Bowel necrosis following endovascular revascularization for chronic mesenteric ischemia: a case report and review of the literature

Abdominal angina or CMI is characterized by postprandial abdominal pain and weight loss. Insufficient intestinal blood flow causes these symptoms and is usually produced by the obstruction of 2 or 3 splanchnic vessels [7]. The underlying etiology of this disease is atherosclerosis in more than 90% of cases. Other causes include fibromuscular dysplasia, vasculitis (such as Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, systemic lupus erythematosus, and thromboangiitis obliterans), malignancy, and radiation. Patients are initially treated with conservative therapy including bowel resting, smoking cessation, and administration of vasodilator drugs. Revascularization is considered if these conservative treatments fail to relieve the symptoms. Open surgery has been the standard method for revascularization in CMI. On the other hand, since the first report by Furrer et al. on the effectiveness of percutaneous transluminal angioplasty for CMI [2], ER has been considered as the treatment of choice in some cases [9]. Previous studies have reported the equivalent technical success and symptom relief rates, and lower morbidity in ER, compared with OR. Additionally, the primary patency rate is lower in ER than in OR, resulting in more secondary interventions [2, 3]. Therefore, ER is currently recommended for high-risk patients [8]. The therapeutic method for CMI should be carefully determined, because the treatment outcomes are often affected by systemic cardiovascular comorbidities, as in our patient.

Patients treated with ER can have associated procedure-specific complications, and sometimes follow catastrophic courses, as in the present case. Distal embolization and arterial dissection are often critical conditions. Eight cases of distal embolization as a complication of ER for CMI have been previously reported [4‐8]. All of these patients underwent bowel resection, and 7 of 8 patients died of postoperative multiple organ failure (Table 1). Bowel necrosis and subsequent sepsis can easily deteriorate the general condition of patients considered high risk for OR, causing 60% of all deaths after ER for CMI [4‐8]. Therefore, efforts should be made to prevent embolization.

Little is known about the impact of stent placement in terms of distal embolization. We did not use an embolic protection device (EPD), because there is little evidence showing its efficacy during ER for CMI. An EPD may be useful in some cases with CMI [10, 11]. Brown et al. [11] reported the feasibility of routine EPD use because there was no major perioperative morbidity in their endovascular treatment. In percutaneous revascularization and stent placement for renal artery stenosis, several reports have suggested the efficacy of EPDs [12, 13]. These studies showed that embolic particles were observed in 60–90% of cases treated for atherosclerotic renal arteries. However, EPD use involves the intrinsic complications of vasospasm, arterial dissection, arterial wall damage, distal hypoperfusion, and even distal embolization [14, 15]. Further studies are necessary to verify the usefulness of EPDs in cases with CMI.