Retrograde Superior Mesenteric Artery Stenting In Case Of SMA Shuttering
Jason Zhang, BS, Ann Gaffey, MD, Julia Glaser, MD, Venkat Kalapatapu, MD
University of Pennsylvania, Philadelphia, PA
DEMOGRAPHICS: A 71-year-old female with history of COPD and active smoking presents with subacute dyspnea and abdominal pain to a tertiary care center.
History: On initial evaluation, the patient was hemodynamically stable. She had a CT angiogram demonstrating type V thoracoabdominal aneurysm (maximum diameter 6.9cm) with significant mural thrombus. The celiac artery was stenotic, and the gastroduodenal artery filled primarily from the superior mesenteric artery (SMA). She underwent TEVAR with a Medtronic Navion Graft (40mm proximally and 46mm distally). The distal landing zone was marginal, so the SMA orifice was intended to be partially covered for a good seal. However, once the distal graft was deployed, the SMA was shuttered significantly. The SMA had sluggish inflow, but had excellent reconstitution from the inferior mesenteric artery. Following unsuccessful attempts to cannulate the SMA orifice, plans were made to observe for bowel ischemia. The following day, the patient developed a transaminitis (AST=1484/ALT=755) and an increasing lactate level (max=2.9).
Plan: Given concern for hepatic and bowel ischemia, the patient underwent emergent exploratory laparotomy. The liver appeared congested with no evidence of frank bowel ischemia. The SMA was isolated at the root of the mesentery, dissected out, and entered with a micropuncture needle following heparinization. A 7-French sheath and Glidewire were passed into the aorta. Using a Rosen wire, the glide catheter was maneuvered into the aortic graft with angiographic confirmation of the wire's location. An 8x38 balloon-expandable stent was then deployed into the distal portion of the thoracic stent and proximal SMA. Completion angiography demonstrated excellent flow into the SMA (figure).
Discussion: Shuttering refers to coverage of the SMA during aortic endovascular repair. Although the true incidence is unknown because patients may be asymptomatic depending on the extent of coverage, severe clinical consequences include mesenteric ischemia and visceral malperfusion. This is especially true in patients with celiac artery stenosis who rely on the SMA to perfuse the liver. Retrograde stenting of the SMA during laparotomy is used for patients with acute or chronic mesenteric ischemia with poor inflow for a bypass, and can be effectively used in patients with SMA shuttering from TEVAR.
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