Akira Ouchi

Atsuyuki Maeda

DJ Brown

EJ Ryer

GS Oderich

IG Schoots

J Gagniere

JF Schellekens

Keitaro Kamei

Masatoshi Isogai

ML Schermerhorn

P Heiss

S Acosta

T Tallarita

TA Block

Toru Harada

Yuji Kaneoka

ZM Arthurs

English

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CASE REPORTDuodenal ulcer penetration into the superior mesenteric arteryafter percutaneous transluminal angioplasty and stent placementfor acute mesenteric ischemia: report of a caseAkira Ouchi • Masatoshi Isogai • Toru Harada •Yuji Kaneoka • Keitaro Kamei • Atsuyuki MaedaReceived: 7 September 2012 / Accepted: 3 February 2013 / Published online: 17 May 2013 The Author(s) 2013. This article is published with open access at Springerlink.comAbstract A 78-year-old male presented with the chiefcomplaints of abdominal pain and vomiting. Contrast-enhanced computed tomography and abdominal angiogra-phy showed occlusion of the superior mesenteric artery dueto thrombosis, and emergency percutaneous transluminalangioplasty and stent placement were carried out. Twomonths later, stent thrombosis developed, and a secondstent was placed. Eight months later, he complained ofgeneral fatigue and anorexia. Gastrointestinal endoscopyrevealed a duodenal ulcer at the third portion close to thesuperior mesenteric artery. Thirteen days after conservativemanagement, duodenal ulcer penetration into the superiormesenteric artery with subsequent air embolism developed,and the patient died of multiple organ failure.Keywords Acute mesenteric ischemia  Percutaneoustransluminal angioplasty  Stent placementIntroductionAcute mesenteric ischemia (AMI) is a life-threateningdisease. Despite the recent advances in the medical diag-noses and treatments, AMI still has a poor prognosis, within-hospital mortality rates of 59–93 % because of the non-specific symptoms and signs of the disease [1]. Even insurviving patients, the long-term prognosis is poor due toshort-bowel syndrome resulting from massive enterectomy.Open surgical treatment with superior mesenteric artery(SMA) bypass or embolectomy has been the standardtreatment for AMI, but the use of percutaneous translu-minal angioplasty (PTA) and stent placement has increasedin frequency. This is a less-invasive therapy than opensurgical treatment, and it enables physicians to proceedimmediately from diagnosis to treatment. According toSchermerhorn et al., PTA and stent placement ‘‘may beuseful in selected patients with AMI and appropriateanatomy’’ [2].PTA and stent placement is an effective treatment forAMI, but there are specific complications associated withthe procedure. For example, it has been reported thatpatients who undergo PTA and stent placement for AMIhave a potential risk of mesenteric artery complications,including distal mesenteric embolization, branch perfora-tion, dissection, stent dislodgement, stent thrombosis andstent fracture [3, 4]. We herein emphasize the potential riskassociated with stent placement in the SMA, particularlywhen it feeds many branches to the intestine by reporting aserious and previously unpublished complication of duo-denal ulcer penetration into the SMA.Case reportA 78-year-old Japanese male presented at our clinic withleft lower quadrant pain and vomiting. He had undergonedistal pancreatectomy and lymph node dissection for pan-creatic body cancer 10 years earlier, and he also had his-tories of diabetes mellitus and hyperlipidemia. There wastenderness in the left lower quadrant of the abdomenwithout signs of peritonitis. Complete blood counts showeda high number of white blood cells (WBC; 19750/lL) anda blood biochemistry analysis showed elevated levels ofA. Ouchi (&)  M. Isogai  T. Harada  Y. Kaneoka K. Kamei  A. MaedaDepartment of Surgery, Ogaki Municipal Hospital,4-86 Minaminokawa-cho, OgakiGifu 503-8502, Japane-mail: akioct9@yahoo.co.jp123Surg Today (2014) 44:1552–1555DOI 10.1007/s00595-013-0557-xlactase dehydrogenase (LDH; 283 IU/L), creatine phos-phokinase (CPK; 558 IU/L) and C-reactive protein (CRP;9.64 mg/L). The fibrin degradation products (5.6 lg/mL)and D-dimer (1.9 lg/mL) levels were also elevated. Con-trast-enhanced computed tomography (CECT) showedocclusion 3 cm across from the origin of the SMA (Fig. 1).The distal blood flow was maintained by collateral bloodcirculation, and there was no finding suggestive of necrosisof the intestine. We made the diagnosis of AMI and carriedout emergency abdominal angiography.Abdominal angiography by the right femoral approachshowed that the SMA was occluded at its origin due tothrombosis resulting from atherosclerotic disease. Weperformed thrombectomy (Thrombuster II, Kaneka Corp.Japan) and obtained recanalization. We also placed a self-expanding metallic stent (Zilver 7/40 mm, Cook MedicalUSA) into the SMA for residual stenosis. The first jejunalartery (JA) was occluded at its origin, and marginal