Retrograde superior mesenteric artery stenting for acute mesenteric arterial thrombosis

Retrograde open superior mesenteric artery stenting: a novel approach to managing occluded ilio-superior mesenteric artery grafts

Acute mesenteric ischaemia (AMI) can be treated either by open bypass grafting or occasionally by antegrade endovascular stenting. We present a patient with symptoms of AMI, in the early postoperative period, following thrombosis of an iliac to superior mesenteric bypass to treat chronic mesenteric ischaemia. A hybrid technique combining open surgery with a retrograde endovascular approach was performed. This allowed for direct visualisation of the bowel and immediate revascularisation of the mesenteric circulation.

Case Report of Percutaneous Retrograde Transcollateral Recanalization of the Superior Mesenteric Artery via the Celiac Artery for Acute Mesenteric Ischemia

Revascularization for acute mesenteric ischemia (AMI) can be achieved through a bypass from the aorta or iliac arteries, embolectomy, open exposure of SMA and retrograde recanalization and stent, or percutaneous antegrade stenting. Flush occlusion of the SMA can make antegrade recanalization very challenging and is usually unsuccessful. We present a novel approach for recanalization of superior mesenteric artery (SMA) via the celiac artery for acute mesenteric ischemia. A 69-year-old lady with previous endarterectomy of SMA and extensive small bowel resection presented with severe abdominal pain, emesis, leukocytosis, and imaging finding of new SMA flush occlusion. She refused to consent for a laparotomy. Percutaneous retrograde transcollateral recanalization of SMA was performed via the celiac artery through the pancreaticoduodenal arcade, and the SMA then stented. This resulted in subsequent resolution of patient's symptoms and discharge. SMA revascularization with retrograde transcollateral wiring technique is an important tool in the armamentarium of the vascular care specialist when antegrade percutaneous approach and open exposure via laparotomy are not an option.

TAP-Stenting Technique for Bifurcation Stenosis of Celiac Artery

We report a clinical course of a patient who developed severe ischemic liver injury and total occlusion of the celiac artery (CA). A 40-year-old man presented with abdominal pain. Computed tomography indicated total occlusion of the CA. Laboratory data demonstrated markedly elevated hepatic enzymes. An exploratory laparotomy was not necessitated due to absence of peritonism. The patient was successfully treated by endovascular recanalization of the CA occlusion via transcatheter balloon angioplasty and TAP-stenting (T-stenting and small protrusion) technique. Endovascular intervention in patients solely with liver failure appears practicable and early treatment is advised.

Endovascular recanalisation of an acute superior mesenteric artery occlusion. A case report and review of the literature

Introduction

Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%.

Presentation of case

A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis.

Discussion

We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI.

Conclusion

Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection.

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Early diagnosis by CT angiography is essential in acute mesenteric ischaemia.

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CT is limited in detecting non-specific secondary signs of bowel ischaemia.

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Endovascular interventions are safe alternatives to surgical revascularisation.

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Laparotomy is often required to determine bowel viability and need for resection.

Retrograde open mesenteric stenting for acute mesenteric ischemia

OBJECTIVE

Acute mesenteric ischemia (AMI) encompasses the sequels of end-stage untreated chronic mesenteric ischemia and acute mesenteric artery thrombosis. Percutaneous mesenteric artery stenting (PMAS) is the preferred treatment of patients with AMI but is not always feasible. Retrograde open mesenteric stenting (ROMS) is a hybrid technique that combines the advantages of open surgical and endovascular approaches. The literature on the results of this new technique is scarce. The aim of this study was to evaluate the results of ROMS in a consecutive series of patients with AMI.

METHODS

All patients with emergent mesenteric revascularization for AMI between January 2007 and September 2011 were entered in our prospective registry. Technical success, mortality, patency, clinical success, and complication rate at 30 days and 6 and 12 months were assessed.

RESULTS

Sixty-eight patients presented with AMI and 54 underwent PMAS, of which four were unsuccessful and followed by ROMS. Eleven patients were directly treated with ROMS, making a total of 15 patients (10 women and five men; median age, 66 years [interquartile range, 54-73 years]). In all patients, only the superior mesenteric artery was revascularized. In nine of the 15 patients, all three mesenteric arteries were severely stenotic or occluded. Technical success was achieved in 14 patients. At ROMS in two patients, the small bowel was severely ischemic. One of these patients needed a partial bowel resection because of irreversible transmural ischemia. At 30 days, the mortality rate was 20% and the primary patency was 92%. Ten patients underwent unplanned relaparotomy, of whom one needed resection of a large part of the small bowel. At 12 months, the mortality rate was still 20%. The primary patency was 83%. Primary assisted patency was 91%, and secondary patency was 100%. Clinical success at 30 days, 6 months, and 12 months, respectively, was 73%, 67%, and 67%.

CONCLUSIONS

AMI is still a devastating event. If PMAS is not feasible, ROMS is a reliable alternative and is associated with a relatively low mortality and morbidity rate.

Intestinal ischemia: current treatment concepts

PURPOSE

Mesenteric ischemia is a condition well-known among physicians treating patients with abdominal symptoms. Even so, mortality rates have not decreased significantly over the last decades. The purpose of this article is to review current treatment concepts of acute and chronic mesenteric ischemia.

RESULTS

Early diagnosis is one of the most important features that determine a patient's prognosis. Conventional angiography and multidetector computed tomography are therefore appropriate to quickly diagnose mesenteric ischemia, the latter being commonly more available. Once a patient presents with signs of peritonitis, instant laparotomy is indicated, and infarcted bowel segments need to be resected, followed by a second-look operation if necessary. If bowel necrosis is clinically not suspected, different approaches should be applied according to source and nature of mesenteric ischemia. Besides established surgical treatment concepts, more and more interventional procedures are developed and evaluated. However, superiority of these new techniques could only be shown for selected patient groups so far. In chronic mesenteric ischemia, interventional approaches seem to be an attractive alternative in patients who are in a condition too bad to undergo surgery. Patients with colonic ischemia are treated best in a conservative manner and by resolving the underlying cause, if identified.

CONCLUSION

Patients with acute mesenteric ischemia are still at highest risk for a fatal course of disease. New diagnostic and therapeutic developments have not been tested in larger studies yet, neither has any of these methods led to an increased survival in studies published so far. Taken together, mesenteric ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons.