1. VISCERAL ARTERY STENTING in CHRONIC MESENTERIC ISCHEMIA (CMI)
SOFIA - BEC 2012
VISCERAL ARTERY STENTING
in CHRONIC MESENTERIC ISCHEMIA (CMI)
K. Mathias
Department of Radiology
Klinikum Dortmund / Germany

2. Natural History of Visceral Stenosis
Majority of stenoses are asymptomatic
Prevalence of mesenteric arterial stenoses 6%–10% in unselected autopsy series
Significant stenoses present in 14%–24% of pts undergoing abdominal angiography
Progression to symptomatic intestinal ischemia is unusual!
Taylor LM. Vasc Surg. Rutherford (Ed) 1995

3. Natural History of Symptomatic CMI
Needs at least 2 of 3 vessels involved
Isolated SMA stenosis can produce symptoms

4. Chronic Mesenteric Ischemia (CMI)
Female : Male 3:1
Smoking 75%
Symptoms (sensitive, not specific)
Postprandial pain
Weight loss
Bloating
Diarrhoe
Gastroparesis
Typically ≥2 stenotic vessels >70%

5. Chronic Mesenteric Ischemia (CMI)
Atherosclerosis
Ostial lesions
High correlation to symptoms in
other vascular territories
Vasculitides
Aorta or mesenteric branches
FMD
Aortic dissection

6. Median Arcuate Ligament Syndrome
Compression of the celiac origin by median
arcuate ligament
Fibers connecting the crura of diaphragm
Worse during expiration
Symptoms may be related to disturbance of
the gastric electrical rhythm and not
vascular insufficiency

7. Diagnostics of CMI coloured duplex ultrasound CTA MRA
selective angiography

8. Doppler of Celiac Artery

9. Doppler of Celiac Artery

10. Doppler of Celiac Artery
Normal
PSV cm/s
EDV > 0 cm/s
Diagnostic criteria for stenosis
PSV > 200 cm/s → >70%
EDV > 0 cm/s → >50%
No flow

11. Doppler of Celiac Artery

12. Doppler of Mesenteric Artery

13. Doppler of Mesenteric Artery

14. Doppler of Mesenteric Artery
Normal (fasting)
PSV 125 cm/s
EDV may be reversed
Diagnostic criteria for stenosis
PSV > 275 cm/s → >70%
EDV > 45 cm/s → >50%
No flow
Blunted response to food → <15% PSV

15. Doppler of Mesenteric Artery

16. CTA of Visceral Arteries

17. Principle of Treatment of CMI
Atherosclerotic lesions of mesenteric arteries
are common
Symptomatic mesenteric arterial lesions are rare
Natural history of asymptomatic SMA stenosis
is not well documented
At present therapy is only indicated in
symptomatic patients

18. Indications for Treatment of CMI
Arterial stenosis causing symptomatic
intestinal ischemia
Prophylactic revascularization in patients
with mesenteric stenosis and planned
abd surgery

19. Treatment Options of CMI
Administration of parenteral
nutrition
Impractical
Preparative before surgery
Open surgery
Endovascular tx

20. Mesenteric Angioplasty & Stenting
Best candidates
“Typical symptoms”
Involvement of multiple visceral arteries
Suitable access and angiographic approach

21. Mesenteric Angioplasty & Stenting
Poor candidates
Underlying malignancy
Median arcuate ligament
syndrome (40% recurrence)
Only IMA involved

22. Technique of Mesenteric Angioplasty & Stenting
femoral, brachial, radial access
sheath 6-F / guiding catheter
guidewires 0.035” and 0.014”
balloon expandable stent (DES)

23. Celiac Angioplasty & Stenting
K.H.F. m-74y SMA Occlusion, Celiac Stenosis; often severe calcifications

24. Celiac Angioplasty & Stenting
K.H.F. m-74y SMA Occlusion, Celiac Stenosis

25. Celiac Angioplasty & Stenting
K.H.F. m-74y SMA Occlusion, Celiac Stenosis; patent IMA; celiac artery pseudo-occlusion

26. Celiac Angioplasty & Stenting
K.H.F. m-74y SMA Occlusion, Celiac Stenosis; retrograde opacification of SMA

27. Mesenteric Angioplasty & Stenting
F.B. m-65y CMI - Pre-dialation, Stenting Herculink Elite 7x18mm

28. Mesenteric Angioplasty & Stenting
R.E. m-76y CMI - aortic atherosclerosis, SMA stenosis 80%, Stenting with Herculink Elite

29. Mesenteric Angioplasty & Stenting
H.P. m-80y SMA Stenosis, Celiac Occlusion

30. Mesenteric Angioplasty & Stenting
H.P. m-80y SMA Stenosis, Celiac Occlusion, Stenting 6x18 mm

31. Mesenteric Angioplasty & Stenting
P.Sch. f-43y Severe SMA Stenosis, Stenting 6x18 mm

32. Mesenteric Angioplasty & Stenting
R.M. f-71y Moderate Celiac Stenosis, Severe SMA Stenosis, Stenting 6.4x18 mm

33. Mesenteric Angioplasty & Stenting
bloated abdomen
B.P. f-51y Severe Celiac Stenosis, SMA Occlusion, Transbrachial stenting 6x18 mm

