Non-surgical treatment of chronic mesenteric ischemia owing to lesion in the SMA through the SMI: An option for consideration in frail patients

Chronic intestinal ischaemia, also called intestinal angina, consists of episodic or constant pain due to hypoperfusion as a result of mesenteric vessel occlusion.

Currently, the first-line treatment consists of angioplasty with percutaneous stenting of the affected vessel. When this technique is not successful, patient management can be difficult and the need for surgery or conservative measures must be assessed according to the patient's condition. This is why being aware of other therapeutic alternatives can be very relevant.

We present the case of a 71-year-old man, a smoker with a history of severe aortic regurgitation, hypertension, dyslipidaemia, who underwent surgery for adenocarcinoma of the head of the pancreas in 2012, who came to the A&E department for hypogastric pain coursing for 6 months, triggered after meals and associated with a weight loss of 10 kg.

On examination, the patient was stable, the abdomen was soft and depressible with discomfort in the hypogastrium without peritonism. Noteworthy test results included a value of 25,000 leukocytes and a C-reactive protein of 100 mg/dl. An abdominal CT scan was performed, showing stenosis and occlusion by thrombus in the middle third of the superior mesenteric artery (SMA) and ileal loops with wall thickening.

In view of this situation, an arteriography was performed to remove the thrombus. However, after several attempts, this proved impossible. Given the patient's comorbidity, the decision was taken, jointly with the Angio-radiology Department, to perform an arteriography of the inferior mesenteric artery (IMA), which presented a stenosis of 30% and in which drainage thereof with the SMA via the arc of Riolan was observed. It was decided to place a stent in the IMA to increase flow through the arc and increase the blood supply throughout the SMA (Fig. 1).

Figure 1.

Angioradiological image during stent implantation in IMA.

Seventy-two hours after the procedure, the patient presented an evident clinical improvement, corroborated by the analytical and imaging tests, whereupon he was discharged with double antiplatelet therapy. Six months after the procedure, the patient is asymptomatic.

Chronic mesenteric ischaemia is caused by hypoperfusion of the mesenteric vessels, usually due to atherosclerosis in them.¹ Up to 18% of the population over 65 years of age present mesenteric vessel involvement although they do not usually have symptoms.² When they do, it is usually post-prandial pain, weight loss and sometimes diarrhoeal stools that may be accompanied by blood.

Due to the presence of disease in these vessels, these patients are predisposed to suffering acute thrombotic occlusions which, when they occur, can develop into life-threatening acute ischaemia.

Treatment ranges from conservative management in patients without clinical symptoms and in whom the diagnosis is made incidentally, to surgery, seeking repermeabilisation endarterectomy, arterial bypass and mesenteric reimplantation. Given their complexity and associated morbidity and mortality, these techniques are currently a second-choice option.³

Today, the percutaneous endovascular approach is the first line of treatment in hospitals where a trained team is available. The technique of choice is angioplasty with stent placement, with success rates greater than 80% in SMA.⁴

If the desired therapeutic effect is not successfully achieved, most authors advocate surgery, an option that may pose a high surgical risk in patients with high comorbidity.

Therefore, being aware of other alternatives, such as performing a study of the IMA and placing a stent in patients with drainage between both regions, is an option to be considered which, while only reported in a small number of cases,⁵ may avoid aggressive surgery on a fragile patient. However, it is worth mentioning that decisions about the therapeutic algorithm to be followed should be made in multidisciplinary teams to provide the best treatment to the patient.

Conflicts of interest

The authors of this manuscript declare that there is no financial or personal relationship that could give rise to a conflict of interest.