Chronic Mesenteric Ischemia from Extrinsic Compression

Background

This is a 67-year-old female with a large retroperitoneal carcinoid tumor who began experiencing postprandial pain and weight loss approximately eight months prior. At that time she underwent angiography which revealed extrinsic compression of both the celiac artery and super mesenteric artery. These were stented which resulted in alleviation of her symptoms. Unfortunately, her symptoms recurred approximately six months later. Repeat imaging revealed progressive stenosis at the distal margin of both stents. Angiography and stent placement was once again performed resulting in rapid revascularization and amelioration of her symptoms.

Image 1.

PET/CT of Carcinoid Tumor

PET/CT at the level of the SMA showing dense circumferential soft tissue mass encasing the artery.


Image 2.

Sagittarius CTA
Sagittal CTA image demonstrating patency of the celiac and super mesenteric artery stents, with significant stenosis involving the native vessels just distal to each stent.


Images 3 and 4.

Angiography of the celiac artery.

AP and lateral angiographic views of the celiac artery demonstrating severe native artery stenosis distal to the existing patent stent.


Images 5 and 6.

Angiography of the SMA.

AP and lateral views of the SMA demonstrating patency of the existing stent, with moderate narrowing of the native vessel distally.


Images 7 and 8.

Drug coated balloon angioplasty of the SMA

4.0mm drug coated balloon angioplasty of the SMA failed to improve the stenosis sufficiently


Images 9 and 10.

Stent placement within the SMAStenting of the SMA.

5 mm balloon expandable bare metal stent was deployed across the stenosis, and nested within the existing stent. This resulted in excellent angiographic flow.


Images 11 and 12.

Primary stenting of the celiac artery

A 5 mm balloon expandable bare metal stent was deployed across the celiac artery stenosis, and nested within the existing stent. This resulted in restoration of excellent flow.


Discussion

This procedure was performed from a left radial artery approach, after an initial attempt via the right common femoral artery was unsuccessful. Difficulties included the steep angularity of both vessels, coupled with the presence of unforgiving stents. From a left radial approach however, the angles were ideal, and access was readily facilitated. Also of interest is the fact that this patient’s pancreaticoduodenal arcade was chronically occluded by tumor compression, thereby isolating her celiac and superior mesenteric artery circulations. This is important because frequently revascularization of the SMA in isolation is sufficient to resolve chronic mesenteric ischemia.

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