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Recanalization using direct stenting before bowel resection for acute-on-chronic superior mesenteric artery
Toshinao Suzuki1, Satoru Murata1, Taichiro Tsunoyama2
1Interventional Radiology Center, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba, 299-0111, Japan.
Introduction:
Acute-on-chronic mesenteric ischemia (ACMI) refers to acute mesenteric ischemia (AMI) developing in a patient displaying typical symptoms of chronic mesenteric ischemia (CMI). Delayed treatment can cause short bowel syndrome and increased mortality. Intervention involves intestinal revascularization and resection of the necrotic intestine. However, the revascularization procedure must consider the chronic nature of the occlusion.
Presentation Of Case:
A 79-year-old man presented with periumbilical pain for 6 h. AMI was diagnosed, together with chronic superior mesenteric artery occlusion and suspected intestinal necrosis. The symptomatic CMI might have insufficient blood flow to intestines. Endovascular recanalization of the superior mesenteric artery using direct stenting was performed before laparotomy to improve blood flow to the intestines. Subsequent laparotomy revealed approximately 60 cm of ischemic small bowel extending from the jejunum (300 cm anal to the ligament of Treitz) to the ileum (30 cm oral to the terminal ileum). The necrotic bowel was resected without anastomosis. At the second-look operation, further resection was not required.
Discussion:
Making a differential diagnosis between acute and acute-on-chronic occlusions is essential for determining the necessity of recanalization and the method of restoring the intestinal blood flow. Here, the patient with symptomatic CMI might have had insufficient blood flow to the intestines despite establishing collateral supply. We determined that recanalization was needed. Direct stenting without predilation could save time to recanalization and result in less risk of distal embolization.
Conclusion:
This case suggests prompt recanalization using direct stenting can minimize subsequent bowel resection in patients with ACMI.
Insights
Acute-on-chronic mesenteric ischemia (ACMI) requires prompt diagnosis and intervention. Direct stenting for superior mesenteric artery recanalization can minimize bowel resection in these critical cases.
Area of Science:
- Vascular Surgery
- Interventional Radiology
- Gastroenterology
Background:
- Acute-on-chronic mesenteric ischemia (ACMI) presents a diagnostic challenge, often superimposed on chronic mesenteric ischemia (CMI).
- Delayed intervention for ACMI can lead to significant bowel necrosis, short bowel syndrome, and increased mortality.
- Effective management necessitates careful consideration of the underlying chronic occlusion during revascularization.
Observation:
- A 79-year-old male presented with acute periumbilical pain, diagnosed with acute mesenteric ischemia (AMI) and chronic superior mesenteric artery occlusion.
- Endovascular recanalization of the superior mesenteric artery via direct stenting was performed prior to laparotomy.
- Laparotomy revealed extensive small bowel ischemia requiring resection of approximately 60 cm of necrotic bowel.
Findings:
- Direct stenting of the superior mesenteric artery successfully restored blood flow, preventing further ischemic damage.
- The patient's necrotic bowel was resected without immediate anastomosis, and no further resection was needed at the second-look operation.
- Prompt recanalization using direct stenting was crucial in minimizing the extent of bowel resection.
Implications:
- Differentiating between acute and acute-on-chronic mesenteric ischemia is critical for appropriate treatment strategy.
- Direct stenting offers a time-efficient approach to recanalization with a potentially lower risk of distal embolization.
- This case highlights the benefit of endovascular intervention in preserving bowel viability in ACMI patients.
