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Radiology
Inferior mesenteric artery stenting in a
case of chronic mesenteric ischemia
A 65-year- lady, non diabetic , non hypertensive presented with post prandial pain - typically 20 min after having food and dramatic loss of weight , (approximately 25 kgs) over four months' duration. There was no history of associated anorexia. Considering the profound and rapid weight loss, an underlying malignancy was suspected; however, the diagnostic work up for this was negative.
Abdominal visceral arterial color Doppler study a revealed complete occlusion of the celiac trunk and the superior mesenteric artery with near total occlusion of the inferior mesenteric artery.
Contrast material enhanced CT confirmed the findings.
Digital subtraction angiogram revealed occlusion of the celiac and the superior mesenteric arteries with a high-grade stenosis at the origin of the inferior mesenteric artery
This critically narrowed IMA was filling the SMA retrogradely through mesenteric-mesenteric collaterals
The stenting of the IMA was performed through the right femoral route using a renal guiding catheter (7F). The stenotic lesion was negotiated using a stabilizer micro - wire (0.014x 260 cms) (Cordis, Johnson and Johnson). The stenting was done using a balloon mounted (6mmx18mm.) Palmaz Genesis Stent. Post stenting angiogram revealed a widely patent stented segment, with good improvement in the mesentrico-mesentric collateral network
The patient had immediate relief of postprandial angina. She did well on follow up, and at three months' follow up, had gained 7 kgs, with no further episodes of post prandial angina.
DISCUSSION:
Chronic visceral ischemia is an uncommon condition caused due to stenosis or occlusion of one or more mesenteric arteries. More often than not, it is caused by atherosclerotic narrowing of at least two of the three visceral arteries. Other rare causes include Takayasu's arteritis, Fibromuscular dysplasias or an encasing neoplasm at the origin of one of the major vessels
Clinically, it presents with rapid loss of weight, post prandial pain, usually 20 min -2 hrs after having food, with or without other associated symptoms such as nausea or dull abdominal pain. Pain is usually minimal at the onset but over weeks or months it can progress to an incapacitating condition. Sitophobia, the fear of eating, is often present due to the patient's apprehension to eat. However, appetite is unaffected. Often, symptoms may be non specific such as dull abdominal pain, dyspepsia, constipation or flatulence
The diagnosis of intestinal ischemia is often missed due to inability of the clinician to suspect and recognize it. Color Doppler examination is a non-invasive and effective tool for the diagnosis. However, the study may be limited due to the presence of bowel gas and respiratory movements. In addition, this study provides information only about the proximal segments of the vessel. CT angiography is the preferred modality for the diagnosis and follow up of chronic mesenteric ischemia as it is non-invasive, easily reproducible and provides objective data for pre and post -operative comparison and to evaluate the exact extent of the disease. CT angiography with a single breath hold technique reduces motion artifacts. Multiplanar reconstructions can be obtained in any desired plane, thus enabling exact localization of the atherosclerotic plaque. It also estimates the size of the plaque and its three dimensional configuration .Magnetic resonance imaging with angiography is an upcoming non-invasive modality. Magnetic resonance imaging with angiography has high sensitivity and specificity similar to those of CTangiography, with the advantage of safer gadolinium agents and lack of ionizing radiation. Although magnetic resonance imaging with angiography is an excellent tool for the evaluation of chronic mesenteric ischemia, it should not be the first technique used in the diagnosis of acute mesenteric ischemia, because of its potentially insufficient resolution to adequately identify non-occlusive low flow states or distal emboli.
Operative revascularization of both major visceral arteries, the celiac artery and the superior mesenteric artery (SMA), is an effective and durable treatment .However, diffuse atherosclerotic disease or abnormal arterial anatomy or a well-developed intact IMA collateral circulation is present also may render the celiac or SMA unacceptable for either bypass grafting or endarterectomy, revascularization of both the celiac and SMA may not be feasible. Extensive scar tissue or adhesions in patients with a history of recent abdominal surgery or visceral revascularization may preclude safe exposure of these arteries.
Revascularization techniques included bypass grafting, transaortic thromboendarterectomy, reimplantation into the aorta or the left common iliac artery, and patch angioplasty. AS patients with chronic mesenteric ischemia are often elderly with significant cardiovascular morbidity, angioplasty followed by mesenteric stenting offers a minimally invasive alternative to surgery especially in high risk patients.
