Celiac Artery Stent Placement for Coronary Ischemia Nicholas J. Madden,1 Carmen Piccolo,1 Ratna Kunasani,2 Chittur Mohan,2 Ali Khoobehi,2 and Richard Sohn,2 Philadelphia, Pennsylvania
Introduction: The use of endovascular technology for mesenteric interventions has become an increasingly accepted treatment modality. We present an unusual case of celiac artery stent placement for coronary ischemia. Case Description: A 66-year-old male with a history most notable for coronary artery disease and coronary artery bypass grafting (CABG) x 3 utilizing left internal mammary artery to left anterior descending, radial artery to first diagonal and his right gastroepiploic artery (GEA) to posterior descending artery presented with chest pain. His work-up included a cardiac catheterization that revealed a 90% stenosis at the origin of the celiac axis. A subsequent computerized tomography angiogram confirmed this and noted moderate stenosis of his superior mesenteric artery (SMA) as well as severe inferior mesenteric artery (IMA) stenosis. The patient was taken for mesenteric angiography by vascular surgery at which time he underwent balloon-expandable stent placement in the celiac axis. The patient tolerated this procedure well and was noted to have an improvement in his symptoms postoperatively. Discussion: Use of arterial conduits for CABG have proven to be superior to vein. Long-term viability of the GEA as a conduit is dependent in part on the patency of mesenteric circulation. Our findings demonstrate a viable endovascular treatment option for angina pectoris secondary to mesenteric stenosis in this unique patient population.
Atherosclerosis of the mesenteric circulation has an estimated prevalence of 20% in postmortem studies.1 While only the minority of these patients go on to develop manifestations of the disease, acute thrombotic occlusion can be associated with significant morbidity and mortality. Fortunately, upwards of 70% of patients present with symptoms such as abdominal pain before an acute thrombotic event which allows for an opportunity to empirically treat hemodynamically significant lesions.2 Historically, open surgical bypass was the mainstay of treatment
No grants, acknowledgements or competing interests. 1
Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA. 2
Division of Vascular Surgery, Aria Health System, Philadelphia,
PA. Correspondence to: Nicholas J. Madden, DO, PO Box 6, Bala Cynwyd, PA 19004, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 1319.e11–1319.e14 http://dx.doi.org/10.1016/j.avsg.2015.02.029 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 20, 2014; manuscript accepted: February 27, 2015; published online: June 12, 2015.
for patients. More recently however, endovascular modalities have proven to be a viable alternative in the management of symptomatic mesenteric occlusive disease.3,4 While ischemia to the gastrointestinal tract is the most common sequelae in the absence of adequate collateral circulation, in unique patient populations, extraintestinal manifestations must be considered and worked up accordingly. Herein, we present an unusual case and the successful endovascular management of coronary artery ischemia associated with a high-grade celiac artery stenosis.
CASE DESCRIPTION Informed consent was obtained before treatment and presentation of this case. A 66-year-old male presented to the emergency department with complaints of chest pain and dyspnea that was becoming progressively worse over 2 days. The pain was relieved with sublingual nitroglycerin. His relevant medical and surgical history was notable for coronary artery disease (CAD), ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, diabetes mellitus, hypertension, carotid endarterectomy in 1319.e11
1319.e12 Case reports
2012, as well as coronary artery bypass grafting in 2012 with the following conduits: left internal mammary artery to left anterior descending artery, radial artery to first diagonal branch, and right gastroepiploic artery (GEA) to posterior descending artery. His physical examination was essentially unremarkable. An electrocardiogram revealed a new inferior infarct. The patient was managed for acute coronary syndrome initially with standard medical therapy and a cardiac catheterization the following day. Left heart catheterization revealed a 90% circumflex lesion which was treated with a drug-eluting stent. In addition, a celiac angiogram revealed a high-grade stenosis at the origin of the celiac artery. Vascular surgery was consulted and a computerized tomography angiogram of the abdominal aorta with mesenteric runoff was obtained to better delineate his mesenteric vasculature. In addition to the celiac lesion (Fig. 1), he was noted to have moderate stenosis of both the superior and inferior mesenteric artery. The patient was consented for a mesenteric angiogram with possible intervention. Angiography revealed a patent conduit beyond the proximal celiac lesion (Figs. 2 and 3). A 7 mm 18 mm Express LD balloonexpandable stent (Boston Scientific, Marlborough, MA) was deployed at the origin of the celiac artery and postdeployment imaging revealed a patent celiac artery with good filling of the gastroepiploic conduit. A threedimensional reconstruction of his anatomy is seen in Figure 4. Postprocedurally, the patient did well and had resolution of his presenting symptoms.
