Recanalization of superior mesenteric artery chronic total occlusion using hybrid algorithm and dissection reentry device

Abstract

Chronic total occlusion (CTO) of mesenteric arteries with associated chronic mesenteric ischemia (CMI) is associated with high morbidity and mortality. Endovascular intervention has been associated with high technical success with high rates of freedom from symptoms and long‐term patency. However, to achieve high procedural success, use of optimal vascular access and expertise in CTO hybrid algorithm including advanced dissection reentry strategies are essential. We present a case of CMI from severe celiac artery (CA) stenosis and CTO of superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). After treatment of CA stenosis, we were unsuccessful in our first attempt at recanalization of SMA CTO. On second attempt, left brachial artery (BA) access was obtained and the hybrid algorithm along with use of Stingray Reentry balloon (Boston Scientific) for dissection reentry into true lumen was successful in recanalizing the SMA CTO with placement of balloon expandable covered stents (CS). To the best of our knowledge, this is the first case report utilizing Sting‐ray Reentry balloon in the mesenteric arteries.

Classification of the superior mesenteric artery

“…The SMA and its clinical aspects have been widely discussed in the literature (Bair et al, 2010; Kothari et al, 2011; Memon et al, 2020; Wall et al, 2014; Wei et al, 2019). However, no classification of the SMA based on its morphology has been generally accepted to date.…”

“…Detailed knowledge of the morphology of the SMA and all its probable branching patterns is a requirement for surgeons planning various types of invasive treatment, and for diagnosticians and radiologists, because these anatomical variations often have a significant bearing on how a patient should be treated, and sometimes they affect the disease process directly as part of its etiology. Procedures such as intestinal autotransplantation (Wei et al, 2019), SMA recanalization (Memon et al, 2020), SMA dissection (Bair et al, 2010; Wall et al, 2014; Wu et al, 2009) and SMA embolization (Ishii et al, 1996) are carried out in a very well vascularized area with a relatively small operating field, which makes them challenging for the clinician. Errors resulting from ignorance of the possible anatomical variations in this region can prove fatal, blocking the arterial supply to all or part of the gastrointestinal tract or causing severe hemorrhage.…”