CTA and MRA in Mesenteric Ischemia: Part 2, Normal Findings and Complications After Surgical and Endovascular Treatment
Ming-Chen Paul Shih1,2,
John F. Angle3,
Daniel A. Leung3,4,
Kenneth J. Cherry5,
Nancy L. Harthun5,
Alan H. Matsumoto3 and
Klaus D. Hagspiel1,3
1 Division of Noninvasive Cardiovascular Imaging, University of Virginia Health
System, 1215 Lee St., PO Box 800170, Charlottesville, VA 22908.
2 Present address: Department of Medical Imaging, Kaohsiung Medical University
Hospital, Kaohsiung, Taiwan.
3 Division of Interventional Radiology, University of Virginia Health System,
Charlottesville, VA.
4 Present address: Division of Interventional Radiology, Medical College of
Virginia, Richmond, VA.
5 Division of Thoracic and Cardiovascular Surgery, Department of Surgery,
University of Virginia Health System, Charlottesville, VA.
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Fig. 1A —43-year-old woman with history of Takayasu's arteritis, descending
thoracic aortic aneurysm (not shown), and premature atherosclerosis. Her
clinical complaint was classic triad of mesenteric ischemia. Thin-slab
maximum-intensity-projection MDCT angiograms before (A) and after
(B) surgery show that aortic endarterectomy was performed at distal
thoracic aorta and celiac trunk (arrowhead) as well as at origin of
superior mesenteric artery and paravisceral abdominal aorta through a
thoracoretroperitoneal approach. Note widely patent postoperative lumen.
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Fig. 1B —43-year-old woman with history of Takayasu's arteritis, descending
thoracic aortic aneurysm (not shown), and premature atherosclerosis. Her
clinical complaint was classic triad of mesenteric ischemia. Thin-slab
maximum-intensity-projection MDCT angiograms before (A) and after
(B) surgery show that aortic endarterectomy was performed at distal
thoracic aorta and celiac trunk (arrowhead) as well as at origin of
superior mesenteric artery and paravisceral abdominal aorta through a
thoracoretroperitoneal approach. Note widely patent postoperative lumen.
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Fig. 2 —56-year-old woman with claudication and intermittent abdominal pain.
Postoperative volume-rendered MDCT angiogram shows aortobifemoral bypass with
14 x 7 mm PTFE (polytetrafluoroethylene) graft, retrograde 6-mm PTFE
superior mesenteric artery bypass off aortobifemoral bypass graft
(arrowhead), and inferior mesenteric artery reimplantation
(arrow).
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Fig. 3A —58-year-old man who underwent placement of supraceliac bypass to
superior mesenteric artery (SMA) using reversed greater saphenous vein for
typical symptoms of chronic mesenteric ischemia. One year after surgery,
symptoms recurred that were found to be caused by stenosis of proximal graft
anastomosis and 70% stenosis in SMA just distal to graft anastomosis on
catheter angiography (not shown). Patient underwent recanalization of occluded
proximal native SMA and placement of balloon-expandable stent as well as
percutaneous transluminal angioplasty (PTA) of SMA just distal to anastomosis.
Stenosis in graft was not treated. MDCT angiogram immediately after
intervention shows vein graft stenosis (arrowhead), stent in proximal
SMA (solid arrow), and widely patent SMA after successful PTA
(black arrow).
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Fig. 3B —58-year-old man who underwent placement of supraceliac bypass to
superior mesenteric artery (SMA) using reversed greater saphenous vein for
typical symptoms of chronic mesenteric ischemia. One year after surgery,
symptoms recurred that were found to be caused by stenosis of proximal graft
anastomosis and 70% stenosis in SMA just distal to graft anastomosis on
catheter angiography (not shown). Patient underwent recanalization of occluded
proximal native SMA and placement of balloon-expandable stent as well as
percutaneous transluminal angioplasty (PTA) of SMA just distal to anastomosis.
Stenosis in graft was not treated. Follow-up MDCT angiogram 1 year later shows
that antegrade graft is now occluded, presumably because of progression of
intimal hyperplasia and reduced flow caused by patent SMA.
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Fig. 4A —47-year-old woman with mesenteric ischemia who received supraceliac
bifurcated bypass graft to celiac artery and superior mesenteric artery (SMA)
using 12 x 7 mm Hemashield Dacron graft (Boston Scientific). On
postoperative day 2, patient complained of abdominal pain. MDCT angiography
was performed and showed graft thrombosis. Sagittal multiplanar reformation
shows stump of graft (arrowhead) as well as two separate areas of
occlusion in SMA (arrows). Patient underwent emergent embolectomy
that restored patency of bifurcated graft. Hepatic graft anastomosis was
revised by inserting interposition graft.