Annals of Vascular Surgery
Fig. 1. Computerized tomography angiogram revealing a high-grade stenosis at the origin of the celiac axis.
DISCUSSION Mesenteric ischemia is a rare clinical entity encountered by vascular surgeons that has the potential to carry with it significant morbidity and mortality. While the sequelae are typically confined to the gastrointestinal tract, in select patients occlusive mesenteric disease can present atypically. For coronary revascularization it is well known that arterial conduits are superior to vein in terms of patency.5,6 The use of the internal mammary artery for instance has a 90% 10-year primary patency rate, while the 10-year patency rate is roughly 50%.7 Additional arterial conduits have been proposed to achieve a complete arterial revascularization. Despite this, the majority of patients are still revascularized with only one arterial conduit.7 Described by Bailey in 1966,8 the use of the right GEA as a myocardial implant (Vineberg-type myocardial implant9) for revascularization proved to be a technical success and ultimately provided symptomatic relief for many patients.8 A direct anastomosis of the GEA to a coronary artery was not reported until 1987 by Pym et al.10 Since that time, the proven long-term patency of the GEA
Fig. 2. Mesenteric angiography revealing a high-grade stenosis at the origin of the CA. CA, celiac axis.
makes it a viable, yet relatively underutilized conduit for coronary artery revascularization with its use mostly limited to only a few centers.11e13 Fifteen-year patency rates have been estimated at 70%.13 The right GEA is a terminal branch of the gastroduodenal artery which arises from the common hepatic artery in most people. It courses along the posterior surface of the proximal duodenum,
Vol. 29, No. 6, August 2015
Case reports 1319.e13
Fig. 3. Traversal of the celiac lesion demonstrates filling of the right gastroepiploic bypass. CA, celiac axis; HA, hepatic artery.
anterior to the pancreas as it travels toward the greater curvature of the stomach between the 2 layers of the gastrocolic omentum. It travels approximately two thirds the length of the greater curvature and has a variable termination point. The average diameter varies between 1 and 3 mm depending on the portion of the vessel.13 One approach to the mobilization of the GEA has been described by Suma.13 The median sternotomy incision is extended to a point halfway between the xiphoid and umbilicus. The peritoneal cavity is entered and the right GEA is identified along the greater curvature of the stomach. The GEA and the surrounding tissue are detached from the greater curvature as a pedicle with electrocautery, harmonic scalpel, or a series of ties. Mobilization begins at the lower margin of the pylorus and continued along the length of the greater curvature as long as a strong pulse is felt. It is then divided at this point and intraluminal papaverine hydrochloride is injected before placing a vascular clamp distally. The pedicle is assessed for hemostasis and the GEA meticulously skeletonized. The gastroepiploic vein which courses with the artery is also ligated at this time. The vessel is then brought anterior to the pylorus and introduced into the pericardial cavity through a small incision in the diaphragm. An anastomosis is then made to the target vessel in the usual fashion and the pedicle secured to the epicardium. Given the high incidence of concomitant CAD in patients with mesenteric atherosclerosis, vascular
Fig. 4. Three-dimensional reconstruction of mesenteric anatomy. CA, celiac axis; GDA, gastroduodenal artery; HA, hepatic artery.
surgeons should be mindful of this unique conduit and the potential consequences of a high-grade celiac stenosis. Additionally, all patients being considered for revascularization with this conduit should have mesenteric imagining preoperatively to ensure adequate patency. Uniform postoperative surveillance of this graft has yet to be defined, but duplex ultrasound in an experienced laboratory may be a cost-effective strategy to ensure patency of the mesenteric vessels.14 In terms of treatment of celiac lesions in this unique patient population, we believe that endovascular strategies are a viable option that should be attempted when possible. Open surgical revascularization of the celiac artery or in this case the posterior descending coronary artery would be an option if endovascular efforts fail.
