Eur J VascSurg 6, 333-336 (1992)
CASE REPORT Mesenteric Angioplasty for Chronic Intestinal Ischaemia M. D. McShane, A. Proctor, P. Spencer, D. C. Cumberland and C. L. Welsh Departments of Radiology and Vascular Surgery, Northern General Hospital, Sheffield, U.K. Mesenteric angina is a difficult diagnosis and surgical treatment carries a significant morbidity and mortality. In patients with stenotic mesenteric vascular disease angioplasty offers an alternative method of treatment. In six patients who underwent mesenteric angioplasty relief of symptoms was achieved in five. Recurrence of symptoms associated with recurrent stenosis occurred in two patients and was remedied by re-dilation in one. Mesenteric angioplasty is a safe alternative to surgical revascularisation for mesenteric stenosis causing chronic intestinal ischaemia. Key Words: Mesenteric; Angioplasty.
Introduction Chronic intestinal ischaemia is a difficult diagnosis to make. Almost by definition it is arrived at after exclusion of other pathology and by demonstrating significant mesenteric vascular disease with angiography. Dunphy 1 first linked the characteristic history of postprandial abdominal pain with subsequent intestinal infarction. To relieve symptoms and prevent such a disaster surgical intervention has, until recently, been the mainstay of treatment. 2 The patients are generally elderly with widespread atherosclerosis and may often be considered a poor risk for surgery. Percutaneous transluminal angioplasty offers an alternative to surgical intervention. Since 1985 this technique has been used in Sheffield in selected patients. The results to date are presented.
mesenteric vascular disease. Angioplasty was performed by the femoral artery approach. The target vessels were selectively catheterised and the lesions traversed with a guide wire. The appropriate balloon catheter was then used. Balloon diameters ranged from 4 to 8 mm and inflation pressures of 6-10 atmospheres were used. The criterion for a technical success was angiographic improvement in the vessel diameter i.e. a less than 50% diameter residual stenosis of the vessel after angioplasty. Since January 1989 image-directed Doppler ultrasound (duplex scanning) has also been used to assess the continued patency of the dilated vessels. Patient details were obtained from the notes in each case. Each case is presented in detail and summarised in Table 1.
Case Reports Subjects and Methods
Case I
A 63-year-old woman presented with abdominal pain following meals, loose motions and weight loss. Previous investigations over a period of 12 months included endoscopy, barium meal and follow through, barium enema and ultrasound scan. All had been reported as normal. Mesenteric angiography revealed superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) occlusion and severe coeliac stenosis. The coeliac stenosis was dilated. Please address all correspondenceto: C. L. Welsh, Department of Vascular Surgery, Northern General Hospital, Herries Road, Shef- Eighteen months later she remained asymptomatic field $5 7AU, U.K. and had a 7.5-kg weight gain. Six patients were referred for mesenteric angiography. They had all undergone prior investigation to exclude more common causes of their symptoms. Mesenteric angiography, performed by abdominal aortography in antero-posterior, lateral and oblique projections, supplemented if necessary by selective catheterisation, confirmed the presence of significant
0950-821X/92/030333+04 $03.00/0© 1992Grune & StrattonLtd.
