Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

19 January 2024: Articles  Japan

Successful Endovascular Treatment of Calcified Superior Mesenteric Artery Complicated by Intramural Hematoma in Chronic Mesenteric Ischemia

Unusual clinical course, Unusual or unexpected effect of treatment, Diagnostic / therapeutic accidents

Takuya Nakahashi1ABCDEF*, Hayato Tada2BDF, Shota Inaba2BCE, Masafumi Hashimoto1BCE, Akihiro Nomura ORCID logo2BCE, Noboru Terayama3BCE, Kenji Sakata2BCE, Masayuki Takamura2E

DOI: 10.12659/AJCR.942641

Am J Case Rep 2024; 25:e942641

0 Comments

Abstract

0:00

BACKGROUND: Chronic mesenteric ischemia (CMI) is defined as ischemic symptoms caused by insufficient supply of blood to the gastrointestinal tract. Patients diagnosed with advanced symptomatic CMI should be treated subsequently, as the transition from CMI to acute mesenteric ischemia can be unpredictable. However, there is little information regarding the management of potential procedural complications during endovascular therapy (EVT) for CMI.

CASE REPORT: A 70-year-old man was admitted to our hospital with recurrent abdominal pain just after hemodialysis. The angiogram showed significant stenosis with heavy calcification in the proximal of the superior mesenteric artery (SMA), leading to the diagnosis of CMI. To alleviate the symptom, EVT for the stenotic lesion of the SMA was indicated. During the procedure, a cutting balloon was inflated to facilitate vessel expansion in the target lesion. As a result, intravascular ultrasound (IVUS) imaging revealed dissection into the media with extension into the medial space without reentry and demonstrated a semilunar intramural hematoma. We were able to contain the intramural hematoma by covering the whole dissection in the SMA with implantation of self-expandable stents.

CONCLUSIONS: This case highlights the potential of EVT for heavy calcification of the SMA complicated by dissection without reentry. Intramural hematoma was observed with IVUS examination. We were able to contain the hematoma by the implantation of self-expandable stents over the whole length of the SMA dissection under IVUS-guided EVT.

Keywords: endovascular procedures, Postoperative Complications, Cardiac Imaging Techniques

Background

Chronic mesenteric ischemia (CMI) is defined as ischemic symptoms caused by insufficient supply of blood to the gastrointestinal tract. Mesenteric ischemia is predominantly caused by atherosclerosis affecting the ostia of the superior mesenteric artery (SMA) [1]. Compared with open surgical bypass, endovascular therapy (EVT) has been associated with decreased morbidity and length of hospital stay [2]. Therefore, it has been generally accepted that EVT for SMA stenosis or occlusion provides excellent symptom relief in patients with CMI [3]. However, there is little information on the management of potential procedural complications during EVT for CMI [4,5].

Intramural hematoma can sometimes occur during cardiovascular intervention, and a possible mechanism is dissection into the media with extension into the medial space where blood has accumulated due to a distal dead end [6]. Since the intramural hematoma formation might be an important trigger of life-threatening sequelae, prompt management is crucial [7]. Herein, we describe a patient with CMI who underwent successful EVT for SMA despite a complicated intramural hematoma.

Case Report

A 70-year-old man was admitted to our hospital with recurrent abdominal pain, which had persisted for 3 months and worsened 1 month prior to admission. The patient had undergone hemodialysis for 30 years. Furthermore, he had been diagnosed as having a history of coronary artery disease and lower-extremity arterial disease. On admission, the patient had recurrent abdominal angina just after hemodialysis. Plain computed tomography showed calcification in the proximal celiac artery (Figure 1A) and SMA (Figure 1B), suggesting severe stenosis of the entrance of the intestinal arteries. There was no evidence of ileus or free air. At first, the patient’s symptoms appeared to become apparent because of volume reduction through hemodialysis in a patient exhibiting CMI; thus, we attempted to control the optimal dry weight. However, the recurrent abdominal pain during hemodialysis did not improve substantially, which indicated the need for revascularization. Given the lower risk of mobility and mortality in the endovascular intervention, EVT was indicated for the stenotic lesion of the SMA, with surgical back-up in the event of endovascular failure.