CONCLUSION The right GEA is a rare conduit for coronary revascularization. In the setting of mesenteric atherosclerosis, this conduit can be compromised.
1319.e14 Case reports
Endovascular treatment modalities are a viable treatment option in this unique patient population. REFERENCES 1. Roobottom CA, Dubbins PA. Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: predictive value of Doppler sonography. Am J Roentgenol 1993;161:985e8. 2. Acosta S. Epidemiology of mesenteric ischemia: clinical implications. Semin Vasc Surg 2010;23:4e8. 3. Loffroy R, Guiu B, Cercueil JP, et al. Chronic mesenteric ischemia: efficacy and outcome of endovascular therapy. Abdom Imaging 2010;35:306e14. 4. Kougias P, El Sayed HF, Zhou W, et al. Management of chronic mesenteric ischemia. The role of endovascular therapy. J Endovasc Ther 2007;14:395e405. 5. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1e6. 6. Lytle BW, Blackstone EH, Sabik JF, et al. The effect of bilateral internal thoracic artery grafting on survival during 20 post-operative years. Ann Thorac Surg 2004;78:2005e12.
Annals of Vascular Surgery
7. Taggart D. Current status of arterial grafts for coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2: 427e30. 8. Bailey CP, Hirose T, Brancato R, et al. Revascularization of the posterior (diaphragmatic) portion of the heart. Ann Thorac Surg 1966;2:791e805. 9. Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation. Can Med Assoc J 1958;78: 871e9. 10. Pym J, Brown PM, Charrette EJP, et al. Gastroepiploic to coronary anastomosis: a viable alternative bypass graft. J Thorac Cardiovasc Surg 1987;94:256e9. 11. Dietl CA, Benoit CH, Gilbert CL, et al. Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery. Circulation 1995;92:92e7. 12. Pym J, Brown P, Pearson M, et al. Right gastroepiploic-tocoronary artery bypass. The first decade of use. Circulation 1995;92:45e9. 13. Suma H. Gastroepiploic artery in coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2:493e8. 14. Zwolak RM. Can duplex ultrasound replace arteriography in screening for mesenteric ischemia? Semin Vasc Surg 1999;12:252e60.
Introduction: The use of endovascular technology for mesenteric interventions has become an increasingly accepted treatment modality. We present an unusual case of celiac artery stent placement for coronary ischemia. Case Description: A 66-year-old male with a history most notable for coronary artery disease and coronary artery bypass grafting (CABG) x 3 utilizing left internal mammary artery to left anterior descending, radial artery to first diagonal and his right gastroepiploic artery (GEA) to posterior descending artery presented with chest pain. His work-up included a cardiac catheterization that revealed a 90% stenosis at the origin of the celiac axis. A subsequent computerized tomography angiogram confirmed this and noted moderate stenosis of his superior mesenteric artery (SMA) as well as severe inferior mesenteric artery (IMA) stenosis. The patient was taken for mesenteric angiography by vascular surgery at which time he underwent balloon-expandable stent placement in the celiac axis. The patient tolerated this procedure well and was noted to have an improvement in his symptoms postoperatively. Discussion: Use of arterial conduits for CABG have proven to be superior to vein. Long-term viability of the GEA as a conduit is dependent in part on the patency of mesenteric circulation. Our findings demonstrate a viable endovascular treatment option for angina pectoris secondary to mesenteric stenosis in this unique patient population.
Atherosclerosis of the mesenteric circulation has an estimated prevalence of 20% in postmortem studies.1 While only the minority of these patients go on to develop manifestations of the disease, acute thrombotic occlusion can be associated with significant morbidity and mortality. Fortunately, upwards of 70% of patients present with symptoms such as abdominal pain before an acute thrombotic event which allows for an opportunity to empirically treat hemodynamically significant lesions.2 Historically, open surgical bypass was the mainstay of treatment
No grants, acknowledgements or competing interests. 1
Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA. 2
Division of Vascular Surgery, Aria Health System, Philadelphia,
PA. Correspondence to: Nicholas J. Madden, DO, PO Box 6, Bala Cynwyd, PA 19004, USA; E-mail: [email protected] Ann Vasc Surg 2015; 29: 1319.e11–1319.e14 http://dx.doi.org/10.1016/j.avsg.2015.02.029 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 20, 2014; manuscript accepted: February 27, 2015; published online: June 12, 2015.
for patients. More recently however, endovascular modalities have proven to be a viable alternative in the management of symptomatic mesenteric occlusive disease.3,4 While ischemia to the gastrointestinal tract is the most common sequelae in the absence of adequate collateral circulation, in unique patient populations, extraintestinal manifestations must be considered and worked up accordingly. Herein, we present an unusual case and the successful endovascular management of coronary artery ischemia associated with a high-grade celiac artery stenosis.