M.D. McShane et aL
334
Table 1. Summary of cases
Case
Age (years)
Sex
Angiography
Vessel dilated
Follow up
1
63
F
Coeliac stenosis SMA, IMA occluded
Coeliac
18 months: asymptomatic; +7.5kg
2
63
F
(1) Coeliac SMA and IMA stenoses
Coeliac and SMA
16 months: symptoms recurred at 4 months; currently asymptomatic; +2kg
(2) Coeliac and SMA stenoses recurred
Coeliac and SMA
3
69
F
Coeliac and SMA stenoses IMA occluded
Coeliac and SMA
42 months: symptoms recurred at 18 months; +2kg
4
63
M
(1) IMA stenosis (2) Coeliac and IMA stenosis (3) Coeliac patent, IMA stenosed
IMA Coeliac and IMA No procedure
24-h: pain Slow improvement 7 months: asymptomatic: +7kg
5
46
M
Coeliac and SMA occluded; IMA stenosis
IMA
24 months: asymptomatic; +15kg
6
68
M
(1) Coeliac and SMA stenosis; IMA occluded (2) Coeliac and SMA stenoses recurred (3) Mesenteric infarction 4 months after second angioplasty: died
Coeliac partial dilation of SMA Coeliac and SMA
24 h: pain; symptomatic at 2 months Symptomatic weight loss
Case 2
A 63-year-old woman with abdominal pain I h after food ("food fear") and weight loss had been investigated for 4 months. Endoscopy, ultrasound and barium enema had all been reported as normal. Mesenteric angiography demonstrated narrow coeliac, SMA and inferior mesenteric artery (IMA) origins. The coeliac and superior mesenteric stenoses were dilated. There was initial relief of symptoms for 4 months following which there has been gradual recurrence of symptoms. Duplex scanning at 8 months after dilation suggested reoccurence of the coeliac and SMA stenoses with the vessels remaining patent. These findings were confirmed by angiography and 14 months after the initial procedure the coeliac artery was successfully redilated (see Fig. 1). Dilation of the SMA was attempted but was considered an angiographic failure. One month following redilation there had been improvement in her symptoms.
Case 3
A 69-year-old woman presented with post-prandial epigastric pain and weight loss. Previous investigations included oral cholecystography and endoscopy which were showed normal results. Mesenteric Eur J Vasc Surg Vol 6, May 1992
angiography demonstrated stenoses in the coeliac and SMA. Both lesions were dilated and the patient showed a marked symptomatic improvement and 2kg weight gain. After 18 months her symptoms recurred. She has refused further treatment and remained alive but symptomatic 42 months after treatment.
Case 4
A 63-year-old man presented with a 3-year history of pain precipitated by food, weight loss and anorexia. Extensive investigation over 2 years included a barium meaI and enema, endoscopy and endoscopic retrograde cholangio-pancreatography (ERCP), ultrasound and abdominal CT scan. Mesenteric angiography suggested an occluded coeliac artery and SMA with stenosis at the origin of the IMA. Angioplasty resulted in 24 h of abdominal pain with subsequent symptomatic relief for 48h. The symptoms then returned and repeat angiography demonstrated recurrence of the IMA stenosis and a severe stenosis of the coeliac trunk. Both stenoses were dilated. Initial symptomatic relief was followed 1 week later by abdominal pain which then gradually improved.
Mesenteric Angioplasty
(a)
335
(b)
Fig. 1. (a) Lateralviewof the coeliacartery (C) and the superior mesentericartery (S) with stenosisnear the originof the coeliacarteryand for several centimetresof the superior mesenteric artery. (b) Successfuldilationof the coeliacartery (C) has been achievedwith partial success in the SMA. This was sufficientto abolish the patient's symptoms. Repeat angiography after 5 weeks demonstrated a patent coeliac trunk and restenosis of the IMA. No further procedure was considered necessary. Seven months after the second dilation he was asymptomatic and had gained 7 kg in weight.
Case 5
A 46-year-old man who had previously undergone ilio-femoral and femoro-popliteal bypass grafting had a history of epigastric pain after food and weight loss. Investigations lasting 16 months included barium meal, endoscopy and ultrasound, which were all normal. Mesenteric angiography demonstrated coeliac artery and SMA occlusion with IMA stenosis. Dilation of the stenosis resulted in marked improvement in symptoms and weight gain of 15kg. He remains asymptomatic 24 months after dilation.
Case 6
A 68-year-old man presented with a history of abdominal pain 30 min after food and weight loss. He had a history of claudication. Investigations performed over a 10-month period included barium enema, barium meal and follow through and ultrasound, which were all normal. Mesenteric angiogra-
phy revealed a severe stenosis at the origin of the coeliac trunk and for the first 7 cm of the SMA. The IMA was occluded. The coeliac stenosis was dilated and the SMA partially dilated due to the fact that a coronary-type co-axial system was needed to cross diffuse disease thus permitting only a 4-mm balloon to be used. The patient complained of pain after eating 48 h after the procedure with associated pain and pallor in both legs. The symptoms in his legs resolved without intervention. His original symptoms recurred. Repeat angiography at 3 months revealed recurrence of the stenoses and subsequent angioplasty failed to relieve his symptoms. Four months after the second attempt at mesenteric angioplasty he suffered a mesenteric infarction and died.