Case
21: Contributed by Dr Suvarna Barhate
Other Cases
A 65-year- lady, non diabetic , non hypertensive presented with post prandial pain - typically 20 min after having food and dramatic loss of weight , (approximately 25 kgs) over four months' duration. There was no history of associated anorexia. Considering the profound and rapid weight loss, an underlying malignancy was suspected; however, the diagnostic work up for this was negative.
Abdominal visceral arterial color Doppler study a revealed complete occlusion of the celiac trunk and the superior mesenteric artery with near total occlusion of the inferior mesenteric artery.
Contrast material enhanced CT confirmed the findings.
Digital subtraction angiogram revealed occlusion of the celiac and the superior mesenteric arteries with a high-grade stenosis at the origin of the inferior mesenteric artery
 |
| Fig
1 |
This critically narrowed IMA was filling the SMA retrogradely through mesenteric-mesenteric collaterals
 |
| Fig
2 |
The stenting of the IMA was performed through the right femoral route using a renal guiding catheter (7F). The stenotic lesion was negotiated using a stabilizer micro - wire (0.014x 260 cms) (Cordis, Johnson and Johnson). The stenting was done using a balloon mounted (6mmx18mm.) Palmaz Genesis Stent. Post stenting angiogram revealed a widely patent stented segment, with good improvement in the mesentrico-mesentric collateral network
 |
| Fig
3 |
The patient had immediate relief of postprandial angina. She did well on follow up, and at three months' follow up, had gained 7 kgs, with no further episodes of post prandial angina.
DISCUSSION:
Chronic visceral ischemia is an uncommon condition caused due to stenosis or occlusion of one or more mesenteric arteries. More often than not, it is caused by atherosclerotic narrowing of at least two of the three visceral arteries. Other rare causes include Takayasu's arteritis, Fibromuscular dysplasias or an encasing neoplasm at the origin of one of the major vessels
Clinically, it presents with rapid loss of weight, post prandial pain, usually 20 min -2 hrs after having food, with or without other associated symptoms such as nausea or dull abdominal pain. Pain is usually minimal at the onset but over weeks or months it can progress to an incapacitating condition. Sitophobia, the fear of eating, is often present due to the patient's apprehension to eat. However, appetite is unaffected. Often, symptoms may be non specific such as dull abdominal pain, dyspepsia, constipation or flatulence
The diagnosis of intestinal ischemia is often missed due to inability of the clinician to suspect and recognize it. Color Doppler examination is a non-invasive and effective tool for the diagnosis. However, the study may be limited due to the presence of bowel gas and respiratory movements. In addition, this study provides information only about the proximal segments of the vessel. CT angiography is the preferred modality for the diagnosis and follow up of chronic mesenteric ischemia as it is non-invasive, easily reproducible and provides objective data for pre and post -operative comparison and to evaluate the exact extent of the disease. CT angiography with a single breath hold technique reduces motion artifacts. Multiplanar reconstructions can be obtained in any desired plane, thus enabling exact localization of the atherosclerotic plaque. It also estimates the size of the plaque and its three dimensional configuration .Magnetic resonance imaging with angiography is an upcoming non-invasive modality. Magnetic resonance imaging with angiography has high sensitivity and specificity similar to those of CTangiography, with the advantage of safer gadolinium agents and lack of ionizing radiation. Although magnetic resonance imaging with angiography is an excellent tool for the evaluation of chronic mesenteric ischemia, it should not be the first technique used in the diagnosis of acute mesenteric ischemia, because of its potentially insufficient resolution to adequately identify non-occlusive low flow states or distal emboli.
Operative revascularization of both major visceral arteries, the celiac artery and the superior mesenteric artery (SMA), is an effective and durable treatment .However, diffuse atherosclerotic disease or abnormal arterial anatomy or a well-developed intact IMA collateral circulation is present also may render the celiac or SMA unacceptable for either bypass grafting or endarterectomy, revascularization of both the celiac and SMA may not be feasible. Extensive scar tissue or adhesions in patients with a history of recent abdominal surgery or visceral revascularization may preclude safe exposure of these arteries.
Revascularization techniques included bypass grafting, transaortic thromboendarterectomy, reimplantation into the aorta or the left common iliac artery, and patch angioplasty. AS patients with chronic mesenteric ischemia are often elderly with significant cardiovascular morbidity, angioplasty followed by mesenteric stenting offers a minimally invasive alternative to surgery especially in high risk patients.