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Fig. 4B —47-year-old woman with mesenteric ischemia who received supraceliac
bifurcated bypass graft to celiac artery and superior mesenteric artery (SMA)
using 12 x 7 mm Hemashield Dacron graft (Boston Scientific). On
postoperative day 2, patient complained of abdominal pain. MDCT angiography
was performed and showed graft thrombosis. Sagittal multiplanar reformation
(B) and volume-rendered MDCT angiogram (C) show patent
anastomosis and two patent limbs of Y-graft (arrowheads, C)
after successful surgical revision.
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Fig. 4C —47-year-old woman with mesenteric ischemia who received supraceliac
bifurcated bypass graft to celiac artery and superior mesenteric artery (SMA)
using 12 x 7 mm Hemashield Dacron graft (Boston Scientific). On
postoperative day 2, patient complained of abdominal pain. MDCT angiography
was performed and showed graft thrombosis. Sagittal multiplanar reformation
(B) and volume-rendered MDCT angiogram (C) show patent
anastomosis and two patent limbs of Y-graft (arrowheads, C)
after successful surgical revision.
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Fig. 5A —63-year-old woman with history of postprandial pain, 50-lb [22.5-kg]
weight loss, and aversion to food underwent MDCT angiography for assessment of
mesenteric circulation. Volume-rendered CT angiogram reveals severe celiac
artery stenosis as well as 4-cm-long proximal occlusion of superior mesenteric
artery (SMA) (arrows). Inferior mesenteric artery was prominent and
supplied SMA territory via Riolan's arch (arrowhead).
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Fig. 5B —63-year-old woman with history of postprandial pain, 50-lb [22.5-kg]
weight loss, and aversion to food underwent MDCT angiography for assessment of
mesenteric circulation. Volume-rendered CT angiogram after surgery shows
placement of supraceliac jump grafts in coronary artery and SMA using
Hemashield Dacron (Boston Scientific), which resulted in complete symptomatic
relief despite stenosis just distal to anastomosis with SMA
(arrowhead).
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Fig. 6 —86-year-old man who underwent placement of aortobiiliac graft and
inferior mesenteric artery (IMA) reimplantation (arrowhead) for
aneurysmal disease of aorta with insufficient intraoperative backbleeding from
IMA. Note right internal iliac artery aneurysm (arrow).
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Fig. 7 —45-year-old woman with median arcuate ligament syndrome who
underwent surgical median arcuate ligament release with antegrade celiac
artery bypass. Patient developed stenosis at proximal anastomosis
(arrowhead) that was subsequently treated with percutaneous
transluminal angioplasty.
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Fig. 8 —66-year-old man who underwent placement of aortobiiliac graft and
retrograde graft to superior mesenteric artery (SMA). He presents with acute
onset of abdominal pain. Sagittal multiplanar reformatted MDCT angiogram shows
occlusion of retrograde graft close to anastomosis caused by acute thrombus
(arrow). Anastomotic stenosis was identified at surgery as underlying
culprit lesion.
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Fig. 9 —26-year-old woman with Takayasu's arteritis who underwent placement
of extraanatomic aortic bypass for abdominal aortic occlusion (solid
arrow). Superior mesenteric artery (SMA) is supplied by graft off left
iliac artery (arrowheads), and right and left kidneys, via graft from
supraceliac aorta and extraanatomic aortic graft, respectively. Note old
thrombosed graft off right common iliac artery that previously supplied SMA
and celiac artery (open arrows).
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Fig. 10A —64-year-old woman with severe postprandial abdominal pain and weight
loss who underwent successful recanalization with percutaneous transluminal
angioplasty and stenting of celiac artery and superior mesenteric artery
(SMA), resulting in temporary reperfusion syndrome with ascites and
pancreatitis. Abdominal aortogram shows total occlusion of celiac trunk, SMA,
and inferior mesenteric artery at their ostia ("bald aorta").
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Fig. 10B —64-year-old woman with severe postprandial abdominal pain and weight
loss who underwent successful recanalization with percutaneous transluminal
angioplasty and stenting of celiac artery and superior mesenteric artery
(SMA), resulting in temporary reperfusion syndrome with ascites and
pancreatitis. Coronal subvolume maximum-intensity-projection (MIP) MDCT
angiogram after endovascular revascularization shows massive mesenteric
hyperemia as evidenced by strong portal venous enhancement in this arterial
phase scan.
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Fig. 10C —64-year-old woman with severe postprandial abdominal pain and weight
loss who underwent successful recanalization with percutaneous transluminal
angioplasty and stenting of celiac artery and superior mesenteric artery
(SMA), resulting in temporary reperfusion syndrome with ascites and
pancreatitis. Subvolume MIP of same MDCT angiogram shows ascites
(arrowhead) and enlarged pancreatic vessels (arrow). Liver
function abnormalities, pancreatitis, abdominal pain, and inability to
tolerate food normalized after 5 days, and patient was discharged with no
symptoms.
