Primary percutaneous revascularization using coronary stent in a patient with acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) is an uncommon disorder with serious morbidity and mortality caused by acute obstruction of the intestinal vessels. The obstruction is generally due to cardiac thromboembolism or, less frequently, by the acute thrombosis on an existing atherosclerotic plaque. The most commonly involved vessel is the superior mesenteric artery (SMA).Surgical revascularization and resection is still the treatment of choice. Although percutaneous transluminal revascularization has been found to be as effective as surgical revascularization in chronic mesenteric ischemia, there is not enough evidence in literature for its use in acute cases. A 70-year-old female patient presented to our emergency department with an ongoing abdominal pain of 12-hour duration, nausea, vomiting and palpitation. She had a previous medical history of cerebrovascular accident (CVA), hypertension, chronic obstructive pulmonary disease, type 2 diabetes mellitus and atrial fibrillation (AF). She was under treatment with aspirin and warfarin for CVA and AF. On physical examination, the blood pressure was 80/50 mmHg and pulse rate 142 per minute. The heart sounds were normal and rhonchus was heard over bilateral lungs fields. The abdomen was tender and rebound pain was present. ECG was normal except for AF with high ventricular response. Laboratory results showed normal values of ALT, AST, amylase, lipase and troponin I, but leukocyte count and CRP were high (leukocyte: 20200/mm3, CRP: 237 mg/L). Her INR was 2.4. On abdominal computed tomography, diffuse increased wall thickness of the ileum and mesenteric edema were seen, and acute mesenteric ischemia was confirmed. Because of the patient’s clinical conditions, accompanying systemic diseases and the extended ischemia of the intestines, surgical mortality was considered very high. Percutaneous transluminal angioplasty was contemplated as is carried out in acute myocardial infarction. After obtaining written informed consent from the patient, celiac angiography was performed via the right femoral artery approach. A 100% occlusion was seen in the proximal SMA (Figure 1). Right Judkins catheter was used to engage the ostium of the SMA. The total occlusion was crossed with the floppy guide wire. After predilatation with a 2.75x30 mm balloon, two bare metal coronary stents of 4.5x24 mm and 4.5x20 mm were implanted end to end at 18 atm (Figure 2). A good distal flow was achieved (Figure 3). In addition to antibiotic and antiarrhythmic medications, heparin infusion was started. Clopidogrel loading and maintenance doses of 600 mg and 75 mg and acetyl salicylic acid 300 mg were also prescribed. Abdominal pain began to subside dramatically after the procedure and disappeared completely after one week. At the two-month follow-up, the intestinal functions have recovered and tomography taken at the 3-month follow-up