Mesenteric Stenting

Mesenteric Stenting

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Pre-Procedure

Indications:
• Chronic mesenteric ischemia
• Intestinal blood flow cannot support functional demands
• Rule of thumb: 2 vessels narrowed or occluded to cause symptoms

Contraindications:
• Uncorrectable coagulopathy
• Long segment occlusion
• Diffuse small branch stenoses
• Mesenteric artery <4mm

Preoperative evaluation:
Symptoms can be vague:
• Weight loss
• Postprandial pain - midline, epigastric or periumbilical
• Cibophobia - eating phobia
• Evaluate other history of vascular disease: cardiac, PVD, CVA
Exam:
• Signs of malnutrition
• Abdominal pain without rebound/guarding
• Abdominal bruit
Risk factors:
• Hypertension
• Diabetes
• Smoking
• Hyperlipidemia
Available imaging CTA/MRA
Clinical history and blood pressure meds
Coagulation labs
Consider checking for plavix non-responders prior to procedure

Procedure

Access:
• Femoral most common
• Radial or brachial
• Administer heparin: loading dose followed by either continuous infusion or periodic dosing

Aortogram with pigtail or Omni flush catheter in AP and lateral projection
Engage mesenteric vessel, commonly SMA
• Angle of SMA drives sheath/catheter choice
• Ansel 2 (Cook) can be helpful
• Start with C2 catheter or Sos
• Estimate size of mesenteric artery, length of stenosis, location of adjacent branch vessels
and for presence of ostial plaque extension into aorta

Cross stenosis or occlusion
• Start with angled Glidewire (Terumo)
• Can escalate to Stiff Glidewire (Terumo)
• Keep guidewire fixed in position to avoid vasospasm

Predilate with 4 or 5 x 40 mm balloon
As balloon is deflated, advance sheath across stenosis
• May need stiff wire for support
Deploy balloon expandable stent
• Some use bare metal stent particularly if concerned about covering side branches
• Studies have shown superiority of covered stents over bare metal stents
• Land stent with proximal end within aorta. Try to avoid placing proximal end of stent >1-2 mm into aorta.
Redilate if necessary
Nitroglycerin through sheath or catheter

Post-Procedure

Postoperative care:
• Bed rest for 2-6 hours following procedure.
• Continue IV fluids
• Loading dose of Plavix 300 mg day of stenting
• Continue 75 mg Plavix and 325 mg Aspirin for 3-6 months

Potential complications:
• Mesenteric artery embolization with bowel infarction
• Guidewire perforation of artery with mesenteric hematoma
• Rupture of mesenteric artery by balloon or stent
• Misplacement of stent and dislodgement of stent
• Stent restenosis, thrombosis and infection
• Mesenteric artery pseudoaneurysm
• Acute bowel ischemia

Follow-up
• Depending on renal function, repeat CTA
• Can also follow with serial vascular US. See patient within 2 weeks to establish new baseline
• Follow patient in clinic at 3,6 and 12 months; then yearly
• Maximize medical therapy
• Re-emphasize lifestyle modifications such as smoking cessation

Related Procedures

No related procedures.

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References

[1] Pillai AK, Kalva SP, Hsu SL, et al. Quality Improvement Guidelines for Mesenteric Angioplasty and Stent Placement for the Treatment of Chronic Mesenteric Ischemia. J Vasc Interv Radiol. 2018;29(5):642‐647. doi:10.1016/j.jvir.2017.11.024
[2] Wilkins LR, Stone JR. Chronic mesenteric ischemia. Tech Vasc Interv Radiol. 2015;18(1):31‐37. doi:10.1053/j.tvir.2014.12.005
[3] Hagspiel KD, Flors L, Hanley M, Norton PT. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol. 2015;18(1):2‐13. doi:10.1053/j.tvir.2014.12.002
[4] Verma H, Oderich GS, Tripathi RK. Surgical and endovascular interventions for chronic mesenteric ischemia. J Cardiovasc Surg (Torino). 2015;56(2):299‐307.
[5] Oderich GS, Erdoes LS, Lesar C, et al. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg. 2013;58(5):1316‐1323. doi:10.1016/j.jvs.2013.05.013
[6] Cognet F, Ben Salem D, Dranssart M, et al. Chronic mesenteric ischemia: imaging and percutaneous treatment. Radiographics. 2002;22(4):863‐880. doi:10.1148/radiographics.22.4.g02jl07863

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RadioGraphics (Jul 2002)

Chronic Mesenteric Ischemia Imaging and Percutaneous Treatment

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