# need help with sma and celiac stenting



## bhargavi (Sep 20, 2018)

Indications 

Mesenteric ischemia due to arterial insufficiency [K55.059 (ICD-10-CM)]
Celiac artery stenosis [I77.4 (ICD-10-CM)]
Superior mesenteric artery stenosis [I77.1 (ICD-10-CM)]
Conclusion 

This patient with known ischemic peripheral arterial disease previous iliac stenting has recently developed weight loss and postprandial abdominal pain and diarrhea.  Workup has revealed stenoses at the ostial segments of both celiac and SMA vessels by CT angiography, appearing to be quite significant.  Diagnostic angiography and possible intervention are planned.
*
After obtaining informed consent for the patient a 7 French sheath was placed into the right common femoral artery and a 5 French pigtail catheter was placed into the abdominal aorta and abdominal aortography with visceral flush angiogram was then performed.  After this a 7 French internal mammary guiding catheter was advanced into the ostium of the SMA with some difficulty.  0.018 wire was advanced into the distal vessel and angioplasty was performed with a 4.0 mm balloon.  Due to residual gradient and recoil, denting was then performed with placement of a single balloon expandable 7 mm x 19 mm Boston Scientific LD express stent deployed to high pressure, 14 and 16 atm.  Inflation was also accomplished with flaring of the ostial segment, the guiding catheter was repositioned with the balloon deflated into the distal stented segment in the balloon and wire were withdrawn for final hemodynamic recording and angiography with excellent angiographic and hemodynamic result.
*
Difficulty was then obtained in access in the ostium of the iliac with the IM catheter therefore a Cobra C1 7 French guide was with some difficulty finally able to access the ostium of the celiac and a 0.014 coronary wire was necessary to advanced distally into the celiac sub-branch.  Initial balloon angioplasty was then performed with a 4.0 mm coronary balloon, which then allowed positioning of the guide better into the ostium and a 0.018 support wire was advanced into the distal segment of the celiac and the initial 0.014 wire was removed.  A single stent was then placed due to residual gradient and recoil, this was a similar Boston Scientific balloon expandable LD express stent, 7 mm x 19 mm, again deployed to high pressure, with excellent angiographic result, after withdrawal of the balloon and wire no residual stenosis and resolution of hemodynamic gradient.
*
The guide was then withdrawn and the sheath was utilized for angiography and was found to be positioned at the common femoral bifurcation therefore closure was obtained with a Mynx closure device, patient did receive 5000 units of heparin at the initiation of the intervention and there were no complications.
*
*
Hemodynamics:
*
There were greater than 50 mm resting gradients across both celiac and SMA ostial proximal stenoses.
*
*
Diagnostic DSA
*
Abdominal aortography revealed single and patent renal vessels, severe calcification and ostial severe stenosis was present at the celiac and SMA origin, with moderate to heavy calcification.  Beyond this the vessels were widely patent both demonstrating post stenotic dilatation.
*
*
*
Intervention:
*
As detailed above both celiac and SMA lumen angioplasty was performed with subsequent stent placement in each, balloon expandable 7 mm stent dilated to near 8 mm final lumen with excellent angiographic and hemodynamic result.
*
*
*
Summary conclusion:
*
Mesenteric ischemia, celiac and SMA stenoses.
*
Successful PTA and balloon expandable stent placement celiac and SMA as detail
thanks in advance
I am thinking 37236,37237,75726,75774,36245,36245?


----------

