An uncommon procedure: inferior mesenteric artery stenting for chronic mesenteric ischaemia

Clinical History

66-year-old female patient admitted at the emergency department with history of abdominal pain (10 days) and weight loss. At physical examination abdomen appeared sore and mobile (Blumberg +/-), with torpid peristalsis. An US investigation did not demonstrate any pathological findings. Therefore a CT scan was performed.

Imaging Findings

CT angiography showed an occlusion at the origin of the coeliac trunk (CTr) and superior mesenteric artery (SMA), a focal stenosis (>50%) at the origin of the inferior mesenteric artery (IMA) and a hypertrophy of Riolano’s arch with rehabitation of SMA and CTr, confirming the diagnosis of "abdominal claudication" (Fig. 1).
An endovascular attempt of recanalisation was performed using a left brachial approach. Preliminary angiography confirmed stenosis of IMA and hypertrophy of the ascending branch of the left colic artery and ascending branch of the middle colic artery (which join, forming “Riolano’s Arch”) (Fig. 2).
The stenosis was crossed with angiographic microguidewire (Thruway-Boston) and the lesion pre-dilatated with low-prophile 3mm balloon catheter (Sterling-Boston) (Fig. 3). After that a balloon-expandable stent (Dynamic Renal-Biotronik 4, 5X15mm) was deployed at the ostium of IMA (Fig. 4).
Final angiography showed restoration of appropriate vessel calibre (Fig. 5). The patient was set on double antiplatelet therapy as by protocol. At 3 months follow-up the patient reported significant improvement of symptoms and regained weight.

Discussion

Chronic mesenteric ischaemia is an unusual, but important cause of abdominal pain. Although this condition accounts for only 5% of all intestinal ischaemic events, it can have significant clinical consequences. Among its many causes, atherosclerotic occlusion or severe stenosis are the most common.
This disorder has an indolent course that results in extensive collateral vascular formation. Thus, symptoms occur when at least two of the three main splanchnic vessels are affected. Intestinal angina, weight loss, and sitophobia are common clinical features. Diagnosis can often be made by noninvasive methods such as CT angiography, MR angiography and duplex ultrasonography, as well as by invasive catheter angiography [1].
Mesenteric vascular insufficiency may lead to bowel infarction, morbidity and mortality that may approach 50%.
Recommended therapy for acute mesenteric ischaemia includes aspiration embolectomy, transcatheter thrombolysis and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischaemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1.
Recommended therapy for chronic mesenteric ischaemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy [2].
Studies show excellent long-term secondary patencies after percutaneous mesenteric artery stenting (PMAS), comparable with published data on long-term patencies after open surgical revascularisation [3].
PTA procedures can have numerous complications, which include plaque embolisation, thrombosis, perforation or dissection of mesenteric arteries [4].
Angioplasty and stenting of coeliac and/or mesenteric arteries provide symptomatic relief in a considerable percentage of patients with chronic mesenteric ischaemia. If symptoms fail to improve, an open surgical revascularisation procedure should be considered [5].
Our case is original because the endovascular treatment was done on the IMA and not on the SMA or the coeliak trunk. In literature, endovascular treatment of stenosis or occlusion of the SMA is reported [5, 6] but stenting of ostial lesion of IMA is only anecdotally described [6, 7]. IMA endovascular treatment is more complex than other visceral arteries due to its small size, however, with the use of tailored materials (low profile balloons and stents) it can be performed with low risks and satisfactory results.

Differential Diagnosis List

Final Diagnosis

Primary stenting of inferior mesenteric artery in chronic mesenteric ischaemia

URL:	https://www.eurorad.org/case/14783
DOI:	10.1594/EURORAD/CASE.14783
ISSN:	1563-4086