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Intramural dissection of superior mesenteric artery
Intramural dissection of superior mesentcric artery A complication of attempted renal artery balloon dilation M a l c o l m O. P e r r y , M . D . , New York, N. Y. A patient with a right renal artery stenosis and renovascular hypertension was admitted for balloon dilation o f the stenotie artery. During the procedure the catheter entered the superior mesenteric artery and caused a mural dissection and occlusion, which was successfully treated by endarterectomy and vein patch angioplasty. Delayed ischemia o f the transverse colon required resection and colostomy, but the patient recovered fully after colostomy closure and cholecystectomy were performed. (J VASC SURG 1985; 2:480-4.)
Dilation o f renal artery stenoses can be used successfully in the treatment o f renovascular hypertension.1 Spontaneous dissections o f atheromatous vessels occur but apparently are less frequent than those associated with fibromuscular dysplasia. 2 Catheterinduced dissections have been reported; they m a y be associated with only a localized injury to the artery and occasionally m a y be followed by spontaneous resolution, but m o r e extensive dissections are likely to produce complete occlusion, a'4 D u r i n g an attempt to dilate a stenotic lesion at the orifice o f the right renal artery in the patient reported here, the catheter entered the superior mesenteric artery (SMA) and p r o d u c e d an extensive dissection that caused immediate occlusion. CASE REPORT
A 65-year-old woman was admitted to The New York Hospital with a diagnosis of renovascular hypertension of several months' duration. She had previously been in another hospital and was found to have a systemic blood pressure of 190/110 mm Hg. At that admission a rightsided hemiparesis had developed as a result of a small cerebral hemorrhage in the left hemisphere, but gradually the symptoms cleared. During that hospitalization a renal sonogram revealed a right kidney of only 7.5 cm in polar length. The patient received atenolol and captopril, but adequate control of the blood pressure was not achieved. In 1976 the patient had an aortobi-iliac Dacron bypass graft to control claudication. At that time she was noted to have a smaller than normal aorta below the renal arteries (diameter <1 cm). From the Division of Vascular Surgery, Cornell University Medical College. Reprint requests: Malcolm O. Perry, M.D., Professor of Surgery, Cornell University Medical College, 1300 York Ave., New York, NY 10021. 480
At the present admission the patient had a blood pressure of 200/120 mm H g in the supine position and 160/ 105 mm H g when sitting. She had recovered from the stroke. Renal vein blood samples were obtained via a transfemoral venous approach and there was significant lateralization of renin production from the small right kidney. Arteriography identified a severe stenosis at the origin of the right renal artery (Fig. 1). The patient was discharged from the hospital and 1 month later was readmitted for balloon dilation of the right renal artery via a right femoral artery approach. Dilation was attempted, but the renal artery was never entered, and during the procedure catheter trauma to the SMA caused an acute intramural dissection and occlusion of the second portion of the SMA (Figs. 2 and 3). Severe abdominal pain developed and immediate surgery was undertaken. When the SMA was exposed, the dissection was noted to include approximately 6 cm of the artery distal to the takeoff of the middle colic artery. There were no puls: ~°. palpable in the mesentery, and the small bowel was gray and ischemic. Systemic heparinization was obtained and a linear arteriotomy was made in the SMA over the area of dissection. The endarterectomy plane was entered and the proximal SMA was deared to the orifice; the endarterectomy plane was terminated at the junction of the plaque with the distal intima. The ledge of distal intima was tacked down with interrupted sutures of 6.0 polyp ropylene. There was no back-bleeding from the middle colic artery, and despite an attempted thrombectomy, flow could not be restored in the smaller branches of this vessel. The longitudinal arteriotomy was closed with an autogenous saphenous vcin graft and flow was restored to the SMA circulation. Distal flow in the SMA was excellent, and there was pulsatile flow in the distal arcades. The small and large bowel appeared to be viable. Postoperatively the patient was in a hemodynamically stable condition, alert and awake, but complained of intermitrent pain in the abdomen at 5- to 15-minute intervals. There was tenderness but no abdominal spasm. The
Volume 2 Number 3 May 1985
Intramural dissection of superior mesenteric artery 481
Fig. 1. Aortogram obtained prior to attempted balloon dilation reveals tight renal artery stenosis (arrow) and aortoiliac bypass graft. pain was mainly centered in the left upper quadrant and had a pleuritic component. She required more fluid replacement than usual; it was suspected that bowel ischemia might be present, although colonoscopy did not reveal ischemic colon mucosa. During the next 8 hours pain increased and the patient was returned to the operating room. The transverse colon and the hepatic and splenic flexures were ischemic and nonviable. The SMA repair was intact and there were visible pulsations m the small bowel mesentery. The transverse colon was resected and an ascending colostomy and a distal mucus fistula were constructed. The wounds were closed and the patient was returned to the intensive care unit. After a convalescence of I month the patient was returned to the operating room and the colostomy was closed. She also underwent cholecystectomy and common duct exploration to control cholelithiasis. Subsequently the patient had a rather prolonged convalescence because of a superficial wound infection, but her blood pressure remained in the range of 160 to 170/80 to 90 mm Hg. She required no antihypertensive medication. She declined to have additional diagnostic studies, but an abdominal sonogram was performed prior to discharge and was reported as being normal. Urinary fimction was normal as evaluated by urinalysis and measurements of blood creatinine levels. After the surgical wound had healed, she was discharged without medication, with a blood pressure of 160/90 mm Hg. The patient returned to the care of her