After achieving arterial access via the right common artery, a 5-Fr JR 4.0 diagnostic catheter was inserted into the SMA selectively. The angiogram showed significant stenosis in the proximal SMA (Figure 2A). At first, a 0.014-inch guidewire (Cruise; Asahi Intecc, Aich, Japan) was inserted into the SMA through a VISTA BRITE TIP JR 4.0-type guiding catheter (Cordis, Florida, USA). To obtain more detailed information regarding the vessel diameter and degree of calcification, we attempted intravascular ultrasound (IVUS) (Eagle Eye Platinum ST; Philips, Massachusetts, USA) using a catheter placed over a 0.014-inch guide wire. The IVUS catheter was then carefully advanced to the culprit lesion under fluoroscopic guidance and revealed severe stenosis with eccentric calcification in the proximal SMA (Figure 2A). To facilitate vessel expansion, a 6.0-mm cutting balloon (Boston Scientific, Massachusetts, USA) was inflated to 6 atm (Figure 2B). As a result, IVUS imaging revealed the dissection into the media with extension into the medial space without reentry and demonstrated a semilunar intramural hematoma (Figure 2C). In addition, cracks were also observed within the calcification with IVUS examination. To completely cover the hematoma, 2 self-expandable stents (SMART CONTOL stent 6.0/60 mm, 7.0/40 mm; Cordis, Florida, USA) were deployed and post-stent dilatation was performed. Acceptable stent expansion (Figure 2D) and good angiographic results were obtained (Figure 2E). The patient was discharged without complications and follow-up showed a good course without any abdominal angina. One year later, enhanced computed tomography showed that patency and flexibility of the 2 self-expandable stents were maintained (Figure 2F).

Discussion

As atherosclerosis is the most common cause of CMI, most patients have no symptoms and the development of CMI may take months or years to become clinically apparent [8]. However, patients diagnosed with advanced symptomatic CMI should be treated subsequently, as the transition from CMI to acute mesenteric ischemia can be unpredictable and lethal [9]. Although the prevalence of CMI remains unknown, patients undergoing hemodialysis who manifest more severe forms of cardiovascular disease have been associated with an increased incidence of CMI.

During the last few years, the number of mesenteric revascularizations has increased because of increasing recognition and the advent of EVT, which allows for a less invasive treatment [10]. Symptoms of mesenteric ischemia usually do not manifest until at least 2 of the 3 mesenteric arteries are significantly stenosed or occluded [11]. The role of 2-vessel stenting (of both the celiac artery and the SMA) remains controversial, but most reports indicate that angioplasty and stenting of a single vessel may be sufficient [12,13]. Treatment selection of the SMA in the present case included consideration of the vessel diameter, extent of stenosis, and degree of calcification.

Severely calcified vascular stenosis remains a challenge for EVT because of suboptimal vessel expansion and a higher rate of dissection [14]. For patients with mesenteric ischemia, stent under expansion has been reported as a major risk factor for stent restenosis [15]. Therefore, adequate plaque modification prior to stent implantation is critical for calcified lesions. The cutting balloon, which includes 3 or 4 radially directed micro-surgical metal blades on the balloon surface, has been used to create incisions in the calcified plaque and expand narrow lesions [16]. In the present case, inflation of the cutting balloon within the calcified lesion likely led to the dissection into the media with extension into the medial space without re-entry and the semilunar intramural hematoma. Remarkably, IVUS examination was useful in identifying the intramural hematoma. Moreover, we deployed the first stent at the distal dead end and the second stent at the entry point of the intramural hematoma under IVUS guidance. Therefore, IVUS examination also contributes to the treatment strategy for patients with CMI who underwent EVT. In endovascular for SMA, coaxial insertion of the guide catheter via the leg is difficult because the SMA branches sharply downward from the aorta [17]. Coaxial positioning of the catheter, via the arm, is essential to prevent potential catastrophic consequences of iatrogenic dissection.

The possible benefits of imaging follow-up after mesenteric revascularization are still unknown. A recent study reported that overall primary patency rates at 12 and 60 months were 77.0% and 45.0%, respectively, suggesting that close imaging and clinical surveillance allow for faster identification of patients with recurrent symptoms [18].

Conclusions

This case highlights the potential of EVT for heavy calcification of the SMA complicated by dissection without reentry. Intramural hematoma was observed with IVUS examination. We were able to contain the hematoma by implantation of self-expandable stents over the whole length of the SMA dissection under IVUS-guided EVT.

