80% superior mesenteric artery
(SMA), and occlusion of the inferior mesenteric
artery (IMA, Fig.97.1).
Fig. 97.1 CTA showing severe SMA stenosis and
marked calcication of the infrarenal aorta
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_97
443
444
97 Endovascular Treatment ofSymptomatic Celiac andSuperior Mesenteric Artery Occlusive Disease
Procedure
Patient underwent abdominal and visceral arteriography on November 26, 2019, in the interventional radiology suite using left brachial
puncture. Using ultrasound guidance, a 5 F
sheath was inserted. A 260-cm-long 035
GLIDEWIRE® (Terumo, Tokyo, Japan) was
advanced into the supraceliac aortogram in AP,
and extreme RAO projection showed occlusion
of the infrarenal abdominal aorta, moderate stenosis of the celiac artery, severe stenosis of the
SMA at its origin, and occlusion of the IMA
with large gastroduodenal collaterals (Fig.97.2).
The 5F sheath was exchanged for a 65-cm-long
Arrow® sheath (Teleex, Wayne, PA). Celiac
artery angioplasty was performed with a
6 mm × 2cm Armada® (Abbott, Abbott Park,
IL) balloon (Fig.97.3). Using Kumpe catheter
(Cook Medical, Bloomington, IN), SMA origin
was engaged using a 035 mm Glidewire
(Fig. 97.4). Glidewire was positioned distally
near the terminal branches of the SMA, and a
pre-angioplasty was performed with a
6mm×2-cm-long Armada balloon followed by
deployment of an 8×19mm Omnilink (Abbott,
Abbott Park, IL) balloon expandable stent with
aring of the stent for 2 mm into the aorta.
Fig. 97.2 Abdominal aortogram via left brachial
approach shows infrarenal aortic occlusion with large gastroduodenal arteries as collaterals
Fig. 97.3 Celiac artery balloon angioplasty with guide-
wire extending into hepatic artery
Fig. 97.4 Wire access into SMA with associated high-
grade stenosis of SMA at its origin
Discussion
Fig. 97.5 Post-stenting SMA with <20% residual steno-
sis. There is diminished lling of the gastroduodenal collaterals following stenting
Completion arteriogram showed less than 20%
stenosis (Fig. 97.5) Gastrointestinal symptoms
showed marked improvement, and she was discharged on December 2, 2019.
Discussion
Patients with celiac and mesenteric artery occlusive disease with symptoms of intestinal angina
may experience acute exacerbation secondary to
low cardiac output (dehydration, hypercoagulability, cardiac arrhythmia). In such patients, careful monitoring in the intensive care unit should be
performed as progression of ischemia may result
in full-thickness necrosis of the small or large
intestine. Patient may need laparotomy for bowel
resection, in addition to the endovascular treatment of the mesenteric artery occlusion.
Correction of uid and electrolyte imbalance in
addition to endovascular treatment as described
in this report may result in reversal of the mucosal ischemia and thus halt the progression to
bowel infarction.
445
Acute mesenteric ischemia is a rare clinical
problem that accounts for 0.09–0.2% of all emergency department admissions representing an
uncommon cause of abdominal pain. The underlying causes can be nonocclusive or occlusive
with the embolic etiology in 50%, thrombotic in
15–25%, and mesenteric venous thrombosis in
5–15%. Mortality rates for 16–80% have been
reported [1]. Prognosis of patients of thrombotic
occlusion of the SMA with bowel infarction continues to remain poor in spite of modern intensive
care unit management, availability of endovascular treatment, and better control of cardiac
arrhythmia [1]. In patients with chronic mesenteric ischemia (intestinal angina) and elective
mesenteric revascularization, two vessel revascularization is preferred. In emergency settings,
bypass to the superior mesenteric artery usually
sufces. Scali et al. reported 82 patients who
underwent aortomesenteric bypass (aortoceliac/
SMA n= 44, aortomesenteric n = 38) for acute
mesenteric ischemia with 76% undergoing antegrade bypass. Concurrent bowel resection was
evenly distributed (antegrade 45% and retrograde
45%). Incidence of complication was 78% with
mortality 37%. The 1-year and 3-year primary
patency rate for both was 82% [1]. There was
higher rate of reintervention in patients undergoing retrograde bypass. In some patients there is
anatomic variation as celiac and SMA may arise
as a common trunk. More commonly, the hepatic
artery may arise from SMA.Bulut etal. reported
excellent long-term secondary patency of celiac
and SMA with percutaneous mesenteric stenting.
They reported primary patency of 77% at
12months and 45% at 16months with primary
assisted patency of 90.3% and 69.8% with overall secondary patency of 98.3% and 93.6% [2].
Superior mesenteric artery stenting with use
of embolic protection devices (EPD) have been
reported by Mendes etal. among 65 patients. The
indication for use of EPD was severe calcication in 22 patients (34%) and total occlusion in
16 (25%) and acute thrombosis in 18 (28%).
They retrieved large microscopic debris in one
third of the patients [3].
446
97 Endovascular Treatment ofSymptomatic Celiac andSuperior Mesenteric Artery Occlusive Disease
References
1. Scali ST, Ayo D, Giles KA, Gray S, etal. Outcomes
of antegrade and retrograde open mesenteric
bypass for acute mesenteric ischemia. J Vasc Surg.
2019;69:129–40.
2. Bulut J, Oosterhof-Berktas R, Geelkerken RH,
Brusse-Keizer M, et al. Long-term results of endo-
vascular treatment of atherosclerotic occlusions of
the celiac and superior mesenteric artery in patients
with mesenteric ischemia. Eur J Vasc Endovasc Surg.
2017;53:583–90.
3. Mendes BC, Oderich GS, Tallarita T, Kanamori KS,
etal. Superior mesenteric artery stenting using embolic
protection device for treatment of acute or chronic
mesenteric ischemia. J Vasc Surg. 2018;68:1071–8.