private physician in her out-of-state home; the blood pressure has remained relatively normal and no additional procedures have been required.
DISCUSSION Although iatrogenic arterial injuries during the course o f diagnostic and therapeutic procedures with arterial catheters are uncommon, on occasion they are responsible for serious complications. 1,4 Arteriography performed by the Seldinger technique via the c o m m o n femoral artery is remarkably free of complications despite being used most often in patients with atherosclerotic arterial disease? More extensive manipulations such as may be required during balloon dilation would appear to be more likely to produce arterial injury and thus predispose to intramural dissection. F r o m June 1978 to September 1981 at The N e w York Hospital 104 renal artery dilations in 89 patients were performed, s There were no deaths caused by the procedure, but 14 significant complications were seen. These included transient renal failure (two) and myocardial ischemia (one). A m o n g the patients with atheromatous lesions (70 arteries) four renal artery dissections occurred; three were successfully treated by surgical repair, and one kidney was
Journal of VASCULAR SURGERY
482 Perry
Fig. 2. Dissection in SMA is clearly seen (large arrow). There is localized, nonobstructing dissection in aorta (small arrow). lost. Two renal artery dissections complicated balloon dilation of fibrous dysplastic lesions (34 arteries). One was repaired with an aortorenal bypass, and nephrectomy was needed in the other patient. Three other patients required surgical repair of the arterial puncture site. The complication rate in this series (15%) compares with the 9% rate reported by Martin and Cassarella. 6 The only nonrenal arterial dissection in this series is the subject of this report, but iliac and femoral artery dissections have been observed by others. 7 A computer search of the world literature failed to reveal other cases of SMA dissection as a complication of attempted balloon dilation of renal arteries, but widespread embolization of the mesenteric and peripheral circulation resulting in death has been reported. 7 Intramural dissection complicating such maneuvers would appear to be more likely in patients who have advanced atheromatous disease, especially when there are compound intimal plaques that might be more susceptible to injury by a catheter. Although the exact mechanisms causing the SMA dissection in
this patient are not known, the angiographers experienced difficulty in manipulating the catheter into the small renal artery orifice, and it went into the SMA on several occasions during the attempt to enter the renal artery. The dissection was easily diagnosed by the routine arteriography being performed durin~ the procedure. The direct surgical approach to the mesenteric artery was chosen because the arteriographic pictures showed the area of dissection clearly. The dissection occurred in the plane normally developed for a standard endarterectomy. Although distal disease was present within the artery, there was sufficient transition from abnormal to relatively normal intima to permit ending the endarterectomy under direct vision, but the distal ledge of intima was secured with interrupted sutures. Despite several attempts the middle colic artery could not be reopened because of its small size and extensive clots. Vein patch graft angioplasty was performed to widen the area of arteriotomy, particularly over the distal ledge ofintima. This technique may be useful especially in preservation of patency in small arteries. The bowel ap-
Volume 2 Number 3 May 1985
Intramural dissection of superior mesenteric artery 483
Fig. 3. Delayed film shows dissection and complete obstruction of SMA (arrow). peared viable and the visible pulsations in the small bowel mesentery indicated there was adequate blood flow to the intestines. Apparently because of loss of the inferior mesenteric artery with the previous aortic grafting procedurc, and perhaps because of a reduction in flow from the hypogastric and the middle hemorrhoidal vessels, there was inadequate blood flow to the transi,~rse colon. The importance of the middle colic artery is well known, especially when other collateral pathways have been interrupted during previous operations. The hypogastric circulation (contributing the middle hemorrhoidal artery), the open SMA, and celiac arteries appeared to be adequate at the initial procedure. The colon was normal in color, and although no pulsations were visible in the colon mesentery, artcrial Doppler signals werc prescnt. Despitc these assurances of viability, delayed ischemia of the colon occurred. There were no hypotensive episodes in the immediatc postoperativc period. Perhaps thromboembolism or distal propagation of clot from the occluded middle colic artcry was the cause of the subsequent ischemic colon. Additional systemic anticoagulants were not added after completion of the vascular repair.
