A-73-year-old male patient with the history of hypertension, diabetes and lower extremity artery disease was referred to our hospital because of a 2-year history of post prandial abdominal angina. Upper and lower gastrointestinal endoscopies showed no abnormal findings. CT images revealed a heavily calcified CTO at the ostium of SMA (Fig. 1A and axial imaging in Supplementary Movie 1) and 3D-CT demonstrated a patent pancreaticoduodenal arcade with filling of the SMA from the celiac artery (Fig. 1B and C). Angiography of the celiac artery in the anteroposterior view revealed collateral blood flow to the SMA; however, the pancreaticoduodenal arcade was not visualized clearly (Fig. 2A and Supplementary Movie 2). According to the collateral route shown by the 3D-CT, we attempted TCA and retrograde wire crossing of the SMA-CTO. A 6.0-Fr Brite Tip Judkins Right4 guiding catheter (Cordis, Miami, FL, US) via the left radial artery was engaged in the ostium of the celiac artery. We advanced a 150 cm Corsair microcatheter (Asahi Intecc, Aichi, Japan) with a Hi-Torque Command 0.014 guide wire (Abbott Medical, Santa Clara, California, US) into the gastroduodenal artery. A Jupiter SFC guidewire (Boston Scientific, MA, US) was advanced into the superior pancreaticoduodenal artery and to the distal portion of the SMA-CTO. The CTO which was subsequently crossed with a Vassallo 14 guidewire (Cordis) (Fig. 2B). A 6.0-Fr long sheath was inserted into the right common femoral artery and a 12.0–20.0 mm En-Snare (Merit Medical, Tokyo, Japan) was used to capture the Vassallo 14 guidewire, which was withdrawn through the right femoral sheath. Eagle Eye intravascular ultrasound (IVUS; Philips Volcano, Rancho Cordova, CA, US) confirmed the intraplaque wire crossing (Supplementary Movie 3). After dilatation with a 6.0 mm Shiden HP balloon (Kaneka Medix, Osaka, Japan) at 20 atm (Fig. 2C), two 6.0 mm × 18 mm Express Vascular SD stents (Boston Scientific) were implanted in the SMA. IVUS revealed that the stents were well expanded (Supplementary Movie 4), and angiography showed antegrade blood flow in the SMA (Fig. 2D). The patient had no major post-operative complications and was discharged from the hospital. During 3 months after the EVT, the patient had no further episodes of abdominal angina on dual-anti-platelet therapy.
Additional file 3: Supplementary Movie 3. Intravascular ultrasound imaging of the superficial mesenteric artery before balloon dilatation.
Additional file 4: Supplementary Movie 4. Post-procedural imaging of Intravascular ultrasound in the superficial mesenteric artery.