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Fig. 11A —70-year-old woman with history of hypercholesterolemia and bilateral
renal stents presents with intermittent abdominal pain, nausea, and diarrhea.
Catheter angiography showed ostial 90% celiac artery stenosis with pressure
gradient greater than 60 mm Hg that was successfully treated with
balloon-expandable stent dilated to 7 mm. Control angiogram immediately after
stent placement shows widely patent proximal celiac artery.
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Fig. 11B —70-year-old woman with history of hypercholesterolemia and bilateral
renal stents presents with intermittent abdominal pain, nausea, and diarrhea.
Catheter angiography showed ostial 90% celiac artery stenosis with pressure
gradient greater than 60 mm Hg that was successfully treated with
balloon-expandable stent dilated to 7 mm. Multiplanar reformation of MDCT
angiogram obtained day after intervention also shows widely patent stent.
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Fig. 12A —81-year-old woman with occlusion of celiac trunk and superior
mesenteric artery (SMA) as well as high-grade inferior mesenteric artery (IMA)
stenosis who underwent treatment with placement of two balloon-expandable
stents in IMA. Curved multiplanar reformation of MDCT angiogram after
revascularization shows widely patent stent lumen.
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Fig. 12B —81-year-old woman with occlusion of celiac trunk and superior
mesenteric artery (SMA) as well as high-grade inferior mesenteric artery (IMA)
stenosis who underwent treatment with placement of two balloon-expandable
stents in IMA. Volume-rendered image shows IMA stent (arrowhead) and
reconstitution of SMA and celiac trunk via Riolan's arch and
pancreaticoduodenal arcades, respectively.
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Fig. 13A —56-year-old man with calcified high-grade ostial superior mesenteric
artery stenosis who was treated with balloon-expandable stent. Angiogram after
completion of stent placement shows mild stenosis at inferior stent border due
to noncompressible plaque (arrowhead).
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Fig. 13B —56-year-old man with calcified high-grade ostial superior mesenteric
artery stenosis who was treated with balloon-expandable stent. Curved
multiplanar reformation of MDCT angiogram shows heavily calcified plaque
causing incomplete stent expansion (arrowhead).
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Fig. 14A —76-year-old woman who presented with persistent nausea, vomiting,
abdominal pain, and diarrhea of approximately 2 months' duration. Catheter
angiogram reveals 90% stenosis of superior mesenteric artery (SMA), large
calcified plaque at its ostium, and 50% celiac artery stenosis. After
successful stenting of SMA origin, patient experienced almost immediate
symptomatic relief from her abdominal pain.
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Fig. 14B —76-year-old woman who presented with persistent nausea, vomiting,
abdominal pain, and diarrhea of approximately 2 months' duration. Follow-up
MDCT angiogram shows widely patent stent. Nonocclusive protrusion of calcified
aortic plaque was present proximal to stent but could not be seen on
angiographic films.
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Fig. 15A —83-year-old woman with chronic occlusion of celiac trunk and
superior mesenteric artery (SMA) and high-grade stenosis of inferior
mesenteric artery (IMA) who underwent treatment with placement of
balloon-expandable stent in IMA (not shown). Preprocedure-rendered MDCT
angiogram shows IMA (arrowhead) and reconstitution of SMA and celiac
trunk via Riolan's arch and pancreaticoduodenal arcades, respectively. Patient
did well after discharge but presented 4 months later in emergency department
with acute abdomen.
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Fig. 15B —83-year-old woman with chronic occlusion of celiac trunk and
superior mesenteric artery (SMA) and high-grade stenosis of inferior
mesenteric artery (IMA) who underwent treatment with placement of
balloon-expandable stent in IMA (not shown). Emergent MDCT angiogram showed
occluded IMA stent (not shown) as well as complete bowel necrosis as evidenced
by extensive pneumatosis. Patient subsequently died.
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Fig. 16B —64-year-old man 16 months after placement of balloon-expandable
stent in superior mesenteric artery (SMA). Curved multiplanar reformation of
MDCT angiogram also shows hypodense intimal hyperplastic tissue in stent
(arrowhead).
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Fig. 17 —64-year-old woman 3 years after placement of balloon-expandable
stent in superior mesenteric artery (SMA). Curved multiplanar reformation of
MDCT angiogram shows stent fracture (arrowhead) and preserved stent
patency in this asymptomatic patient.
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Fig. 18A —60-year-old man who underwent stenting of ostial celiac artery
stenosis that was complicated by migration of stent due to undersizing.
Catheter angiogram shows stent free-floating in celiac artery
(arrowhead). Stent was then deployed more distally with larger
balloon but was not covering ostial lesion. A second stent was therefore
placed in ostium.
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Fig. 18B —60-year-old man who underwent stenting of ostial celiac artery
stenosis that was complicated by migration of stent due to undersizing.
Volume-rendered MDCT angiogram shows two stents (arrowheads).
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Copyright © 2007 by the American Roentgen Ray Society.
