Percutaneous transluminal angioplasty and stenting of coeliac artery stenosis in the treatment of mesenteric angina: a case report and review of therapeutic options

A. MOHAMMED#, N. B. TEO*, I. R. PICKFORD# and J. G. MOSS†
*Glasgow Royal Infirmary, #Victoria Infirmary,†Western Infirmary, Glasgow, U.K.

Introduction Case report

Method Discussion References

We report the case of a 72-year-old gentleman with mesenteric angina who was successfully treated with stenting of a coeliac artery stenosis using a Palmaz stent, and review the therapeutic options in the management of mesenteric angina.

Keywords: Chronic mesenteric ischaemia, coeliac artery stenosis, mesenteric angina, percutaneous transluminal angioplasty, stenting

J.R.Coll.Surg.Edinb., 45, December 2000, 403-407

INTRODUCTION

Mesenteric angina, also known as chronic mesenteric ischaemia or intestinal angina, is an uncommon and difficult diagnosis to make. The incidence has increased significantly over the past few decades due to the increasing number of elderly patients with atherosclerotic disease.

It is strongly associated with the presence of coronary artery disease, non-cardiac vascular disease and increasing age.^1-3

Mesenteric vascular disease is present in 18 per cent of patients aged over 65.⁴ Due to extensive collaterals, the great majority of patients remain asymptomatic with respective gastrointestinal symptoms.

Patients with mesenteric angina classically present with colicky abdominal pain following meals.^5-9 Over time, this leads to fear of eating and progressive weight loss. Symptoms often start 30-60 minutes after food ingestion and last up to several hours. Other patients present with more vague symptoms such as nausea, vomiting, diarrhoea and occasionally malabsorption.^9-12

The eventual diagnosis is often made after extensive gastrointestinal investigations have all proved to be negative and a high index of suspicion is required before arranging mesenteric angiography which provides the definitive diagnosis.

CASE REPORT

A 72-year-old gentleman presented with post-prandial colicky abdominal pain that started within 15-30 minutes of eating and lasted for up to several hours. This was associated with significant weight loss of more than 2 stones in less than six months. His past medical history revealed him to be a smoker, to have ischaemic heart disease and to have also had a previous cerebrovascular accident.

Extensive gastrointestinal investigations were performed and were normal. A computersied tomography (CT) scan was carried out and showed severe atherosclerosis affecting the aorta. In view of the patient's past medical history and the CT finding, a provisional diagnosis of mesenteric angina was made and it was decided to proceed to mesenteric angiography. This was carried out and revealed occlusion of the superior mesenteric artery and stenosis of the coeliac artery. The inferior mesenteric artery was patent.

In view of the fairly convincing history of chronic mesenteric ischaemia and progressive weight loss, it was decided to proceed to percutaneous transluminal angioplasty and stent placement at the site of stenosis affecting the coeliac artery.

METHOD

Due to the relatively unfavourable angle of the vessel, the patient was initially accessed via the left brachial artery but, unfortunately, an unknown asymptomatic left subclavian occlusion was encountered and this approach had to be abandoned.

The procedure, therefore, was carried out from the right groin. Figure 1 demonstrates the initial mesenteric angiograph that shows a stenosis of the coeliac artery. The ostial coeliac stenosis was crossed with a guidewire and the lesion dilated with a 6mm balloon (Figure 2).

There was considerable recoil and a Palmaz P154 stent was placed using a guiding catheter. Following the 6mm dilatation there was an excellent morphological result (Figure 3). Figure 4 shows the stent to be patent with good distal run off after seven months.

Figure 1: Mesenteric angiography: stenosis of coeliac artery 

Figure 2: Mesenteric angiography: cannulation of coeliac artery

Figure 3: Mesenteric angiography: patent stent at 7th month follow-up

DISCUSSION

Mesenteric angina occurs when stenosis or occlusion of the mesenteric artery limits blood flow to the intestine. Over 95 per cent of cases are due to aortic atherosclerosis encroaching on the ostia of visceral vessels. Other causes are extremely rare and include Fabry's disease,¹³ antiphospholipid antibody syndrome,^14,15 Behcet's disease,^16,17 thromboangitis obliterans,¹⁸ Takayasu's arteritis,¹⁹ Crohn's disease and external compression.

It is thought that two of the three vessels must be affected for the disease to become symptomatic, because the development of a collateral circulation between these vessels is fairly extensive. The failure to provide an increase in gastrointestinal blood flow following a meal due to the underlying narrowing of the mesenteric artery leads to gastrointestinal ischaemia and the onset of symptoms of "intestinal angina". The treatment of mesenteric angina aims to increase and, therefore, restore intestinal blood flow towards normal levels and various therapeutic options are available to achieve this.

