The kissing stent technique is very useful in cases of the severe SMA stenosis with a rare anatomical variation wherein the SMA replaced common hepatic artery. Such anatomical variation causes the symptoms of CMI, although only one of three main mesenteric artery was involved.
The classic symptoms of CMI include abdominal pain, weight loss, and food fear (Gustavo and Oderich 2014). CMI rarely occurs concomitantly with PI and pneumoperitoneum, and the radiographic signs often indicate acute mesenteric ischemia (Yukaya et al. 2014). There are only a few cases of CMI presentation. Nicholas Dawe et al. reported a CMI case with PI and pneuemoperitoneum (Wayne et al. 2010). In our case, the symptoms of PI and pneumoperitoneum were caused by CMI, because there was no evidence of mesenteric artery occlusion nor intestinal ischemia.
As PI and pneumoperitoneum are often life-threatening if untreated, urgent surgical intervention is required (Dawe and Akhtar 2010; Greenstein et al. 2007). In our case, there were no signs of occluded mesenteric arteries or abdominal peritonitis; thus, non-surgical therapy was selected. Our patient received repeated and careful observation to evaluate the conservative management.
The mesenteric circulation is rich in collateral networks between the three main visceral artery territories and internal iliac arteries. Most symptomatic patients with CMI have significant stenosis or occlusion of at least two of the three mesenteric arteries (Gustavo and Oderich 2014). Michels reported that the percentage of the common hepatic arteries arising from the SMA is 2.5% (Michkels 1966).
Our patient had mesenteric ischemia due to severe stenosis of the origin of the common hepatic artery and SMA. If the common hepatic artery had not replaced the SMA, PI and pneumoperitoneum could not have occurred, because there is rich collateral flow between the celiac artery and SMA. This rare variation of the common hepatic artery and the SMA caused CMI symptoms due to severe stenosis of the two mesenteric arteries.
PI is a sign of underlying disease (St. Peter et al. 2003). One of many non-surgical causes of pneumoperitoneum is PI (Wayne et al. 2010). The pathogenesis is hypothesized to be a relationship of the multifaceted factors causing PI (St. Peter et al. 2003). One of these factors is vascular disease as an underlying disease. Vascular disease causes mucosal injury and increasing bacteria gas production due to a defect in the mucosal immune barrier. This pathologic combination induces gas translocation to the intramural compartment and peritoneum.
In our case, severe stenosis of the SMA origin replacing the common hepatic artery caused prolonged, reduced blood flow to the intestine. This contributed to mucosal injury. Over the past 5 months when CMI symptoms occurred, delayed stenosis treatment caused PI and pneumoperitoneum. If the SMA origin was occluded, necrosis of the intestine, a sign of acute mesenteric ischemia, would develop.
Revascularrization is indicated in patients with CMI symptoms to relieve symptoms and prevent bowel infarction (Pecoraro et al. 2013). ET and open bypass strategy is performed in patients with CMI. Angioplasty with stenting is superior to open bypass as the first treatment option (Oderich et al. 2009). In our case, ET was selected, because it is a minimally invasive strategy. In addition, to preserving blood flow to the SMA and the common hepatic artery, the kissing stent technique was performed to avoid potential risks, such as occlusion or embolization of another vessel. The kissing stent technique is common for complex aortoiliac bifurcation treatment. Many reports have demonstrated the efficacy of the technique (Houston et al. 2007). However, to our knowledge, there are no reports of the kissing stent technique used in the SMA and the common hepatic artery.
It is uncertain whether patients will need DAPT to prevent stent thrombosis. However, in our case, DAPT was continued for 12 weeks, after which aspirin was continued. Performing ET is more likely to develop restenosis and to undergo another intervention (Oderich et al. 2009). It is important to observe patients carefully because of this rare adverse effect when using ET with the kissing stent technique.