arteriesof the first JA were maintained through collateral bloodcirculation from the second JA (Fig. 2). The patient’ssymptoms disappeared after the operation. We started toadminister aspirin at 100 mg/day from the day after theoperation to prevent stent thrombosis. He made satisfactoryprogress and was discharged from the hospital on post-admission day 23.Two months later, he returned to our clinic withabdominal pain. CECT showed stent thrombosis of theSMA. We carried out emergency abdominal angiographyagain, which showed stent occlusion due to thrombosis. Weperformed thrombectomy and secondary stent placement(Zilver 4/60 mm) into the distal side of the previous stentacross the origin of the second JA for residual stenosis,because we could not perform SMA bypass or embolec-tomy because of his past history of distal pancreatectomyand poor performance status. The blood flow of the secondJA was good, but had decreased in the marginal arteries ofthe first JA (Fig. 3). We started to administer clopidogrel(at 75 mg/day) and warfarin, in addition to aspirin. Hemade satisfactory progress and was discharged from hos-pital on post-admission day 17.Fig. 1 Contrast-enhanced computed tomography showed occlusion3 cm across from the origin of the SMA (down arrow)Fig. 2 Angiography during the first operation showed that the firstjejunal artery (JA) was occluded at its origin, and the marginal arteriesof the first JA were maintained through collateral blood circulationfrom the second JAFig. 3 Angiography during the second operation showed that theblood flow of the second jejunal artery (JA) was good, but that it haddecreased in the marginal arteries of the first JASurg Today (2014) 44:1552–1555 1553123Eight months later, he returned to our clinic again withgeneral fatigue, anorexia and melena. His complete bloodcount showed a low hemoglobin level (7.2 g/dL). Gastro-intestinal endoscopy showed a duodenal ulcer at the thirdportion (Fig. 4). We performed conservative managementwith fasting and a proton pump inhibitor. Thirteen daysafter admission, severe abdominal pain developed withsigns of peritonitis, which spread to the entire abdomen.The complete blood count and blood biochemistry analysisshowed a high WBC (12610/lL) and elevations of LDH(483 IU/L), CPK (467 IU/L) and CRP (24.16 mg/dL).Computed tomography showed an air embolism of theSMA, massive abdominal fluid collection and extensivemesenteric ischemia (Fig. 5). We diagnosed AMI due to airembolism of the SMA from a duodenal ulcer penetrationinto the SMA. At this time, his general condition wasalready too poor to tolerate open surgery, so we did notperform an operation. He died 18 days after admission.DiscussionPTA and stent placement for AMI has rapidly spreadaround the world during the last decade[5], based on recentstudies reporting favorable short-term outcomes withrevascularization rates of 73–100 % and in-hospital mor-tality rates of 24–36 % [6–10]. With the availability ofembolic protection devices and low-profile stent systems,mesenteric stent placement has emerged as a useful treat-ment strategy [11]. However, nearly 40 % of patients withmesenteric stent placement were reported to developin-stent restenosis, half of whom required reintervention [12].Furthermore, mesenteric stent placement remains con-troversial in terms of its complications. Here, we reportedthe development of duodenal ulcer penetration into theSMA with subsequent air embolism, which developed afterPTA and stent placement for AMI. To the best of ourknowledge, this is the first report of a serious complicationof PTA and stent placement.One possible cause of the duodenal ulcer related tomesenteric stent placement is a blood flow disturbance inthe duodenum wall. Angiography during the first operationshowed that the first JA was occluded at its origin, but thatthe marginal arteries of the first JA were maintainedthrough collateral blood circulation from the 2nd JA. At thesecond operation, however, the additional stent placedacross the origin of the second JA may have disturbed oroccluded the collateral blood circulation from the secondJA to the first JA, leading to reduced blood flow to the thirdportion of the duodenum. Moreover, there might have beenprior disruption of the collateral vessels due to the distalpancreatectomy for a pancreatic tumor. In our case, theduodenal ulcer occurred some time after stent placement.At the second operation, the blood flow of the second JAhad decreased, but was maintained at a sufficient level. Thethird portion of the duodenum would also be nourishedthrough the gastroduodenal artery (GDA)-inferior pan-creatoduodenal artery (IPDA) communication for a while.Although it is mere conjecture due to the lack of angio-graphic evidence, the duodenal ulcer might have beenassociated with the formation of a new microthrombusdistal to the first JA.Another possibility is mechanical irritation by the stents.One of the most serious complications after Y-graftplacement for an abdominal aortic aneurysm is an aorto-enteric fistula. Thus, chronic duodenal wall irritation bymesenteric stent placement might also be another possiblecause of duodenal ulcer formation. However, gastrointes-tinal endoscopy did not show any ischemic changes of theduodenum. We also consider that the duodenal ulcer mighthave occurred due to multiple causes, including blood flowdisturbance and mechanical irritation.Fig. 4 Gastrointestinal endoscopy showed a duodenal ulcer at thethird portion 8 months laterFig. 