Chronic mesenteric ischaemia is a condition which can present to both physicians and surgeons and one which is often difficult to diagnose and requires a high index of suspicion for the diagnosis to be made. It is a condition that is missed and failure to institute treatment can result in high mortality and morbidity. Successful management of the condition involves close clinical co-operation between physicians, surgeons and interventional radiologists in order for the best outcome for the patient.

Colour flow duplex scanning is increasingly used as the first line investigation of patients suspected of having mesenteric ischaemia.²⁰ It is non-invasive, risk free and can provide both anatomical and functional information about the visceral circulation in both the resting and post-prandial state.^21-24 It is also easily repeated and may be used to examine the effects of ongoing pharmacological and/or surgical therapy. However, ultrasonographic assessment of the mesenteric arteries is technically demanding, operator-dependent and time consuming. The images are frequently unsatisfactory owing to bowel gas, obesity and complex or post-operative anatomical relationships. Even when good images are obtained, interpretation is difficult. The gold standard investigation in the diagnosis of mesenteric angina is mesenteric angiography carried out by a skilled interventional radiologist. This will show either occlusion or narrowing of one or more of the visceral arteries.

Over the last 20 to 30 years the management of mesenteric angina has progressed through various phases. Initially, surgical treatment in the form of an endarterectomy or bypass procedure was used.^25-27 The most popular procedure was aortomesenteric bypass using a vein or synthetic materials.²⁸ Studies have reported that interventional surgery carries a significant mortality of up to 12%. ^25-27 Long-term results can, however, be excellent with patency rates as high as 96% ²⁶ and it seems unlikely that percutaneous transluminal angioplasty will ever match these patency rates.

Percutaneous transluminal angioplasty, on the other hand, carries a significantly lower morbidity.²⁹ It is minimally invasive and avoids the necessity for general anaesthesia. Where stenoses have been demonstrated, percutaneous transluminal angioplasty has obvious advantages over surgical intervention. It may, however, carry the risk of creating arterial spasm, emboli or thrombosis with significant morbidity^29-32. However, the limited evidence in the medical literature indicates that it is a relatively safe procedure. The long-term results, however, are less satisfactory and recurrence of stenosis is significantly greater and up to 50% of patients develop re-stenosis within one year.³⁷

More recently, reports have appeared in the literature in which successful revascularisation of narrowed mesenteric arteries has been carried out using percutaneous transluminal angioplasty and stent placement. Although the technique is in the very early stages of being used in such conditions, it obviously has a place in patients with mesenteric angina. Like percutaneous transluminal angioplasty, it is minimally invasive and relatively safe.

However, the long-term results of this technique need to be evaluated and at the time of writing this report, the authors are only aware of two other published cases in which mesenteric angina has been successfully treated with percutaneous transluminal angioplasty and stenting. These have had follow-up periods of four months and nine months, respectively. ^{20, 29}

In the above patient we have a follow-up period of 12 months following stent insertion and during this period the patient has remained asymptomatic and has gradually gained weight. Follow-up angiography at seven months post-stenting was carried out and has demonstrated the stent to be patent (Figure 4).

Figure 4: Mesenteric angiography: satisfactory distal run-off at 7th month follow-up

Although the follow-up for the above cases is for a relatively short period of time, these early results would indicate that the technique is certainly one that is effective. The patency rates for stents may be better than the patency rates following simple percutaneous transluminal angioplasty although this would require a randomised and controlled clinical trial. However, in view of the relatively low prevalence of chronic mesenteric ischaemia it is unlikely that a randomised and controlled clinical trial will ever be done.

From the early reports in the literature, and our own case, the indications are that percutaneous transluminal angioplasty and stenting is a relatively safe procedure which is minimally invasive, and is effective in the treatment of mesenteric angina. Clinical follow-up of the patient is essential to identify any return of gastrointestinal symptoms and therefore instigate repeat mesenteric angiography to ascertain stent patency. However, follow-up mesenteric angiography is also important to demonstrate that the stent is patent, even in the absence of symptoms.

Long-term follow-up of these patients is important. The indications, at present, are that it is likely to have a favourable outcome. We would, therefore, advocate the use of percutaneous transluminal angioplasty and stenting of mesenteric arteries in selected patients with mesenteric angina.

Although significantly better long-term results are available from surgical revascularisation, percutaneous transluminal angioplasty does not compete with surgery but offers an alternative approach in the high-risk patient. As the mortality rate for coronary artery disease and stroke have fallen over the last 25 years the aged population has increased. Consequently, minimally invasive techniques, such as percutaneous transluminal angioplasty and stenting, have much to offer, albeit with possibly slightly inferior long-term results compared with surgery.

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Copyright date: 10th July 2000

 Correspondence to: Mr Nee Beng Teo, General Surgical Department, Hairmyres Hospital, Eaglesman Road East Kilbride G75 8RG, U.K.

E-mail: teonb@hotmail.com

©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 45, 6: 403-407