Rare case of "wandering artery of drummond" as a result of chronic triple mesenteric vessel occlusion treated by isolated angioplasty and stenting of the inferior mesenteric artery

Abstract

We report a rare clinical scenario of chronic mesenteric ischemia (CMI) patient with obstruction of all the three major gut vessels including celiac, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) with a sole artery supplying the collaterals through marginal artery of left colon (the "wandering artery of Drummond"). A 70-year-old man was presented to hospital with acute onset of dyspnea, diaphoresis, severe epigastric pain, nausea, and vomiting that started after lunch. Initially, patient was diagnosed and treated for non-ST elevation myocardial infarction (NSTEMI). Furthermore, work-up, including computed tomographic scan of abdomen followed by angiogram, revealed 100% obstruction of celiac and SMA, whereas inferior IMA had 90% ostial lesion with poststenotic dilatation and collaterals supplying to entire colon. Subsequently, IMA ostial lesion was stented through percutaneous intervention and patient noted significantly improved symptoms and quality of life. To conclude, percutaneous endovascular treatments confer favorable strategy for CMI, and it may either be curative or allow nutritional optimization before definitive surgery.

Keywords: inferior mesenteric artery; non-ST elevation myocardial infarction; superior mesenteric artery.

Fig. 1

Computed tomography abdomen (anteroposterior reconstruction) showing ostial occlusion at origin of inferior mesenteric artery (short arrow) with poststenotic dilatation and wandering artery of Drummond (long arrows).

Fig. 2

Computed tomography abdomen (sagital reconstruction) shows ostial occlusion at origin of inferior mesenteric artery with poststenotic dilatation (right) (A), and complete occlusion of aorta with wandering artery of Drummond anteriorly (long arrows) (B).

Fig. 3

Diagnostic angiogram of abdomen (anteroposterior view) revealed ostial inferior mesenteric artery lesion with poststenotic dilatation (broad arrow), complete occlusion of abdominal aorta, and, collateral network of wandering artery of Drummond (long arrows).

Fig. 4

Endovascular revascularization of ostial inferior mesenteric artery (anteroposterior view) done in sequence from right to left depicts angioplasty followed by stenting.

Fig. 5

Diagram depicts the various collateral networks exist with celiac trunk, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) occlusion. The pancreaticoduodenal arteries (arrow) connect the celiac artery and proximal SMA. The marginal artery of Drummond and the paracolic arcade (arrowhead) run between the SMA and the IMA. When the IMA is also occluded, the systemic vessels (mainly the internal iliac artery) can feed the IMA (reverse flow) and the other vessels via previously described anastomoses (open arrow). Figure curtsey from Loffroy et al.