Author + information
Patient initials or identifier number
Y.I ID: 2481120
Relevant clinical history and physical exam
Thepatient was a 73-year-old man.
His history included AP and AF.
He was taking a single anti-platelet agentwith a direct oral anticoagulant.
He underwent percutaneous coronaryintervention (PCI) for AP 10 month prior. He currently hospitalized for afollow up coronary angiography (CAG).
He had stomachache upon entering the catheterizationlaboratory and his status seemed to be very serious with a cold sweat.Therefore, we cancelled the CAG and started screening tests of his symptoms.
Relevant test results prior to catheterization
Hepatic portal venous gas and intestinal edema was observed on the CT scan. Contrast enhanced Ct scan revealed an ostial occlusion of the superior mesenteric artery (SMA), severe stenosis of the inferior mesenteric artery (IMA), and rich collateral circulation. In his previous enhanced CT scan in 2013, the finding of the severe stenos of the SMA and IMA with rich collateral circulation had already been observed.
Relevant catheterization findings
We began the procedure with a left brachial artery approach via a 6-Fr sheath.The initial angiography showed that the ostium of the IMA was slightly visible and the ostium of the SMA was invisible.
We exchanged a 6-Fr guiding sheath (Destination 90 cm) to advance it to the abdominal aorta. A 6-Fr guiding catheter (multi-purpose 110 cm) engaged into IMA. We inserted a 0.014-inch wire (Cruise 300 cm) to cross the IMA lesion and it passed easily. We calculated the lesion diameter and marked the landing point using an IVUS catheter (Eagle Eye). We expanded the lesion with a 2.5/20 mm balloon (Ikazuchi PAD). Then, we deployed a 7/40 mm self-expanding stent (Zilver 518) into the IMA and added post dilatation of the stent with a 4.0/20 mm balloon (Ikazuchi PAD). We advanced the wire with a microcatheter (prominent 150 cm) along with a collateral artery. It was then identified that the catheter had reached the distal cap of SMA occlusion site by using a tip injection. We tried to pass the obstructive lesion retrogradely and it passed easily. Then a gooseneck snare catheter inserted into the abdominal aorta from a right femoral artery. We captured the wire in the abdominal aorta with the snare catheter and guided it outside the femoral sheath. A 6-Fr guiding catheter (RDC1) inserted from the right femoral artery and engaged into the SMA along the externalized wire. We expanded the lesion with a 4.0/20 mm balloon. The IVUS catheter revealed severe calcification in the lesion. An expansion added with a 4.0/20 mm scoring balloon (Angioscarpt), a 6.0/18 mm balloon-expanding stent (Express SD) was deployed to the SMA. The final IVUS and angiography showed good dilatation and a good flow.
We succeed in salvaging the mesenteric ischemia with emergent EVT. It was difficult to cross SMA occlusion with only an ante grade approach. Therefore, we attempted to pass the lesion with the retrograde approach. There was a rich collateral circulation with chronic severe stenosis. The 3D reconstruction image of the CT scan was very useful for the guidance of this procedure.