5 Computed tomography showed an air embolism of the SMA(down arrow), massive abdominal fluid collection and extensivemesenteric ischemia1554 Surg Today (2014) 44:1552–1555123Brown et al. [11] reported that mesenteric stenting isassociated with early restenosis and recurrent symptomsrequiring secondary procedures. But later, Block et al.reported that the results after endovascular and open sur-gical revascularization of AMI were favorable, in particu-lar, among the endovascularly treated patients [12]. Thesuperiority of mesenteric stenting remains controversial. Inour case, the patient’s performance status was poor, so weselected the less-invasive therapy.Our case suggests a possible role of mesenteric stentplacement in duodenal ulcer formation. Patients withmesenteric stent placement should be followed closely,especially those with reduced duodenal blood flow or withrepeated interventions due to an ongoing high risk for opensurgery. Long-term follow-up with a larger number ofpatients is necessary to ultimately determine the role ofmesenteric stent placement in duodenal ulcer formation.Conflict of interest Akira Ouchi and the co-authors have no con-flicts of interest to declare.Open Access This article is distributed under the terms of theCreative Commons Attribution License which permits any use, dis-tribution, and reproduction in any medium, provided the originalauthor(s) and the source are credited.References1. Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM.Systematic review of survival after acute mesenteric ischemiaaccording to disease etiology. Br J Surg. 2004;91:17–27.2. Schermerhorn ML, Giles KA, Hamdan AD, Wyers MC, Pom-poselli FB. Mesenteric revascularization: management andoutcomes in the United States, 1988–2006. J Vasc Surg.2009;50:341–8.3. Oderich GS, Tallarita T, Gloviczki P, Duncan AA, Kalra M,Misra S, et al. Mesenteric artery complications during angioplastyand stenting for atherosclerotic chronic mesenteric ischemia.J Vasc Surg. 2012;55:1063–71.4. Schellekens JF, Vos JA, van den Heuvel DA, Boersma D, deVries JP. Superior mesenteric artery stent fracture leading torecurrent mesenteric ischemia. Vasc Endovascular Surg.2011;45:654–9.5. Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S,et al. Revascularization for acute mesenteric ischemia. J VascSurg. 2012;55:1682–9.6. Acosta S, Block T, Bjornsson S, Resch T, Bjorck M, Nilsson T.Diagnostic pitfalls at admission in patients with acute superiormesenteric artery occlusion. J Emerg Med. 2012;42:635–41.7. Gagniere J, Favrolt G, Alfidja A, Kastler A, Chabrot P, CassagnesL, et al. Acute thrombotic mesenteric ischemia: primary endo-vascular treatment in eight patients. Cardiovasc Intervent Radiol.2011;34:942–8.8. Heiss P, Loewenhardt B, Manke C, Hellinger A, Dietl KH, SchlittHJ, et al. Primary percutaneous aspiration and thrombolysis forthe treatment of acute embolic superior mesenteric artery occlu-sion. Eur Radiol. 2010;20:2948–58.9. Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S,Sarac TP, et al. A comparison of endovascular revascularizationwith traditional therapy for the treatment of acute mesentericischemia. J Vasc Surg. 2011;53:698–704.10. Block TA, Acosta S, Bjorck M. Endovascular and open surgeryfor acute occlusion of the superior mesenteric artery. J Vasc Surg.2010;52:959–66.11. Brown DJ, Schermerhorn ML, Powell RJ, Fillinger MF, RzucidloEM, Walsh DB, et al. Mesenteric stenting for chronic mesentericischemia. J Vasc Surg. 2005;42:268–74.12. Tallarita T, Oderich GS, Macedo TA, Gloviczki P, Misra S,Duncan AA, et al. Reinterventions for stent restenosis in patientstreated for atherosclerotic mesenteric artery disease. J Vasc Surg.2011;54:1422–9.Surg Today (2014) 44:1552–1555 1555123

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Duodenal ulcer penetration into the superior mesenteric artery after percutaneous transluminal angioplasty and stent placement for acute mesenteric ischemia: report of a case

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Duodenal ulcer penetration into the superior mesenteric artery after percutaneous transluminal angioplasty and stent placement for acute mesenteric ischemia: report of a case

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