Drug-eluting stent for recurrent mesenteric artery in-stent restenosis

Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia

Background: To analyse the long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) in the treatment of chronic mesenteric ischemia (CMI), and to assess predictive factors for a better clinical outcome. Patients and methods: Retrospective analysis of 76 consecutive patients, treated percutaneously for CMI between January 1999 and January 2018 and followed up until the end of 2018. Patients' pre-, peri- and post-interventional clinical and radiological data were gathered from the institutional electronic medical records. The Kaplan Meier method with log rank test or the Cox model were used to analyse overall survival; the cumulative incidence function with Pepe and Mori test or the Fine and Grey model were used to analyse relapse-free survival, considering death as a competing event. Results: Seventy-six consecutive patients with a mean age of 72 years were included in the study. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23 (29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical success was achieved in n=68 (89.5%), and procedural complications were observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n=21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0% and 28.2% after two, five and ten years of follow-up, respectively. A trend towards longer relapse-free survival was found in the circumferential stenosis group (78.2% at five years) compared with the non-circumferential stenosis group (55.5%) (P=0.063). Conclusions: Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite a substantial number of patients experiencing clinical relapse over time. Patients with focal, circumferential stenosis might have longer relapse-free survival than patients with non-circumferential stenosis.

Successfully superior mesenteric artery stenting in operated type A aortic dissection complicated with delayed mesenteric malperfusion

Here, we describe a case of a 61-year-old male patient with acute type A aortic dissection involving the ascending aorta, aortic arch, descending aorta, and the abdominal aorta down to the iliac bifurcation with evidence of left common iliac artery occlusion. Computed tomography angiography revealed progressive dissection into the superior mesenteric artery and left renal artery with no clinical signs of mesenteric ischemia. Emergent ascending aortic reconstruction of the dissected aorta relieves the leg ischemia. On a postoperative day 9, the evolution was complicated by massive right hemothorax. Although the patient was hemodynamically stable after obtaining hemostasis, the patient developed paralytic ileus with a high elevated lactate level. Visceral malperfusion was not detected by exploratory laparotomy. Emergency abdominal aortic angiography revealed superior mesenteric artery intermittent occlusion, successfully treated by stenting implantation.

Exploring the value of the double source CT angiography in diagnosing in-stent restenosis in lower limb artery

OBJECTIVES

This paper is aimed to explore the value of double source CT angiography (DS-CTA) for diagnosing in-stent restenosis in lower limb artery.

METHODS

From January 2016 to October 2018, all patients with stent in lower limb artery in our hospital were investigated by both DS-CTA and digital subtraction angiography. We measured the minimum lumen diameter and the diameter of the proximal normal vessels under each stent placement. The in-stent restenosis is defined as restenosis when the lumen area decreased by more than 50%. Digital subtraction angiography was performed within 1 week after DS-CT scan. Relationship between DS-CTA and digital subtraction angiography for diagnosing in-stent restenosis in lower limb artery was analyzed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of DS-CTA for diagnosis of in-stent restenosis were analyzed with digital subtraction angiography as the reference standard. A total of 68 stents were placed in 51 patients. Among these patients, 27 cases were diagnosed as in-stent restenosis, presenting as endovascular contrast agent bias or crescent filling defect with the lumen area reducing over 50%, 6 cases of which had no significant in-stent restenosis by digital subtraction angiography analysis. Furthermore, 12 cases were occlusion, in which there was no high density contrast agent in stents; the remaining 41 stents were unobstructed and the contrast agent was filled well, 8 cases of which had significant in-stent restenosis by digital subtraction angiography analysis. In addition, four stents were deformed or distorted. Statistical analysis demonstrated the concentrations of DS-CTA and digital subtraction angiography in diagnosing in-stent restenosis for lower limb artery were closely related, and the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of DS-CTA were 72.4%, 84.6%, 77.8%, 80.5%, and 79.4%, respectively.

CONCLUSION

DS-CTA has a potential reliability for diagnosis of in-stent restenosis in lower limb artery, which may be further improved to be used for clinical interventional treatment of vascular diseases.

Endovascular treatment of chronic mesenteric ischemia

PURPOSE

Data regarding endovascular treatment of chronic mesenteric ischemia (CMI) are sparse. Angioplasty is often accompanied by early restenosis and the need of further interventions. Thus we present our own patients' data and review the recent literature.

METHODS

We retrospectively reviewed all endovascular CMI treatments performed from 2008 to 2012 (27 patients, 14 females, mean age 70 ± 9 years). Patients' data were retrieved from electronic health records. Patients' follow-up included routinely performed color-coded ultrasonography, and, if performed for other clinical reasons, computed tomography or angiography. In addition, data extracted from 11 studies focusing on endovascular CMI treatment were analyzed.

RESULTS

Procedures were performed without clinical complications in all patients. Seven patients received pure angioplasty and 20 patients stent-assisted angioplasties using bare metal stents, respectively. Three patients died 3, 5 and 32 months after the intervention. Five patients underwent re-intervention (one early restenosis at day 4 after pure angioplasty with stent placement and four because of in-stent restenosis, 5 to 23 months after placement). Another patient was treated surgically because of stent occlusion and reoccurring abdominal angina 15 months after the intervention. The 11 studies found in the literature included 429 cases with 196 treatments of the coeliac trunk (truncus coeliacus = TC), 319 of the superior mesenteric artery (SMA) and 42 of the inferior mesenteric artery (IMA). Patency rates in the more recent studies were high with up to 80% within 1 year. Data of earlier studies report longer follow-up periods and indicate low patency rates after three years. Our 2-year patency rate of 50% is within the range of reported patency data.

CONCLUSIONS

The presented data show that endovascular SMA treatment is a suitable and safe procedure in patients suffering from CMI, but long-term results are limited.