Percutaneous Revascularization for Chronic Mesenteric Ischemia

Introduction

The mesenteric arteries supply blood flow to both the large and small intestines. Diseases that involve this circulation bed usually result in significant complications and even death. Ischemia occurs when there is an impediment to blood flow through these arteries, and the intestines do not receive the necessary oxygen and nutrients to function normally. Chronic mesenteric ischemia (CMI) is the result of either episodic or constant lack of flow to the intestines, which usually is seen in patients with blockages in arteries involving many other vascular territories. Mesenteric ischemia usually occurs in people older than age 60. It is more commonly recognized in individuals who smoke, have elevated cholesterol or diabetes. We present a case of a male with abdominal pain, presumed to be "intestinal angina", suggestive of mesenteric ischemia who ultimately had the diagnosis confirmed by radiological imaging. Subsequent to making the diagnosis, we illustrate the treatment strategy employed, which involved balloon angioplasty and stenting of the diseased arteries with an excellent clinical result achieved.

Case Report

A 78-year-old male was referred for further evaluation and management of abdominal pain and bloating that consistently occurred within 1 hour of eating and lasted for 1–2 hours. He experienced a dramatic weight loss of 35 pounds over a 6-month period and developed a fear of food, wishing to eat frequent small meals to avoid worsening of pain. He had a history of hypertension and diabetes mellitus, was an active smoker with previous coronary artery stenting at time of a heart attack, and had known circulation abnormalities in his leg arteries (peripheral artery disease). He was receiving medication for hypertension and elevated cholesterol. Prior upper and lower gastrointestinal endoscopic procedures had been unremarkable. His primary care physician referred him to a vascular medicine specialist for treatment after ordering a computed tomographic (CT) scan of his abdomen with contrast dye, which revealed severe narrowings in 2 out of 3 arteries that serve to supply blood to his intestine. The specialist thought the CT scan findings were the explanation for the patient’s abdominal pain and weight loss, so-called “abdominal angina,” due to a lack of blood serving the intestinal tract. Following detailed discussion by the vascular physician with the patient and his wife, it was decided to proceed with angiography (dye test with catheter) of the patient’s mesenteric (intestinal) arteries. Angiography of the aorta and its branches (mesenteric arteries) of the abdomen showed 2 vessels — celiac and superior mesenteric arteries (SMA) — to be severely narrowed at their origins by atherosclerotic plaque. It was decided to intervene on the SMA disease first, given the severity of the lesion and large territory of intestine it served. After commencing blood-thinning medication with heparin, a curved catheter was used to enter the SMA and perform further angiography. This confirmed the tight stenosis, which was balloon-dilated with an angioplasty catheter. Following this, a balloon-expandable stent (slotted-tube) was deployed across the stenosis and subsequently dilated with a larger balloon catheter to ensure complete stent expansion. A similar technique was employed in the assessment, and percutaneous angioplasty and stenting of the celiac artery lesion was successfully performed. The procedure was well tolerated by the patient, who was discharged the next day on 2 blood-thinning medications to keep the stents patent.

Brief Overview of Chronic Mesenteric Ischemia

Autopsy data have shown a very high prevalence of mesenteric artery stenosis affecting 35–70% of the population.¹ Similarly, over 17% of unselected patients over the age of 65 years have been found to have one or more mesenteric arteries with >70% stenosis.² However, the vast majority of these stenoses remain clinically silent, as evidenced by the reported incidence of clinically apparent CMI of only 1 in 100,000 admissions to the hospital.³ Classically, the patient with CMI is a frail, malnourished female with multiple cardiovascular risk factors, aged 50–60 years, with a history of post-prandial pain which occurs 20–30 minutes after eating, leading to substantial weight loss due to a fear of food. Physical examination may reveal an abdominal bruit (murmur) in half of the cases. The vast majority of CMI cases are due to progressive atherosclerosis, but rarer causes include dynamic compression of the celiac artery from the diaphragm, and fibromuscular dysplasia. A high index of suspicion is required and diagnosis may be confirmed non-invasively with ultrasonography, magnetic resonance angiography, or CT angiography, as was employed in our case. Since 2002, endovascular therapies (balloon angioplasty and stenting) have overtaken open surgery as the treatment of choice for this condition. Endovascular therapy has been associated with shorter hospital admission and lower peri-procedural complications and deaths in a review of multiple series.⁴

References

1. Zelenock GB, Graham LM, Whitehouse WM Jr, et al. Splanchnic arteriosclerotic disease and intestinal angina. Arch Surg 1980;115:497–501.

2. Kaleya RN, Boley SJ. Acute mesenteric ischemia: An aggressive diagnostic and therapeutic approach: 1991 Roussel Lecture. Can J Surg 1992;35:613–623.

3. Taylor LM, Jr, Moneta GL. Intestinal ischemia. Ann Vasc Surg 1991;5:403–406.

4. Schermerhorn ML, Giles KA, Hamdan AD, et al. Mesenteric revascularization: Management and outcomes in the United States, 1988-2006. J Vasc Surg 2009;50:341–348.

From Massachusetts General Hospital, Boston, Massachusetts.

Address for correspondence: Robert Schainfeld, DO, FSVM, FSCAI, Massachusetts General Hospital, Division of Vascular Medicine, Boston, MA 02135. E-mail: rschainfeld@partners.org.

Disclosure: The authors report no conflicts of interest regarding the content herein.