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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 37-39

Transbrachial approach for successful recanalization and stenting of celiac artery


Departments of Cardiology, SJIC and R, Bengaluru, Karnataka, India

Date of Submission07-Jan-2020
Date of Decision11-Jan-2020
Date of Acceptance02-Feb-2020
Date of Web Publication20-Apr-2020

Correspondence Address:
Dr. V A Sathwik Raj
Department of Cardiology, SJIC and R, #77, 2nd Cross Road, 6th Main, 3rd Phase JP Nagar, Bengaluru - 560 078, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_1_20

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  Abstract 


Mesenteric ischemia is an infrequent condition that presents either acutely or chronically. Endovascular treatment of mesenteric artery stenosis or short-segment occlusion by balloon dilation or stenting represents a less invasive therapeutic alternative to open surgical intervention, particularly in patients with comorbidities. We describe a case of ostio proximal celiac artery occlusion that was treated using balloon-expandable stent through the left brachial approach.

Keywords: Celiac artery stenting, mesenteric ischemia, percutaneous transluminal coronary angioplasty, intestinal angina


How to cite this article:
Nagesh C M, Sathwik Raj V A, Raghu T R, Manjunath C N. Transbrachial approach for successful recanalization and stenting of celiac artery. J Indian coll cardiol 2020;10:37-9

How to cite this URL:
Nagesh C M, Sathwik Raj V A, Raghu T R, Manjunath C N. Transbrachial approach for successful recanalization and stenting of celiac artery. J Indian coll cardiol [serial online] 2020 [cited 2020 Jun 1];10:37-9. Available from: http://www.joicc.org/text.asp?2020/10/1/37/282971




  Introduction Top


Mesenteric arterial disease is a relatively uncommon but potentially devastating condition that generally presents in patients more than 60 years of age. The superior mesenteric artery is the most common vessel in acute mesenteric ischemia (AMI). AMI is a surgical emergency and manifests as sudden onset of abdominal cramps often associated with bloody diarrhea. Chronic mesenteric ischemia (CMI) is a more insidious syndrome most often present with postprandial abdominal pain (intestinal angina); nausea and vomiting, leading to fear of eating (phagophobia); and pronounced weight loss.


  Case Report Top


A 54-year-old male known hypertensive, ischemic heart disease had undergone percutaneous transluminal coronary angioplasty (PTCA) with stent to left anterior descending and right coronary artery (RCA) in 2012 and PTCA with stent to RCA in 2015 for insegment restenosis. The patient presented with gradual-onset postprandial abdominal pain for 3 months with fear of taking food and resultant weight loss of 10 kg. The patient was only on liquid diet for 3 months. The patient was diagnosed to be having gallstones and had undergone cholecystectomy and appendectomy 2 months back for pain abdomen, despite that not relieved of his symptoms. Extensive gastrointestinal investigations done were normal. With high degree of clinical suspicion, contrast-enhanced computed tomography of the abdomen was done and it showed severe stenosis of ostio proximal celiac artery and inferior mesenteric artery with total occlusion of superior mesenteric artery. Angiography was done through right femoral approach to delineate the mesenteric vasculature, which revealed 95% stenosis of ostio proximal celiac artery [Figure 1]a. Percutaneous transluminal angioplasty (PTA) was attempted to the celiac artery via femoral artery approach but was failed due to relatively unfavorable angulation of the vessel, and hence, the brachial artery approach was used.
Figure 1: Angiogram. (a) Mesenteric angiography showing stenosis of celiac artery (arrow) and inferior mesenteric artery, with superior mesenteric artery occlusion. (b) Cannulation and wiring of celiac artery. (c) Balloon dilatation of celiac artery. (d)Postballoon dilatation angiogram of celiac artery. (e) Stent deployment to celiac artery. (f) Poststent deployment angiogram

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  Methods Top


Brachial arterial access was achieved with 6F shuttle flexor introducer sheath. A 0.014 inch × 300 cm Whisper ES guidewire was used [Figure 1]b. Celiac artery was predilated with 4.0 mm × 12 mm and 5.0 mm × 12 mm compliant balloon at 16 atm for 30 s and a 7.0 mm × 18 mm Herculink Elite stent deployed at 16 atm [Figure 1]c and d]. Thrombolysis in myocardial ischemia 3 flow achieved with successful PTA and stenting to celiac artery with no residual stenosis [Figure 1]e and f]. The patient showed significant improvement in condition with decreased postprandial angina and food fear and increased food intake with substantial weight gain.


