Minimally Invasive Stenting Option for Mesenteric Ischemia
Date: June 15, 2012
Although coronary atherosclerosis is in the news all the time, there’s little attention paid to the fatty deposits that build up in the arteries that feed the intestines. Therefore, chronic mesenteric ischemia is often diagnosed at a later, life-threatening stage. By the time patients come for treatment, they are usually very weak and undernourished and are not good candidates for an open operation to bypass the blockages.
Johns Hopkins vascular and endovascular surgeon Christopher Abularrage has been treating patients who have chronic mesenteric ischemia in a minimally invasive way, using covered stents. Patients are awake but sedated and can go home the next day.
“Patients with mesenteric ischemia typically have multivessel blockages in their superior mesenteric artery and the celiac axis,” Abularrage says. “We start by inserting a catheter through the patient’s arm, down the chest into the abdominal aorta. From there, we pass a wire through each blockage and then deploy a covered stent that is mounted on a balloon to open the vessels.”
Abularrage explains that the procedure can be performed through the brachial artery in the arm or through the femoral artery in the groin. However, going through the arm may be an easier route than going through the groin due to the sharp angled take-off of the superior mesenteric and celiac arteries. Both procedures can be performed percutaneously with minimal pain for the patient.
Abularrage and his colleagues are studying whether covered stents increase patency of the vessels compared with the older, bare metal stents. He theorizes that they are able to stay open longer because they have more radial force and also decrease restenosis because of their effect on intimal hyperplasia.
“Uncovered stents have been used as a bridge to bypass—treating patients’ symptoms so that they are pain-free and able to eat more and build their strength. However, covered stents may replace the need for a bypass,” says Abularrage, who adds that none of the patients he treated more than a year ago with covered stents has had a recurrence.
One of his recent patients, 62-year-old Homer Pullen, of West Virginia, had already gone through a triple coronary artery bypass surgery when he developed mesenteric ischemia. “It was heartbreaking,” Pullen says. “I tried to eat but couldn’t because of the pain, and I went from 180 pounds to 132.”
He was referred to Abularrage, who performed the percutaneous procedure, starting in Pullen’s arm. Within a month, Pullen had gained back more than 20 pounds. “I now eat everything—even spaghetti with meat sauce and ham and eggs, and I feel great,” says Pullen, who has been able to go back to hunting, fishing and other activities with his friends that he couldn’t enjoy before.
Abularrage says most patients with chronic mesenteric ischemia are over age 60, often with a history of smoking and a high cholesterol level. It affects more men than women. Patients present with postprandial abdominal pain and significant weight loss, but sometimes the symptoms can be mistaken for gallbladder disease or kidney stones, which is why it is often diagnosed after it has progressed.
The risk factors for chronic mesenteric ischemia are the same as those for coronary artery disease and peripheral arterial disease. Abularrage says the short-term prognosis for Pullen and others following treatment is excellent, provided that they make healthy diet and lifestyle changes and they stop smoking.