Challenging Cases

Mesenteric Ischemia Revisited

By James A. M. Smith, DO
 

CASE PRESENTATION
An 81-year-old white female who had a diagnostic aortogram for symptoms of intermittent claudication presented to my office. She reported that symptoms had worsened in the past 6 months. She also complained of early satiety and postprandial abdominal fullness depending on the extent of her meal. In addition, she lost 8 lbs in the past 4 weeks.

The patient’s medical history included dyslipidemia, hypertension s/p two renal artery stents, coronary artery bypass surgery, left ventricular hypertrophy, and s/p right carotid endarterectomy.
Her medications consisted of daily doses of the following: Lopressor, 50 mg (metoprolol; Novartis, East Hanover, NJ); Lipitor, 10 mg (atorvastatin; Parke-Davis, Morris Plains, NJ); Altace, 20 mg (ramipril; Monarch, Bristol, TN); and Plavix, 75 mg (clopidogrel; Bristol-Meyers Squibb, Princeton, NJ).

Upon examination, I found the patient to be an alert, well-developed, mesomorphic female in no acute distress, measuring 5’2? tall and weighing 127 lbs. Her left arm BP was 149/68, and her right arm BP was 167/79. The patient had bilateral subclavian and carotid bruits. Her cardiac rhythm was regular with a soft systolic murmur heard at the lower left sternal border and her abdomen was flat with active bowel sounds and no tenderness or visceromegaly. An examination of the lower extremities revealed no edema, ulcerations, or synovitis. The pedal pulses were present but diminished at the posterior tibial location. The ankle:brachial index was 0.8 on the right and 0.76 on the left.

ANGIOGRAPHIC FINDINGS
The abdominal aortogram showed previously placed bilateral renal artery stents. There was a large, meandering artery of Drummond in the left lower quadrant. (Figure 1). I completed a lateral abdomen view through a pigtail cath-eter and used a JR4 catheter to find the superior mesenteric artery (SMA) (Figure 2). The celiac axis was also subtotally occluded with considerable poststenotic dilatation (Figure 3A).

HOW WOULD YOU PROCEED?
1. Would you perform angioplasty with stents?
2. Is vascular surgery an option?
3. What is the morbidity associated with each option?
course of action

I chose a transbrachial approach to SMA stenosis. Using a micropuncture to enter the brachial artery, I placed a short 6F catheter sheath and gave the patient 3,000 units of heparin. I used a 6F JR4 catheter with a Terumo guidewire (Terumo, Tokyo, Japan) to cross the left subclavian stenosis where I found a resting 18-mm pressure gradient. Although the subclavian lesion was difficult to cross, I dilated it with an 8-mm X 4-cm balloon. I decided against placing a stent.

Next, I positioned the 6F JR4 catheter in the juxtarenal aorta. Working in the lateral projection, I advanced the catheter into the SMA ostium and injected contrast. There was essentially no flow through the ostium. I then advanced a .014” Spartacore guidewire (Guidant Corporation, Indianapolis, IN) across the lesion and used a 4-mm X 4-cm ViaTrack balloon (Guidant Corporation) to dilate the ostium (Figure 3B).

At this point, I placed a 5-mm balloon with an 18-mm Megalink biliary stent (Guidant Corporation) into the dilated segment. I then performed an angiogram (Figure 3C). Because of this spiral dissection beyond the proximal stent, I placed a self-expanding Smart stent (Cordis Corporation, a Johnson & Johnson Company, Miami, FL) beyond the original stent. The angiogram showed brisk flow with no residual stenosis (Figure 3D).

OUTCOME
The abdominal aortogram strongly suggested stenosis in the superior mesenteric artery because of the large collateral artery coming from the inferior mesenteric artery. I was surprised to find a subtotal occlusion and aneurysm in the celiac axis.

Most patients with symptoms of mesenteric ischemia have severe stenosis in two of three mesenteric vessels and profound weight loss in combination with almost immediate postprandial bloating or diarrhea. This very stoic patient only expressed symptoms of postprandial abdominal bloating and early satiety after I saw the original angiogram and questioned her rigorously. She lost 8 lbs more than 1 month prior to the procedure.

The mesenteric vessels are in close proximity to the renal arteries where atherosclerotic plaques are frequently present. As patients survive other forms of atherosclerotic disease (this patient had undergone a previous CABG and two renal artery stents), they are increasingly manifesting signs and symptoms of disease elsewhere.

In the past, we could only accomplish mesenteric revascularization surgically and the procedure was associated with considerable morbidity. The endovascular techniques now available make this disease much easier to treat.

This case utilized a combination of products, both self-expanding and balloon-expandable stents in conjunction with small catheter and guidewire systems. Current technology enhances our ability to solve clinical problems in a facile, cost-efficient way with far less morbidity to the patient. n

James A.M. Smith, DO, is Director of Vascular Medicine at the University of Pittsburgh Medical Center in McKeesport, Pennsylvania. Dr. Smith may be reached at (412) 664-2507; smithja2@msx.upmc.edu.

 

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