Discussion
Atherosclerosis of the visceral arteries is common and the frequency increases with age. There does not appear to be a strong relation between the degree of arterial occlusion found at post-mortem and alimentary symptoms during life. 3 The diagnosis of intestinal angina depends on the exclusion of other possible causes and the correlation of clinical symptoms with angiographic findings. 2 The necessity to exclude other causes of the patients symptoms is self-evident. Eur J VascSurg Vol 6, May 1992
336
M.D. McShane et al.
In this series all the patients had been extensively investigated for some months or years prior to referral for selective mesenteric angiography. It may be possible to use duplex scanning in the future as a screening procedure prior to angiography, 4 but this should not replace investigations to exclude more common causes of abdominal pain and weight loss. Having determined that there is evidence of significant mesenteric vascular disease a decision as to how this should be treated is required. In cases of complete occlusion of all three main trunks, surgical intervention is the only option at present. Where stenoses have been demonstrated, percutaneous angioplasty has obvious advantages over surgical intervention. It is minimally invasive and avoids the necessity for general anaesthesia. It may, however, carry the risk of creating arterial spasm, emboli or thrombosis with possibly disastrous consequences. Following angioplasty two patients have experienced 24 h of intense abdominal pain raising the possibility of spasm or abrupt re-stenosis of the treated vessel. In both cases re-stenosis has been demonstrated. The limited evidence in the literature indicates that it is a relatively safe procedure. 5-7 Close co-operation between surgeon and radiologist is essential in case surgical intervention should become necessary. This also emphasises the necessity for full and thorough investigation tO preclude unnecessary angiography and angioplasty. Continued objective follow up of these patients is essential as, in common with angioplasty in other vessels, there may be a recurrence of the stenosis. 6 In order to obtain objective evidence of the long-term outcome of dilation, all patients undergoing mesenteric angioplasty are now being followed using duplex ultrasound. In two patients, in this retrospective series, symptoms have returned 4 and 18 months after treatment. In one patient recurrence of stenoses was confirmed using duplex scanning. Similar cases of re-stenosis have been noted by Odurny et al. 6 with
Eur J Vasc Surg Vol 6, May 1992
symptoms recurring in five of eight patients treated successfully. We would agree with their conclusion that angioplasty can be repeated as necessary. However should repeated angioplasty fail to relieve symptoms then consideration should be given to surgical intervention as mesenteric infarction is an ever present risk. This is clearly demonstrated by the final case described in this series. There is no simple diagnostic test for chronic mesenteric ischaemia, but there is now a simpler method of treatment which may avoid the hazards of surgical revascularisation. Percutaneous mesenteric angioplasty appears safe but if it is to gain acceptance must be subject to rigorous assessment and careful application involving both surgeons and radiologists.
References 1 DUNPHY JE. Abdominal pain of vascular origin. Am J Med Sci 1936; 192: 109-112. 2 MARSTON A. Vascular Disease of the Gut: Pathophysiology, Recognition and Management. 2nd edn. Sevenoaks: Edward Arnold, 1986; 116-142. 3 CROFT RJ, MENON GP, MARSTON A. Does intestinal angina exist? A critical study of obstructed visceral arteries. Br J Surg 1981; 68: 316-318. 4 LILLYMP, HARWARDTRS, FLINN WR, BLACKBURNDR, ASTLEFORD PM, YAO JST. Duplex ultrasound measurement of changes in mesenteric flow velocity with pharmacologic and physiologic alteration of intestinal blood flow in man. J Vasc Surg 1989; 9: 1825. 5 ROBERTSL, WERTMAN DA, MILLS SR, MOORE AM, HEASTON DK. Transluminal angioplasty of the superior mesenteric artery: an alternative to surgical revascularisation. AJR 1983; 141: 10391042. 60DURNY A, SNIDERMAN KW, COLAPINTO RF. Intestinal angina: percutaneous transluminaI angioplasty of the celiac and superior mesenteric arteries. Radiology 1988; 167: 59-62. 7 GOLDEN DA, RING EJ, MCLEAN GK, FREIMAN DB. Percutaneous transluminal angioplasty in the treatment of abdominal angina. AJR 1982; 139: 247-249.