  Discussion Top


Three arteries supply the mesenteric viscera: celiac artery, superior mesenteric artery, and inferior mesenteric artery. Mesenteric angina or infarction is very uncommon because of multiple collateral networks in the mesentery.[1] In acute embolic mesenteric ischemia, the emboli typically originate from a cardiac source and frequently occur in patients with atrial fibrillation (AF) or following myocardial infarction (MI). Nonocclusive mesenteric ischemia is characterized by a low flow state in otherwise normal mesenteric arteries and most frequently occurs in critically ill patients on vasopressors.[2]

CMI usually results from long-standing atherosclerotic disease of two or more mesenteric vessels.[3] The disease is usually adjacent and involves advanced atherosclerosis of the aorta and origins of the mesenteric arteries.[1]

The natural progression of atherosclerosis in 50% of CMI patients leads to AMI. Embolism (e.g. cardiac source) is the usual cause of AMI, accounting for up to 30%–50% of cases; de novo thrombosis accounts for 15%–30% of cases. Mortality rates after AMI are high, with rates of 90% for embolic etiology and 70% for thrombotic event.[4] Endovascular treatment has been used in AMI only in the absence of peritoneal signs and when intestinal viability can be assessed by clinical means of diagnostic imaging.[5]

Diagnosis of CMI is more challenging and requires high index of suspicion. Failure to diagnose and institute treatment can result in high morbidity and mortality.

Surgical revascularization with reimplantation of the arteries has high mortality and morbidity (10%–15%) because of the advanced age and other comorbidities. Percutaneous angioplasty with stenting has lower mortality (>5%) and morbidity and achieves good resolution of symptoms in 70%–80% of patients over several years.[6] An endovascular approach for CMI has produced variable results, depending upon the technique used. The success is highest using a primary stenting approach followed by selective stenting, and finally PTA alone.[5] Open surgical repair and endovascular procedures for CMI demonstrated equivalent survival at 3-year follow-up (62% ± 9% open vs. 63% ± 14% endovascular), with a significantly lower morbidity rate and shorter hospital stay in the endovascular group (open vs. endovascular; morbidity: 46% vs. 19%; hospital stay: 23 days vs. 1 day).[7]


  Conclusion Top


Mesenteric arterial disease is a potentially devastating condition if unrecognized. High degree of clinical suspicion is of paramount importance. Endovascular treatment is less invasive and has excellent success rate with shorter hospital stay and early recovery.

Declaration of patient consent

The authors certify that they have obtained patient consent forms. In the form, the patient has given his consent for his images and other information to be published in the journal. The patients understand that his names and initials will not be disclosed and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kinlay S, Bhatt LD. Treatment of noncoronary obstructive vascular disease. In: Mann LD, Zipes PD, editors. Braunwald's Heart Disease. 10th ed. Philadelphia: Elsevier; 2015. p. 1360.  Back to cited text no. 1
    
2.
Lin PH, Kougias P, Bechara C, Cagiannos C, Huynh TT, Chen CJ, et al. Arterial disease. In: Brunicardi CF, Anderson KD, editors. Schwartz's Principles of Surgery. 9th ed. McGraw-Hill; 2010. p. 730-6.  Back to cited text no. 2
    
3.
Moawad J, Gewertz BL. Chronic mesenteric ischemia. Clinical presentation and diagnosis. Surg Clin North Am 1997;77:357-69.  Back to cited text no. 3
    
4.
Herbert GS, Steele SR. Acute and chronic mesenteric ischemia. Surg Clin North Am 2007;87:1115-34, ix.  Back to cited text no. 4
    
5.
Kougias P, El Sayed HF, Zhou W, Lin PH. Management of chronic mesenteric ischemia. The role of endovascular therapy. J Endovasc Ther 2007;14:395-405.  Back to cited text no. 5
    
6.
Zeller T, Rastan A, Sixt S. Chronic atherosclerotic mesenteric ischemia (CMI). Vasc Med 2010;15:333-8.  Back to cited text no. 6
    
7.
Sivamurthy N, Rhodes JM, Lee D, Waldman DL, Green RM, Davies MG. Endovascular versus open mesenteric revascularization: Immediate benefits do not equate with short-term functional outcomes. J Am Coll Surg 2006;202:859-67.  Back to cited text no. 7
    


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