CASE DESCRIPTION Informed consent was obtained before treatment and presentation of this case. A 66-year-old male presented to the emergency department with complaints of chest pain and dyspnea that was becoming progressively worse over 2 days. The pain was relieved with sublingual nitroglycerin. His relevant medical and surgical history was notable for coronary artery disease (CAD), ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, diabetes mellitus, hypertension, carotid endarterectomy in 1319.e11
1319.e12 Case reports
2012, as well as coronary artery bypass grafting in 2012 with the following conduits: left internal mammary artery to left anterior descending artery, radial artery to first diagonal branch, and right gastroepiploic artery (GEA) to posterior descending artery. His physical examination was essentially unremarkable. An electrocardiogram revealed a new inferior infarct. The patient was managed for acute coronary syndrome initially with standard medical therapy and a cardiac catheterization the following day. Left heart catheterization revealed a 90% circumflex lesion which was treated with a drug-eluting stent. In addition, a celiac angiogram revealed a high-grade stenosis at the origin of the celiac artery. Vascular surgery was consulted and a computerized tomography angiogram of the abdominal aorta with mesenteric runoff was obtained to better delineate his mesenteric vasculature. In addition to the celiac lesion (Fig. 1), he was noted to have moderate stenosis of both the superior and inferior mesenteric artery. The patient was consented for a mesenteric angiogram with possible intervention. Angiography revealed a patent conduit beyond the proximal celiac lesion (Figs. 2 and 3). A 7 mm 18 mm Express LD balloonexpandable stent (Boston Scientific, Marlborough, MA) was deployed at the origin of the celiac artery and postdeployment imaging revealed a patent celiac artery with good filling of the gastroepiploic conduit. A threedimensional reconstruction of his anatomy is seen in Figure 4. Postprocedurally, the patient did well and had resolution of his presenting symptoms.
Annals of Vascular Surgery
Fig. 1. Computerized tomography angiogram revealing a high-grade stenosis at the origin of the celiac axis.
DISCUSSION Mesenteric ischemia is a rare clinical entity encountered by vascular surgeons that has the potential to carry with it significant morbidity and mortality. While the sequelae are typically confined to the gastrointestinal tract, in select patients occlusive mesenteric disease can present atypically. For coronary revascularization it is well known that arterial conduits are superior to vein in terms of patency.5,6 The use of the internal mammary artery for instance has a 90% 10-year primary patency rate, while the 10-year patency rate is roughly 50%.7 Additional arterial conduits have been proposed to achieve a complete arterial revascularization. Despite this, the majority of patients are still revascularized with only one arterial conduit.7 Described by Bailey in 1966,8 the use of the right GEA as a myocardial implant (Vineberg-type myocardial implant9) for revascularization proved to be a technical success and ultimately provided symptomatic relief for many patients.8 A direct anastomosis of the GEA to a coronary artery was not reported until 1987 by Pym et al.10 Since that time, the proven long-term patency of the GEA
Fig. 2. Mesenteric angiography revealing a high-grade stenosis at the origin of the CA. CA, celiac axis.
makes it a viable, yet relatively underutilized conduit for coronary artery revascularization with its use mostly limited to only a few centers.11e13 Fifteen-year patency rates have been estimated at 70%.13 The right GEA is a terminal branch of the gastroduodenal artery which arises from the common hepatic artery in most people. It courses along the posterior surface of the proximal duodenum,
Vol. 29, No. 6, August 2015
Case reports 1319.e13
Fig. 3. Traversal of the celiac lesion demonstrates filling of the right gastroepiploic bypass. CA, celiac axis; HA, hepatic artery.