References:

1.. Zeller T, Macharzina R, Management of chronic atherosclerotic mesenteric ischemia: Vasa, 2011; 40; 99-107

2.. Oderich GS, Bower TC, Sullivan TM, Open versus endovascular revascularization for chronic mesenteric ischemia: Risk-stratified outcomes: J Vasc Surg, 2009; 49; 1472-9.e3

3.. Björck M, Koelemay M, Acosta S, Editor’s choice – management of the diseases of mesenteric arteries and veins: Clinical practice guidelines of the European Society of Vascular Surgery (ESVS): Eur J Vasc Endovasc Surg, 2017; 53; 460-510

4.. Oderich GS, Erdoes LS, Lesar C, Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease: J Vasc Surg, 2013; 58; 1316-23

5.. Awouters J, Jardinet T, Hiele M, Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia: Vasa, 2021; 50; 431-38

6.. Maehara A, Mintz GS, Bui AB, Incidence, morphology, angiographic findings, and outcomes of intramural hematomas after percutaneous coronary interventions: an intravascular ultrasound study: Circulation, 2002; 105; 2037-42

7.. Katayama T, Sakoda N, Yamamoto F, Balloon rupture during coronary angioplasty causing dissection and intramural hematoma of the coronary artery; A case report: J Cardiol Cases, 2009; 1; e17-e20

8.. Thomas JH, Blake K, Pierce GE, The clinical course of asymptomatic mesenteric arterial stenosis: J Vasc Surg, 1998; 27; 840-44

9.. Björnsson S, Resch T, Acosta S, Symptomatic mesenteric atherosclerotic disease-lessons learned from the diagnostic workup: J Gastrointest Surg, 2013; 17; 973-80

10.. Schermerhorn ML, Giles KA, Hamdan AD, Mesenteric revascularization: Management and outcomes in the United States, 1988–2006: J Vasc Surg, 2009; 50; 341-8.e1

11.. Zwolak RM, Fillinger MF, Walsh DB, Mesenteric and celiac duplex scanning: A validation study: J Vasc Surg, 1998; 27; 1078-87 ; discussion 1088

12.. Silva JA, White CJ, Collins TJ, Endovascular therapy for chronic mesenteric ischemia: J Am Coll Cardiol, 2006; 47; 944-50

13.. Peck MA, Conrad MF, Kwolek CJ, Intermediate-term outcomes of endovascular treatment for symptomatic chronic mesenteric ischemia: J Vasc Surg, 2010; 51; 140-7.e1-2

14.. Rocha-Singh KJ, Zeller T, Jaff MR, Peripheral arterial calcification: Prevalence, mechanism, detection, and clinical implications: Catheter Cardiovasc Interv, 2014; 83; E212-20

15.. Haben C, Park WM, Bena JF, Improving midterm results justify the continued use of bare-metal stents for endovascular therapy for chronic mesenteric ischemia: J Vasc Surg, 2020; 71; 111-20

16.. Zhu X, Umezu M, Iwasaki K, Finite element analysis of the cutting balloon with an adequate balloon-to-artery ratio for fracturing calcification while preventing perforation: Circ Rep, 2020; 3; 1-8

17.. Soga Y, Yokoi H, Iwabuchi M, Nobuyoshi M, Endovascular treatment of chronic mesenteric ischemia: Circ J, 2008; 72; 1198-200

18.. Bulut T, Oosterhof-Berktas R, Geelkerken RH, Long-term results of endovascular treatment of atherosclerotic stenoses or occlusions of the coeliac and superior mesenteric artery in patients with mesenteric ischaemia: Eur J Vasc Endovasc Surg, 2017; 53; 583-90

In Press

Case report  Japan

A Rare Case of Ileocecal Lymph Node Recurrence After Surgery in Siewert’s Classification Type I Esophagogas...

Am J Case Rep In Press; DOI: 10.12659/AJCR.943080  

0:00

Case report  China (mainland)

Destructive Cryptococcal Osteomyelitis Mimicking Tuberculous Spondylitis

Am J Case Rep In Press; DOI: 10.12659/AJCR.944291  

0:00

Case report  USA

Severe Fatal ARDS Due to Untreated Human Granulocytic Anaplasmosis in a 67-Year-Old Man: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.943966  

Case report  China (mainland)

Optic Neuritis Leading to Vision Loss: A Case of MOG-Associated Disease with Successful Immunotherapy

Am J Case Rep In Press; DOI: 10.12659/AJCR.943112  

Most Viewed Current Articles

07 Mar 2024 : Case report  USA 39,268

Neurocysticercosis Presenting as Migraine in the United States

DOI :10.12659/AJCR.943133

Am J Case Rep 2024; 25:e943133

0:00

10 Jan 2022 : Case report  Germany 31,274

A Report on the First 7 Sequential Patients Treated Within the C-Reactive Protein Apheresis in COVID (CACOV...

DOI :10.12659/AJCR.935263

Am J Case Rep 2022; 23:e935263

23 Feb 2022 : Case report  USA 18,158

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

19 Jul 2022 : Case report  Saudi Arabia 17,956

Atlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19

DOI :10.12659/AJCR.936128

Am J Case Rep 2022; 23:e936128

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923