In the time period between May 2019 and June 2020 in our institute three consecutive patients with CMI and CTOs of the SMA have been recanalized and stented in a retrograde manner via collaterals from the CA.
In two of these patients we found an additional stenosis of the CA. These stenoses were previously dilated and stented. Because the symptoms didn’t improve adequately after therapy, in a further intervention the frustrating attempt to recanalize the chronically occluded SMA directly from the abdominal aorta was performed. After that the recanalization of the proximally occluded SMA was successful using retrograde passage over collaterals from the CA in the same session.
In the third patient, after a failed attempt to recanalize the occluded SMA antegradely, retrograde recanalization of the occlusion of the SMA was done via collaterals from the CA in a second examination.
The patient population consisted of three women aged 77, 87 and 89 years. The complained symptoms had existed in all for several months, consisting of postprandial pain (3x), weight loss (3x; 10–15 kg) and diarrhea (1x).
Cardiovascular risk factors included hypertension (3x), hyperlipidemia (2x) and coronary heart disease (1x).
Technical procedure
Duplex ultrasonography was performed in all cases as pre-interventional imaging. Additionally abdominal computed tomography (CT) - and magnetic resonance imaging (MRI) – examinations were carried out in 2 respectively 1 case.
In all cases, a long 5-French (F) sheath was placed in the right common femoral artery percutaneously. Abdominal angiography with a pigtail catheter in several acquisition planes, including a lateral projection, was followed by selective angiography (Sidewinder I or Cobra catheter) of the SMA (Fig. 1). With a 0.018- or 0.014-in. guide wire, the attempt was made to recanalize the occlusion directly from the abdominal aorta. This attempt was frustrating in all cases. Therefore, the celiac artery was selectively probed with a Cobra- or Sidewinder I-catheter. With a coaxially inserted microcatheter and a 0.014-in. guide wire (300 mm), the passage was then made through the gastroduodenal artery and further via pancreatic arcades into the SMA (Fig. 2). In all cases, the occlusion located proximally in the SMA was first passed with the guide wire and then with the microcatheter from retrograde. The intraluminal position of the tip of the microcatheter was checked by contrast injection. After successful retrograde recanalization of the occlusion of the SMA with the guide wire and the microcatheter, an additional long 5-F sheath was introduced into the left groin. The free end of the 0.014-in. guide wire was captured with a loop catheter inserted through the sheath in the left common femoral artery and externalized (Fig. 3). The microcatheter was then carefully removed over the right sheath via the collaterals of CA. A thin-lumen balloon catheter was thereafter passed over the 0.014-in. guide wire through the left groin to the occluded segment of the SMA and this section was carefully dilated. In all cases we started with a 3 mm × 40 mm balloon; in 2 of the interventions a 4 mm × 40 mm balloon was additionally used afterwards. After removing the balloon catheter, the former occlusion of the SMA was supplied in all cases with a 5 mm × 18 mm balloon-expandable stent pre-mounted on a balloon at the distal tip of a rapid exchange-type delivery catheter. In one patient a second overlapping stent of the same type and size was implanted also via the left femoral artery access (Fig. 4). The catheters and sheaths were finally removed and the access routes supplied with closure systems.