anterior to the pancreas as it travels toward the greater curvature of the stomach between the 2 layers of the gastrocolic omentum. It travels approximately two thirds the length of the greater curvature and has a variable termination point. The average diameter varies between 1 and 3 mm depending on the portion of the vessel.13 One approach to the mobilization of the GEA has been described by Suma.13 The median sternotomy incision is extended to a point halfway between the xiphoid and umbilicus. The peritoneal cavity is entered and the right GEA is identified along the greater curvature of the stomach. The GEA and the surrounding tissue are detached from the greater curvature as a pedicle with electrocautery, harmonic scalpel, or a series of ties. Mobilization begins at the lower margin of the pylorus and continued along the length of the greater curvature as long as a strong pulse is felt. It is then divided at this point and intraluminal papaverine hydrochloride is injected before placing a vascular clamp distally. The pedicle is assessed for hemostasis and the GEA meticulously skeletonized. The gastroepiploic vein which courses with the artery is also ligated at this time. The vessel is then brought anterior to the pylorus and introduced into the pericardial cavity through a small incision in the diaphragm. An anastomosis is then made to the target vessel in the usual fashion and the pedicle secured to the epicardium. Given the high incidence of concomitant CAD in patients with mesenteric atherosclerosis, vascular
Fig. 4. Three-dimensional reconstruction of mesenteric anatomy. CA, celiac axis; GDA, gastroduodenal artery; HA, hepatic artery.
surgeons should be mindful of this unique conduit and the potential consequences of a high-grade celiac stenosis. Additionally, all patients being considered for revascularization with this conduit should have mesenteric imagining preoperatively to ensure adequate patency. Uniform postoperative surveillance of this graft has yet to be defined, but duplex ultrasound in an experienced laboratory may be a cost-effective strategy to ensure patency of the mesenteric vessels.14 In terms of treatment of celiac lesions in this unique patient population, we believe that endovascular strategies are a viable option that should be attempted when possible. Open surgical revascularization of the celiac artery or in this case the posterior descending coronary artery would be an option if endovascular efforts fail.
CONCLUSION The right GEA is a rare conduit for coronary revascularization. In the setting of mesenteric atherosclerosis, this conduit can be compromised.
1319.e14 Case reports
Endovascular treatment modalities are a viable treatment option in this unique patient population. REFERENCES 1. Roobottom CA, Dubbins PA. Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: predictive value of Doppler sonography. Am J Roentgenol 1993;161:985e8. 2. Acosta S. Epidemiology of mesenteric ischemia: clinical implications. Semin Vasc Surg 2010;23:4e8. 3. Loffroy R, Guiu B, Cercueil JP, et al. Chronic mesenteric ischemia: efficacy and outcome of endovascular therapy. Abdom Imaging 2010;35:306e14. 4. Kougias P, El Sayed HF, Zhou W, et al. Management of chronic mesenteric ischemia. The role of endovascular therapy. J Endovasc Ther 2007;14:395e405. 5. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1e6. 6. Lytle BW, Blackstone EH, Sabik JF, et al. The effect of bilateral internal thoracic artery grafting on survival during 20 post-operative years. Ann Thorac Surg 2004;78:2005e12.
Annals of Vascular Surgery
7. Taggart D. Current status of arterial grafts for coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2: 427e30. 8. Bailey CP, Hirose T, Brancato R, et al. Revascularization of the posterior (diaphragmatic) portion of the heart. Ann Thorac Surg 1966;2:791e805. 9. Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation. Can Med Assoc J 1958;78: 871e9. 10. Pym J, Brown PM, Charrette EJP, et al. Gastroepiploic to coronary anastomosis: a viable alternative bypass graft. J Thorac Cardiovasc Surg 1987;94:256e9. 11. Dietl CA, Benoit CH, Gilbert CL, et al. Which is the graft of choice for the right coronary and posterior descending arteries? Comparison of the right internal mammary artery and the right gastroepiploic artery. Circulation 1995;92:92e7. 12. Pym J, Brown P, Pearson M, et al. Right gastroepiploic-tocoronary artery bypass. The first decade of use. Circulation 1995;92:45e9. 13. Suma H. Gastroepiploic artery in coronary artery bypass grafting. Ann Cardiothorac Surg 2013;2:493e8. 14. Zwolak RM. Can duplex ultrasound replace arteriography in screening for mesenteric ischemia? Semin Vasc Surg 1999;12:252e60.