Accepted 16 August 1990
CASE REPORT Mesenteric Angioplasty for Chronic Intestinal Ischaemia M. D. McShane, A. Proctor, P. Spencer, D. C. Cumberland and C. L. Welsh Departments of Radiology and Vascular Surgery, Northern General Hospital, Sheffield, U.K. Mesenteric angina is a difficult diagnosis and surgical treatment carries a significant morbidity and mortality. In patients with stenotic mesenteric vascular disease angioplasty offers an alternative method of treatment. In six patients who underwent mesenteric angioplasty relief of symptoms was achieved in five. Recurrence of symptoms associated with recurrent stenosis occurred in two patients and was remedied by re-dilation in one. Mesenteric angioplasty is a safe alternative to surgical revascularisation for mesenteric stenosis causing chronic intestinal ischaemia. Key Words: Mesenteric; Angioplasty.
Introduction Chronic intestinal ischaemia is a difficult diagnosis to make. Almost by definition it is arrived at after exclusion of other pathology and by demonstrating significant mesenteric vascular disease with angiography. Dunphy 1 first linked the characteristic history of postprandial abdominal pain with subsequent intestinal infarction. To relieve symptoms and prevent such a disaster surgical intervention has, until recently, been the mainstay of treatment. 2 The patients are generally elderly with widespread atherosclerosis and may often be considered a poor risk for surgery. Percutaneous transluminal angioplasty offers an alternative to surgical intervention. Since 1985 this technique has been used in Sheffield in selected patients. The results to date are presented.
mesenteric vascular disease. Angioplasty was performed by the femoral artery approach. The target vessels were selectively catheterised and the lesions traversed with a guide wire. The appropriate balloon catheter was then used. Balloon diameters ranged from 4 to 8 mm and inflation pressures of 6-10 atmospheres were used. The criterion for a technical success was angiographic improvement in the vessel diameter i.e. a less than 50% diameter residual stenosis of the vessel after angioplasty. Since January 1989 image-directed Doppler ultrasound (duplex scanning) has also been used to assess the continued patency of the dilated vessels. Patient details were obtained from the notes in each case. Each case is presented in detail and summarised in Table 1.
Case Reports Subjects and Methods
Case I
A 63-year-old woman presented with abdominal pain following meals, loose motions and weight loss. Previous investigations over a period of 12 months included endoscopy, barium meal and follow through, barium enema and ultrasound scan. All had been reported as normal. Mesenteric angiography revealed superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) occlusion and severe coeliac stenosis. The coeliac stenosis was dilated. Please address all correspondenceto: C. L. Welsh, Department of Vascular Surgery, Northern General Hospital, Herries Road, Shef- Eighteen months later she remained asymptomatic field $5 7AU, U.K. and had a 7.5-kg weight gain. Six patients were referred for mesenteric angiography. They had all undergone prior investigation to exclude more common causes of their symptoms. Mesenteric angiography, performed by abdominal aortography in antero-posterior, lateral and oblique projections, supplemented if necessary by selective catheterisation, confirmed the presence of significant
0950-821X/92/030333+04 $03.00/0© 1992Grune & StrattonLtd.
M.D. McShane et aL
334
Table 1. Summary of cases
Case
Age (years)
Sex
Angiography
Vessel dilated
Follow up
1
63
F
Coeliac stenosis SMA, IMA occluded
Coeliac
18 months: asymptomatic; +7.5kg
2
63
F
(1) Coeliac SMA and IMA stenoses
Coeliac and SMA
16 months: symptoms recurred at 4 months; currently asymptomatic; +2kg
(2) Coeliac and SMA stenoses recurred
Coeliac and SMA
3
69
F
Coeliac and SMA stenoses IMA occluded
Coeliac and SMA
42 months: symptoms recurred at 18 months; +2kg
4
63
M
(1) IMA stenosis (2) Coeliac and IMA stenosis (3) Coeliac patent, IMA stenosed
IMA Coeliac and IMA No procedure
24-h: pain Slow improvement 7 months: asymptomatic: +7kg
5
46
M
Coeliac and SMA occluded; IMA stenosis
IMA
24 months: asymptomatic; +15kg
6
68
M
(1) Coeliac and SMA stenosis; IMA occluded (2) Coeliac and SMA stenoses recurred (3) Mesenteric infarction 4 months after second angioplasty: died
Coeliac partial dilation of SMA Coeliac and SMA
24 h: pain; symptomatic at 2 months Symptomatic weight loss
Case 2
A 63-year-old woman with abdominal pain I h after food ("food fear") and weight loss had been investigated for 4 months. Endoscopy, ultrasound and barium enema had all been reported as normal. Mesenteric angiography demonstrated narrow coeliac, SMA and inferior mesenteric artery (IMA) origins. The coeliac and superior mesenteric stenoses were dilated. There was initial relief of symptoms for 4 months following which there has been gradual recurrence of symptoms. Duplex scanning at 8 months after dilation suggested reoccurence of the coeliac and SMA stenoses with the vessels remaining patent. These findings were confirmed by angiography and 14 months after the initial procedure the coeliac artery was successfully redilated (see Fig. 1). Dilation of the SMA was attempted but was considered an angiographic failure. One month following redilation there had been improvement in her symptoms.
