Angioplasty and Stenting of the Mesenteric Arteries

Acute and chronic arterial mesenteric ischemia is medical and surgical challenge. Diagnosis at the early stage of acute mesenteric ischemia is based on a bundle of unspecific signs and time between initial pain and revascularization is a main factor of postoperative mortality and short bowel syndrome. Therefore, patients should be referred to a multidisciplinary team in order to get a rapid assessment, a multimodal treatment based on specific medical therapy, an emergent bowel revascularization +/− resection and intensive postoperative cares. Endovascular procedures for splanchnic vessels revascularization have overtaken the results of open surgical revascularization especially in acute setting. Different tips and tricks for mesenteric vessels stenting are discussed in the following chapter. Femoral access should remain the first approach using a 6 or 7 Fr long sheath. In patient with acute aortomesenteric angle, a brachial approach or the use of steerable sheath should facilitate the catheterization. In case of antegrade access failure or if a concomitant bowel resection is needed, retrograde open mesenteric artery stenting (ROMS) can be performed associated with mesenteric artery endarterectomy and patch angioplasty. This technique allows rapid revascularization with no aortic or iliac cross-clamping. Regarding their midterm results, balloon expandable covered stents are now the first choice to treat proximal lesion of celiac and mesenteric arteries. The distal end of the stent might be completed with an autoexpandable stent in case of arterial kinking to treat iatrogenic dissection, avoiding early thrombosis, whereas the proximal end can be flared to increase long-term patency and facilitate secondary reinterventions. Mortality of acute mesenteric ischemia decreased from 50–80% to 20% with the creation of dedicated intestinal stroke center and the wide development of endovascular techniques to achieve antegrade stenting, reducing the need for bowel resection and laparotomy. Endovascular management of mesenteric arteries occlusive diseases represents now the first line treatment for acute and chronic ischemia.