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

Abstract

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.

Figure 1.

A plain computed tomography showing calcification at the origin of the celiac artery (A) and the superior mesenteric artery (B).

Figure 2.

Pre-procedural angiography and intravascular ultrasound (IVUS) imaging of the superior mesenteric artery (SMA) (A). A cutting balloon was used to treat the stenosis of the SMA (B). Angiography after balloon angioplasty and intramural hematoma was observed with IVUS examination (C). Covering the whole dissection in the SMA with the implantation of self-expandable stents (D). Selective superior mesenteric angiography after endovascular therapy (E). The three-dimensional construction of computed tomography angiography after deployment of the self-expandable stents (F).