Procedure Guide

Mesenteric Stenting

Step-by-step guidance on how to perform Mesenteric Stenting. Review tools, techniques, pearls, and pitfalls on the BackTable Web App.

Pre-Procedure Prep

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 Steps

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

Post-Operative 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

Mesenteric Stenting Demos

TRA For Addressing Mesentric, Celiac & SFA Lesions

Management of celiac, mesenteric and superficial femoral arterial system endovascular lesions using TRA.

Mesenteric Stenting Literature

RadioGraphics (Jul 2002)

Chronic Mesenteric Ischemia Imaging and Percutaneous Treatment

The first part of this article reviews the pathophysiology and diagnosis of CMI. Then, the role of noninvasive imaging is extensively discussed. Finally, the techniques and results of PTA and stent placement are presented, with abundant reference to 16 consecutive cases managed at our institution during the past 10 years.

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TRA For Addressing Mesentric, Celiac & SFA Lesions

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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

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.