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PATIENT CASE

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A 75-year-old man with a past medical history of coronary artery disease, congestive heart failure, and atrial fibrillation presented with chronic postprandial abdominal pain and significant weight loss. His physical exam revealed a soft abdomen with normal bowel sounds and no tenderness to palpation. He underwent computed tomography angiography (CTA) of the abdomen, which demonstrated severe ostial stenoses of the celiac artery, superior mesenteric artery, and inferior mesenteric artery (Figure 37-1). Invasive digital subtraction angiography confirmed the diagnosis of chronic mesenteric ischemia. Given his age and significant comorbidities, the decision was made to proceed with endovascular revascularization as the primary approach. The patient underwent successful placement of 2 balloon-expandable stents in the celiac and superior mesenteric arteries (Figures 37-2 and 37-3). He was discharged home on the same day of the procedure and was asymptomatic on routine outpatient follow-up.

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Figure 37-1

(A) Abdominal computed tomography angiography (CTA) with 3-dimensional reconstruction in the 75-year-old man presented in the patient case demonstrating a high-grade stenosis in the superior mesenteric artery (green arrowhead) and a high-grade stenosis in the celiac artery (red arrowhead) with downstream poststenotic dilatation (blue arrowhead). (B) CTA slice demonstrating the high-grade stenosis in the ostial celiac artery (red arrowhead) with downstream poststenotic dilatation (blue arrowhead). (C) CTA slice demonstrating the high-grade stenosis in the ostial superior mesenteric artery (green arrowhead).

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Figure 37-2

(A) Digital subtraction angiography (DSA) in the same 75-year-old man as in Figure 37-1 demonstrating the severe ostial celiac artery stenosis (red arrow). (B) Fluoroscopy demonstrating the deployment of a balloon-expandable stent (Herculink 7.0 × 18 mm; Abbott Vascular, Rockville, MD) at ostium of celiac artery after balloon angioplasty. (C) DSA after stent deployment demonstrating good stent apposition and widely patent flow down the celiac artery.

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Figure 37-3

(A) Digital subtraction angiography (DSA) in the same 75-year-old man as in Figures 37-1 and 37-2 demonstrating the severe ostial superior mesenteric artery (SMA) stenosis (red arrow). (B) ­Fluoroscopy demonstrating initial angioplasty of the ostial SMA stenosis with a small-diameter noncompliant balloon (Quantum 3.0 × 20 mm; Boston Scientific, Marlborough, MA). (C) ­Fluoroscopy after deployment of a balloon-expandable stent (Herculink 6.0 × 18 mm) demonstrating good stent apposition and widely patent flow down the SMA.

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