34. Mesenteric Angioplasty & Stenting
B.P. f-51y Severe Celiac Stenosis, SMA Occlusion, Transbrachial stenting 6x18 mm

35. Stenting in Chronic Mesenteric Ischemia
15 patients with 23 stenoses and 11 occlusion
One vessel (n=12) and two vessels (n=3) treated
Technical success
100%
Clinical success
87%
30-days mortality
13%
Restenosis rate
20%
1-yr primary patency
81%
Complication rate
0.06%
Stenting has a potential role in CMI with low incidence of complications and high technical and clinical success rates.
Aksu C, et al. Acta Radiol 2009;50: 610-6

36. Endoluminal Tx of Visceral Arteries
87 mesenteric vessels (57 SMA, 23 celiac, 7 IMA) were treated in 65 patients
Completely occluded vessels in 18 patients
1-year F/U
Results
95% CI
Primary patency
65%
50-80%
Primary assisted patency
97%
92-100%
Secondary patency
99%
96-100%
Survival
89%
80-98%
Sarac TP, et al. J Vasc Surg 2008;47:485-91

37. Surgery for CMI Not fit for surgery ~25% Efficacy Immediate 82%–100%
Long-term (5-yr sx free surv.) 70%–88%
Primary assisted patency ~79%
Mortality 0–17%
Morbidity 15%–45%

38. Surgery vs. Endovascular Therapy for CMI
PTA/stent
No. patients 41 19
F/U (months) 18 9
Lost to f/u 14 7
1 patency (3 m)
83%
80%
Sx relief (1 yr)
68%
27%
Major morbidity
46%
19%
Mortality (30 d)
15%
21%
Sivamurthy et al. JACS 2006

39. Surgical Revascularization vs. Endoluminal Therapy for CMI
PTA/Stent
(n=31)
Surgery
(n=49)
P-value
In-hospital mortality
3.2%
2.0%
0.74
Days of hospitalization
5.6
16.7
0.001
1-yr primary patency
58%
90%
1-yr primary assisted
patency
65%
96%
<0.001
Symptomatic recurrence
23%
22%
0.98
Re-intervention
16%
0.49
2-yr survival
88%
74%
0.28
Atkins MD, et al. J Vasc Surg 2007;45:

40. Endovascular tx vs. open surgery ...
... team approach!

42. Mesenteric Artery Stenting vs. Surgery in CMI
PTA and/or stenting in 48 patients (58 vessels) vs. open repair in 96 patients (157 vessels)
Shorter hospital stay in the endovascular group (3 vs. 12 days, p<0.03)
No difference in 30-day mortality, in-hospital complication, or 3-year survival rate
Freedom from recurrent sx at 3 years was greater in the open repair group (66% vs. 27%, p<0.02)
Both treatments have similar morbidity and mortality. Patients treated with surgical revascularization are more likely experience long term symptomatic relief. Endovascular pts often no candidates for surgery!
Kougias P, et al. Int Angiol 2009;28:

43. Endoluminal Therapy for Chronic Mesenteric Ischemia
31 patients with 41 visceral vessel interventions
Mean age 70 (range years), 84% female
90-day mortality 20%, major morbidity 6%
Restenosis rate 20% at 0.29 years (range )
Fifty percent of restenosis patients were reintervened successfully
Primary and assisted patency rate at 7 years 69+8% and 72+9%, respectively
Endoluminal therapy has a low morbidity and mortality, however, long-term benefit is not achieved. Endovascular therapy should be limited to patients without an open surgical option.
Lee RW, et al. Ann Vasc Surg 2008;22:541-6

44. Mesenteric Angioplasty & Stenting in USA
The study analyzed data on bypass, endarterectomy, embolectomy or angioplasty for acute (AMI) or chronic mesenteric ischemia (CMI).
Angioplasty increased steadily, surpassing all surgery for CMI in For AMI, PTA/S increased and surpassed bypass but has not surpassed all surgical procedures
The mortality rate for both CMI and AMI decreased over the 18-year period, with the lowest rates seen after the year 2000
Bowel resection was associated with increased in-hospital mortality for both repair types (54% and 25%, respectively)
Implications: Angioplasty with or without stenting is being used with increasing frequency for mesenteric ischemia. Treatment indications appear to be expanding to include more pts who previously were not surgical candidates.
Schermerhorn ML, et al. J Vasc Surg Apr 15, 2009;Epub ahead of print.

48. Mesenteric Angioplasty & Stenting
K.H.F. m-74y SMA Occlusion, Celiac Stenosis

49. Endovascular Tx for Acute Mesenteric Artery Occlusion
Embolic occlusion (n=10)
Thrombotic occlusion (n=11)
M:F
4:6
1:10
Median age (yrs) 78 68
Bowel section
10%
36%
Major complication 0%
In-hospital survival rate
90%
82%
Acosta S, et al. Cardiovasc Intervent Radiol 2009;April 14. [Epub ahead of print)