C. Chronic mesenteric ischemia
Imaging findings and history are consistent with chronic mesenteric ischemia. Review of her CT scan shows a moderate stenosis of the celiac artery origin (Figure 1A and 1C), and complete occlusion of the origin and proximal aspect of the SMA (Figure 1B and 1D).
She underwent a mesenteric angiogram, which confirmed celiac stenosis and complete occlusion of the SMA, which fills distally through collaterals from the celiac artery (Figure 2A). Given the relatively long, chronic complete total occlusion of the SMA, she underwent stent placement of the celiac artery origin (Figure 2B) to increase her mesenteric arterial perfusion.
After right common femoral access was obtained with a 5 Fr x 10 cm sheath, a 5 French Cobra-2 catheter was advanced over a Glidewire into the abdominal aorta and used to select the celiac trunk. A 0.035-inch stiff Glidewire was then advanced into the common hepatic artery, and the 5 French vascular sheath was exchanged for a 6 French x 45 cm Terumo Destination Sheath, which was advanced into the celiac artery origin. At this point, she was systemically heparinized.
A 0.018-inch V 18 wire was then advanced using a microcatheter into the celiac artery and into the left hepatic artery to stabilize the access. Digital subtraction angiograms were performed in various obliquities via the sheath, and subsequently a 6 mm x 29 mm Cordis Genesis balloon-mounted uncovered stent was delivered and positioned in the celiac trunk, with slight overhang into the aorta. The stent was expanded and post dilated to 7 mm with a balloon. Completion aortograms demonstrated excellent flow through the stent with improved flow in the celiac and SMA distribution.
She was placed on aspirin and plavix after the procedure, stopping the plavix after 6 weeks with lifetime continuation of her aspirin. Her symptoms of post-prandial pain resolved almost immediately. She was able to tolerate a regular diet and began to gain back her lost weight over the next couple weeks.
The majority of cases of chronic mesenteric ischemia are caused by atherosclerotic narrowing of the origins of the celiac or superior mesenteric arteries. Most patients with atherosclerotic mesenteric vascular disease do not exhibit symptoms, because a large collateral network can compensate for reduced flow. At least 2 of the 3 major visceral vessels (celiac, SMA, IMA) must be occluded or narrowed to produce the symptoms of chronic mesenteric ischemia. Factors that predispose to atherosclerosis (smoking, hypertension, diabetes mellitus, hypercholesterolemia) are associated with increased risk for chronic mesenteric ischemia. Any increase in intestinal demand (as in eating) or decrease in intestinal supply (as in hypovolemia) can result in severe abdominal pain and possibly infarction.
Diagnosis can be made by cross-sectional imaging, such as MRA or CTA as in this case, with high-grade mesenteric vascular stenoses identified in at least two major vessels. Duplex ultrasonography of the mesenteric vessels is also a reasonably accurate screening modality for the detection of high-grade celiac and superior mesenteric artery stenosis. However, ultrasound may be limited by technical considerations, including the expertise of the examiner, large body habitus, intraintestinal gas, and prior abdominal surgery. Management options include angioplasty with or without stent placement and surgical revascularization.