Mesenteric artery Intravascular lithotripsy and Stenting

This didactic procedure concerns a 72 years old women with a history of hypertension and Diabetes, she presented weight loss of 10 kilograms, distaste of meal and post prandial with pain one month before investigation.
CT scan showed: Complete occlusion of calcified celiac trunk with Severely calcified stenosed mesenteric artery. A collateral Riolan arc is present from inferior mesenteric artery to superior mesenteric artery. See CT figures
 

Educational objectives

• Plan a step-by-step procedure.
• How to select and brachial access.
• Use of IVL before stenting
• How to proceed to a safe and successful positioning of the endoprosthesis?
• Materials choice.
• Tips and tricks for vessel preparation a good endoprosthesis positioning
• Endoprosthesis deployment.

Step-by-step procedure:

1) Vascular imaging: CT/angiographic imaging

• Identifying the localization and the extent of the lesion
• Identifying the adjacent vessels that could interfere with the stent
• Identifying access challenges: vessel stenosis, tortuosity, anatomy

2) Vascular access

• 1st access: right brachial access: Gentle navigation through the brachial artery and advance a 90cm 6 Fr braided sheath introducer
• Crossing of mesenteric stenosis with JR4 5F 125cm and a 300 cm 0.014” Guidewire
• Dilatation with IVL catheter

3) Mesenteric artery stenting

• Identifying the proximal and distal landing zone
• Crossing of mesenteric stenosis with JR4 5F 125cm and a 300 cm 0.014” Guidewire
• Wiring lesion with a 0.014 ” Spartacore
• Dilatation with IVL catheter
• Advancement of the balloon Athletis 5 x 4 x 135 cm with active control with gentle navigation
• Predilatation with 12 ATM
• Angiographic control after predilatation
• After predilatation : Positioning of the endoprosthesis.
• Important remarks to take into consideration while positioning the endoprosthesis:
• Angiographic control of the position of the endoprosthesis

4) Deployment of the endoprosthesis

• Opening of the endoprosthesis
• Angiographic control of the deployment and the position of the first struts
• Adjust the endoprosthesis position up/downstream for an optimal positioning
• Complete opening of the endoprosthesis from distal to proximal
• Complete deployment after release the angulation control
• Angiographic control of the final endoprosthesis position

5) Vascular closure with manual compression

6) Clinical observation and Follow-up in CCU for 24h.

7) CT scan after procedure showed : Excellent deployment of the stent . Minimal residual stenosis

Before

After

Bibliography