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|Year : 2023 | Volume
| Issue : 3 | Page : 182-183
A case of abdominal angina treated by hybrid surgery
S Dighe1, R Shinde1, S Shinde2, P Raghuvanshi1
1 Department of Surgery, DMIMSU, AVBRH Campus Sawangi, Wardha, Maharashtra, India
2 Department of Pharmacology, DMIMSU, AVBRH Campus Sawangi, Wardha, Maharashtra, India
|Date of Submission||19-Jun-2022|
|Date of Decision||15-Sep-2022|
|Date of Acceptance||19-Sep-2022|
|Date of Web Publication||10-May-2023|
Dr. S Dighe
Department of Surgery, DMIMSU, AVBRH Campus Sawangi, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dighe S, Shinde R, Shinde S, Raghuvanshi P. A case of abdominal angina treated by hybrid surgery. J Postgrad Med 2023;69:182-3
We are reporting a case of a 65-year-old male—chronic smoker and tobacco-chewer—with complaint of diffuse abdominal pain since 2 years. He gave history of similar complaints in the past. He had been diagnosed as having celiac artery occlusion and had undergone endovascular stenting of celiac artery. Following the procedure, he was non-compliant to regular follow-up and had continued to smoke. Over a period of time, his abdominal discomfort had increased for which he consulted us. Physical examination revealed a mildly distended, non-tender abdomen with no guarding or rigidity. Peripheral arterial examination was normal. Per-rectal examination was non-significant. A CT angiography (CTA) and digital subtraction angiography (DSA) were performed which revealed a functional celiac artery stent with atherosclerotic changes in aorta along with a long-segment, calcified plaque at ostium of superior mesenteric artery (SMA) [Figure 1].
|Figure 1: Pre-operative CT angiography image—green indicates celiac artery with functioning stent, and red indicates superior mesenteric artery occlusion with calcified plaque at its ostium|
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Endovascular revascularization was attempted twice through the right brachial artery to bypass the occlusion, but this maneuver was abandoned as negotiation of the lesion via the guidewire was not possible as it failed to pass through the tight stenosis. We could not continue the same procedure as the patient was at a higher risk of arterial dissection. No percutaneous techniques were used as there would have been higher risk of bowel ischemia and perforation. Thus keeping all these contraindications in mind, we switched to a multidisciplinary approach of retrograde open mesenteric stenting (ROMS) which included interventional radiology as well as open exploratory laparotomy. A supra-umbilical midline laparotomy was performed. Intra-operatively, the bowel was inspected for any changes. As there were no significant findings, the small bowel mesentery was brought under vision, and SMA was located by palpating pulsations and re-confirmed by intra-operative doppler. Doppler also localized the pathology in the artery. After confirmation, a 21-G needle was inserted through SMA without creating an arteriotomy incision to achieve a retrograde access. A micro-guidewire was passed through this puncture site. After complete passage through SMA, the guidewire was then directed towards the aorta. Throughout the procedure, the position of guidewire was confirmed by imaging under fluoroscopic guidance. For completion, an antegrade guidewire was passed through the right brachial artery to reach the retrograde guidewire. At the meeting point, ends of the two guidewires were looped. A drug-eluting stent was then passed downward to the SMA via the right brachial artery to incorporate into stenosed segment to open the block. By fluoroscopic imaging, the correct position of the stent and complete revascularization of SMA were confirmed. The previously placed celiac artery stent was also noted at the same time [Figure 2].
|Figure 2: Post-operative CT angiography image—green indicates functional celiac artery stent in situ, and red indicates functional superior mesenteric artery stent in situ|
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In the present case, we used the hybrid technique to treat a long-standing case of chronic mesenteric ischemia (CMI), which showed a calcified plaque at the ostium of SMA along with a chronically stenosed long segment. Generally, such cases are managed using antegrade right brachial approach or femoral approach.
Here, negotiation of the guidewire across the stenosed segment of SMA was tried via antegrade approach but was unsuccessful due to patient's prior history and high-risk status. Therefore, we used the ROMS approach by puncturing it with a micro-needle, without performing a conventional repair of the mesenteric artery or making an incision (arteriotomy) over it.
In the literature, hybrid surgery with ROMS has been reported but without the technique of micro-needle puncturing which was used in the present case. Milner and Woo were the first surgeons to perform a hybrid ROMS in an old patient with acute mesenteric ischemia (AMI). Later on, quite a few surgeons have performed this hybrid surgery, but as per the available literature, all cases were patients with AMI unlike the present case which was of CMI. Very few reports mention its use in CMI. All the other conducted studies except one conducted on AMI has mentioned a ROMS with use of transverse arteriotomy followed by balloon angioplasty or stent placement. We performed ROMS via micro-puncturing of SMA with placement of drug-eluting stent through right brachial approach into stenosed SMA, which is novel in a way as it has not been documented earlier.,,,
Declaration of patient consent
The authors certify that appropriate patient consent was obtained.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| :: References|| |
Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemia: A case report. Vasc Endovascular Surg 2004;38:89-91.
Shinde R, Dighe S, Shinde S. A rare case of triple vessel disease of abdomen. Med Sci 2021;25:101-5.
Hohenwalter EJ. Chronic mesenteric ischemia: Diagnosis and treatment. Semin Intervent Radiol 2009;26:345-51.
Chen YA, Zhu J, Ma Z, Dai X, Fan H, Feng Z, et al.
Hybrid technique to treat superior mesenteric artery occlusion in patients with acute mesenteric ischemia. Exp Ther Med 2015;9:2359-63.
[Figure 1], [Figure 2]