Case 3
A 69-year-old woman presented with post-prandial epigastric pain and weight loss. Previous investigations included oral cholecystography and endoscopy which were showed normal results. Mesenteric Eur J Vasc Surg Vol 6, May 1992
angiography demonstrated stenoses in the coeliac and SMA. Both lesions were dilated and the patient showed a marked symptomatic improvement and 2kg weight gain. After 18 months her symptoms recurred. She has refused further treatment and remained alive but symptomatic 42 months after treatment.
Case 4
A 63-year-old man presented with a 3-year history of pain precipitated by food, weight loss and anorexia. Extensive investigation over 2 years included a barium meaI and enema, endoscopy and endoscopic retrograde cholangio-pancreatography (ERCP), ultrasound and abdominal CT scan. Mesenteric angiography suggested an occluded coeliac artery and SMA with stenosis at the origin of the IMA. Angioplasty resulted in 24 h of abdominal pain with subsequent symptomatic relief for 48h. The symptoms then returned and repeat angiography demonstrated recurrence of the IMA stenosis and a severe stenosis of the coeliac trunk. Both stenoses were dilated. Initial symptomatic relief was followed 1 week later by abdominal pain which then gradually improved.
Mesenteric Angioplasty
(a)
335
(b)
Fig. 1. (a) Lateralviewof the coeliacartery (C) and the superior mesentericartery (S) with stenosisnear the originof the coeliacarteryand for several centimetresof the superior mesenteric artery. (b) Successfuldilationof the coeliacartery (C) has been achievedwith partial success in the SMA. This was sufficientto abolish the patient's symptoms. Repeat angiography after 5 weeks demonstrated a patent coeliac trunk and restenosis of the IMA. No further procedure was considered necessary. Seven months after the second dilation he was asymptomatic and had gained 7 kg in weight.
Case 5
A 46-year-old man who had previously undergone ilio-femoral and femoro-popliteal bypass grafting had a history of epigastric pain after food and weight loss. Investigations lasting 16 months included barium meal, endoscopy and ultrasound, which were all normal. Mesenteric angiography demonstrated coeliac artery and SMA occlusion with IMA stenosis. Dilation of the stenosis resulted in marked improvement in symptoms and weight gain of 15kg. He remains asymptomatic 24 months after dilation.
Case 6
A 68-year-old man presented with a history of abdominal pain 30 min after food and weight loss. He had a history of claudication. Investigations performed over a 10-month period included barium enema, barium meal and follow through and ultrasound, which were all normal. Mesenteric angiogra-
phy revealed a severe stenosis at the origin of the coeliac trunk and for the first 7 cm of the SMA. The IMA was occluded. The coeliac stenosis was dilated and the SMA partially dilated due to the fact that a coronary-type co-axial system was needed to cross diffuse disease thus permitting only a 4-mm balloon to be used. The patient complained of pain after eating 48 h after the procedure with associated pain and pallor in both legs. The symptoms in his legs resolved without intervention. His original symptoms recurred. Repeat angiography at 3 months revealed recurrence of the stenoses and subsequent angioplasty failed to relieve his symptoms. Four months after the second attempt at mesenteric angioplasty he suffered a mesenteric infarction and died.
