Should Mesenteric Revascularization Be Staged: Report of 3 Cases One With Reperfusion Hemorrhage

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1 Should Mesenteric Revascularization Be Staged: Report of 3 Cases One With Reperfusion Hemorrhage Ayhan Olcay MD 1, Kivanc Yalin MD 1, Sukriye Ebru Golcuk MD 1, Sukru Sanli MD 2 1. Bayrampasa Kolan Hospital, Department of Cardiology, İstanbul, Turkey 2. Bayrampasa Kolan Hospital, Department of Radiology, İstanbul, Turkey

2 Disclosure Speaker name: AYHAN OLCAY MD I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) X I do not have any potential conflict of interest

3 Chronic Mesenteric Ischemia (CMI) Presenting symptoms: Abdominal pain (92%), Weight loss (87%) Diarrhea (44%), Anorexia (33%), food fear (18%) Most commonly atherosclerotic Female (70%)>Male Generally 2/3 mesenteric arteries must be stenotic for patient to be symptomatic SMA revascularization is the key!

4 One or Two Vessel Stenting Two vessel stenting was associated with more complications (33%) compared with stenting of SMA (18%) or celiac stenting (6%) Higher restenosis in CA (Malgor RD) Symptom recurrence lower with 2 vessel stenting (24% vs 6%) (Silva JA) Reperfusion hemorrhage in CMI not adressed in literature except case report (Moore M)

5 SMA Only vs Complete OR Bypass grafting to the SMA alone appears to be both an effective and durable (Foley MI)

6 Patient 1 A 70 yr man, HT, DM Type 2, PAD, CABG Typical CMI symptoms and severe weight loss CT angiography: severe CA stenosis, total SMA occlusion and stenotic IMA Previous endovascular intervention failed CA and total SMA was stented in same session transaxillary Severe hematemesis 6 hour after intervention Discharged after 5 days on Clopidogrel and pantoprazol

7 Patient 1 7x18 mm balloon expandable stenting of celiac stenosis 5x30 balloon expandable stenting of total SMA in the same session

8 Gastric bleeding in patient 1 Multiple gastric ulcerations in gastroscopy48 hours after bleeding. No ulcers in gastroscopy 15 days before procedure

9 Patient 2 A 65 yr woman, HT, CRF Cr 1.8 mg/dl Atherosclerotic CA and left renal stenting 6 month ago, total SMA was not intervened, IMA was open Typical recurrence of CMI symptoms CA, total SMA and left renal was revascularized transfemorally Patient discharged without any complications

10 Patient 2 7x20 mm balloon expandable stenting of celiac stent restenosis 5x30 mm balloon expandable stenting of SMA occlusion in the same session

11 Patient 3 A 55 yr man, HT, Smoker Typical CMI symptoms and bilateral leg intermittant claudication CT angiography: Severe CA stenosis, SMA subtotal occlusion, stenotic IMA and severe distal aortic stenosis SMA was stented first but patient started to have abdominal pain and CA stenting postponed. Patient discharged 2 days later without bleeding or peritoneal irritation and CA and distal aorta was stented 5 months later. Patient discharged without any complications

12 Patient 3 6x30 mm balloon expandable stenting of SMA stenosis 7x22 mm balloon expandable stenting of celiac stenosis 5 month later

13 Control Cardiology Skills and Ambition!!

14 Conclusions We suggest to stop interventional urge to do all in one session Cardiology CTO experience is very valuable but be careful about periotoneal signs and collaborate closely with surgery! ER of two vessel may provide better symptomatic relief but staging should be tested in randomized trials Multivessel ER becomes more widely used for CMI and strategies to reduce reperfusion hemorrhages are needed (heparin, antiaggregants, staging..)

15 References 1. Schermerhorn ML, Giles KA, Hamdan AD, et al. Mesenteric revascularization: management and outcomes in the United States, J Vasc Surg 2009;50: e1. 2. Malgor RD et al.results of single- and two-vessel mesenteric artery stents for chronic mesenteric ischemia.ann Vasc Surg Nov;24(8): doi: /j.avsg Silva JA, White CJ, Collins TJ, et al. Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol 2006;47: Sivamurthy N, Rhodes JM, Lee D, et al. Endovascular versus open mesenteric re-vascularization: immediate benefits do not equate with short-term functional outcomes. J Am Coll Surg 2006;202: van Petersen AS, Kolkman JJ, Beuk RJ, et al. Open or percutaneous re-vascularization for chronic splanchnic syndrome. J Vasc Surg 2010;51: Cunningham CG, Reilly LM, Rapp JH, et al. Chronic visceral ischemia. Three decades of progress. Ann Surg 1991;214: ; discussion Mateo RB, O Hara PJ,Hertzer NR, et al. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes. J Vasc Surg 1999;29: ; discussion Silva JA, White CJ, Collins TJ, et al. Endovascular therapy for chronic mesenteric ischemia. JAmColl Cardiol 2006;47: Peck MA, Conrad MF, Kwolek CJ, et al. Intermediate-term outcomes of endovascular treatment for symptomatic chronic mesenteric ischemia. J Vasc Surg 2010;51: , e1 e van Petersen AS, Kolkman JJ, Beuk RJ, et al. Open or percutaneous re-vascularization for chronic splanchnic syndrome. J Vasc Surg 2010;51: Moore M1, McSweeney S, Fulton G, Buckley J, Maher M, Guiney M. Reperfusion hemorrhage following superior mesenteric artery stenting. Cardiovasc Intervent Radiol Jul;31 Suppl 2:S Epub 2007 Oct Roobottom CA, Dubbins PA. Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: predictive value of Doppler sonography. AJR Am J Roentgenol 1993;161: Hansen KJ, Wilson DB, Craven TE, Pearce JD, English WP, Edwards MS, et al. Mesenteric artery disease in the elderly. J Vasc Surg 2004;40: Thomas JH, Blake K, Pierce GE, Hermreck AS, Seigel E. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg 1998; 27: Connolly JE, Kwaan JH. Prophylactic revascularization of the gut. Ann Surg 1979;190: Furrer J, Gruntzig A, Kugelmeier J, et al.treatment of abdominal angina with percutaneous dilatation of an arteria mesenterica superior stenosis. Preliminary communication.cardiovasc Intervent Radiol. 1980;3: Foley MI et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg Jul;32(1):37-47

16 Should Mesenteric Revascularization Be Staged: Report of 3 Cases One With Reperfusion Hemorrhage Ayhan Olcay MD 1, Kivanc Yalin MD 1, Sukriye Ebru Golcuk MD 1, Sukru Sanli MD 2 1. Bayrampasa Kolan Hospital, Department of Cardiology, İstanbul, Turkey 2. Bayrampasa Kolan Hospital, Department of Radiology, İstanbul, Turkey