Teaching Case

Seventy-two-year-old female patient presented with complaints of severe abdominal pain following her meals.
The patient reported a history of similar complaints in the past for which she was intervened in an outside centre. She was being treated for chronic hypertension. Her recent blood parameters were within normal limits.

A CT abdominal angiography was performed at an outside centre which showed a blocked coeliac artery stent along with an occluded superior mesenteric artery (SMA). The outside images were reviewed after acquiring detailed history and assessment of the patient. The patient was planned for an endovascular rescue procedure by the intervention radiology team.
On conventional angiography, previously placed coeliac artery stent was noted with no flow across. SMA showed occlusion from the origin. Balloon angioplasty was performed, following which a ballon expandable stent was lodged. Check angiogram showed good flow across the SMA. Patient was continued on anti-platelet treatment.

Chronic mesenteric ischaemia (CMI) is a rare condition which often goes mis-diagnosed. The condition, when missed, is associated with severe complication and is hence a diagnosis of exclusion. The patient comes with complaints of pain in the abdomen and weight loss, which are often non-specific, however, a diagnosis of CMI can be made based completely on non-invasive imaging techniques to look at the involved visceral arteries.
The most common cause of occlusion leading to CMI is atheroma, other causes include vasculitis (mainly Takayasu arteritis), thromboangiitis obliterans, dysplastic causes, and radiation-induced lesions. The criteria to diagnose CMI require at least two vessels to be involved prior to which the natural collateral mechanism in the body prevents from symptom development. The collateral systems include 1) between the coeliac artery and the superior mesentric artery via the pancreaticoduodenal artery and 2) between the superior mesentric artery and inferior mesentric artery via the arch of Riolan and marginal artery of Drummond. Patients with CMI mainly present with abdominal angina which constitutes acute onset of pain in the abdomen in post prandial state associated with weight loss and anorexia, sometimes also associated with vomiting and bowel habit changes.
Imaging plays an important role in the diagnosis of this vascular condition. Duplex ultrasound is a very good screening tool for detection of proximal artery stenosis/occlusion. Peak systolic volume of SMA more than 275 cm/sec [1] or End diastolic volume >45 cm/sec [2]. CT and MR angiography provides insight to both the visceral artery abnormality and the bowel wall vascularity.
Management: Percutaneous treatment option for re-vascularisation is generally performed on one obstructed vessel, most commonly the SMA. Coeliac artery is reserved in case of failure of SMA. Usually single vessel treatment suffices for the patient symptoms, however, two vessel treatments have shown reduction in rate of recurrence [3]. SMA occlusions are better treated with angioplasty over fibrinolysis, especially in chronic cases, as the occlusions are usually small due to the collateral circulation maintained by the coeliac and inferior mesenteric artery. Primary stenting is an effective technique in the treatment of CMI [4]. Abu Rahma et al. noted a 35% restenosis rate [5]. Matsumoto et al. found that up to 18% of patient underwent repeat procedure for restenosis [6].