Discussion
Atherosclerosis of the visceral arteries is common and the frequency increases with age. There does not appear to be a strong relation between the degree of arterial occlusion found at post-mortem and alimentary symptoms during life. 3 The diagnosis of intestinal angina depends on the exclusion of other possible causes and the correlation of clinical symptoms with angiographic findings. 2 The necessity to exclude other causes of the patients symptoms is self-evident. Eur J VascSurg Vol 6, May 1992
336
M.D. McShane et al.
In this series all the patients had been extensively investigated for some months or years prior to referral for selective mesenteric angiography. It may be possible to use duplex scanning in the future as a screening procedure prior to angiography, 4 but this should not replace investigations to exclude more common causes of abdominal pain and weight loss. Having determined that there is evidence of significant mesenteric vascular disease a decision as to how this should be treated is required. In cases of complete occlusion of all three main trunks, surgical intervention is the only option at present. Where stenoses have been demonstrated, percutaneous angioplasty has obvious advantages over surgical intervention. It is minimally invasive and avoids the necessity for general anaesthesia. It may, however, carry the risk of creating arterial spasm, emboli or thrombosis with possibly disastrous consequences. Following angioplasty two patients have experienced 24 h of intense abdominal pain raising the possibility of spasm or abrupt re-stenosis of the treated vessel. In both cases re-stenosis has been demonstrated. The limited evidence in the literature indicates that it is a relatively safe procedure. 5-7 Close co-operation between surgeon and radiologist is essential in case surgical intervention should become necessary. This also emphasises the necessity for full and thorough investigation tO preclude unnecessary angiography and angioplasty. Continued objective follow up of these patients is essential as, in common with angioplasty in other vessels, there may be a recurrence of the stenosis. 6 In order to obtain objective evidence of the long-term outcome of dilation, all patients undergoing mesenteric angioplasty are now being followed using duplex ultrasound. In two patients, in this retrospective series, symptoms have returned 4 and 18 months after treatment. In one patient recurrence of stenoses was confirmed using duplex scanning. Similar cases of re-stenosis have been noted by Odurny et al. 6 with
Eur J Vasc Surg Vol 6, May 1992
symptoms recurring in five of eight patients treated successfully. We would agree with their conclusion that angioplasty can be repeated as necessary. However should repeated angioplasty fail to relieve symptoms then consideration should be given to surgical intervention as mesenteric infarction is an ever present risk. This is clearly demonstrated by the final case described in this series. There is no simple diagnostic test for chronic mesenteric ischaemia, but there is now a simpler method of treatment which may avoid the hazards of surgical revascularisation. Percutaneous mesenteric angioplasty appears safe but if it is to gain acceptance must be subject to rigorous assessment and careful application involving both surgeons and radiologists.
References 1 DUNPHY JE. Abdominal pain of vascular origin. Am J Med Sci 1936; 192: 109-112. 2 MARSTON A. Vascular Disease of the Gut: Pathophysiology, Recognition and Management. 2nd edn. Sevenoaks: Edward Arnold, 1986; 116-142. 3 CROFT RJ, MENON GP, MARSTON A. Does intestinal angina exist? A critical study of obstructed visceral arteries. Br J Surg 1981; 68: 316-318. 4 LILLYMP, HARWARDTRS, FLINN WR, BLACKBURNDR, ASTLEFORD PM, YAO JST. Duplex ultrasound measurement of changes in mesenteric flow velocity with pharmacologic and physiologic alteration of intestinal blood flow in man. J Vasc Surg 1989; 9: 1825. 5 ROBERTSL, WERTMAN DA, MILLS SR, MOORE AM, HEASTON DK. Transluminal angioplasty of the superior mesenteric artery: an alternative to surgical revascularisation. AJR 1983; 141: 10391042. 60DURNY A, SNIDERMAN KW, COLAPINTO RF. Intestinal angina: percutaneous transluminaI angioplasty of the celiac and superior mesenteric arteries. Radiology 1988; 167: 59-62. 7 GOLDEN DA, RING EJ, MCLEAN GK, FREIMAN DB. Percutaneous transluminal angioplasty in the treatment of abdominal angina. AJR 1982; 139: 247-249.
Accepted 16 August 1990