The patient continued to have a relatively normal blood pressure throughout the postoperative period despite not receiving any antihypertensive medication. This may be because the right renal artery was occluded, and the kidney was no longer elaborating renin; but since she declined additional studies, this can only be speculative. It is clear that most of these angiographic procedures can be performed safely. If local injury to the artery does occur, and if it culminates in occlusion, expeditious repair is likely to be successful if it is not delayed beyond the time when clots can be successfully extracted, and blood flow can be reestablished. 8 An attempt should be made to open all major collateral vessels, because, as was seen in this patient who had previous aortic surgery, removal of another significant collateral artery may result in severe ischemia. 9 Vigorous early attempts to restore normal flow are appropriate in these patients. REFERENCES 1. Dean RH. Renovascular hypertension: An overview. In Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saundcrs Co, 1984:1100-8. 2. Pcrry MO. Spontaneous renal artery dissection. J Cardiovasc Surg 1982; 23:54-8.
484
Journal of VASCULAR SURGERY
Perry
3. Lang EK. A survey of the complications of percutaneous retrograde arteriography. Radiology 1963; 81:257-63. 4. Charlesworth PM, Brewster DC, Darling RC. Renal artery injury from a Fogarty balloon catheter, J VASC SURG 1984; 4:573-6. 5. Sos TA, Picketing TG, Sniderman .K, Saddekni S, Case DB, Silane MF, Vaughan ED, Laragh JH- Percutaneous transluminal renal angioplasty in renovascular hypertension due to atherorna or fibromuscular dysplasia. N Engl J Med 1983; 309:274-9. 6. Martin EC, Casarella WJ. Percutaneons transluminal anglo-
plasty in renovascular hypertension. In: Stanley JC, Ernst C~s, Fry WJ, eds. Renovascular hypertension. Philadelphia: WB Saunders Co, 1984:254-74. 7. Connolly JE, Kwaan JH, McCort PM. Complications after percutaneous transluminal angioplasty. Am J Surg 1981; 142:60-6. 8. Sachs SM, Morton JH, Schwartz SI. Acute mesenteric ischemia. Surgery 1982; 92:646-53. 9. Bergan JJ, Dean RH, Coma J, Yao JST. Revascularization in treatment of mesenteric infarction. Ann Surg 1975; 182: 430-8.
B O U N D VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF VASCULARSURGERY for 1985 are available to subscribers only. Active members of the two sponsoring societies will automatically receive a complimentary bound volume. They may be purchased from the publisher at a cost of $26.00 ($38.40 international) for Vol. 2 (January to December). Price includes shipping charges. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the voltmle. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Circulation Fulfillment, The C. V. Mosby Company, 11830 Westlinc Industrial Drive, St. Louis, M O 63146, USA. In the United States call toll free: (800)325-4177, ext. 351. In Missouri call collect: (314)872-8370, ext. 351. Subscriptions must bc in force to qualify. Bound volumes are not available in place o f a regular JOURNAL subscription.
Dilation o f renal artery stenoses can be used successfully in the treatment o f renovascular hypertension.1 Spontaneous dissections o f atheromatous vessels occur but apparently are less frequent than those associated with fibromuscular dysplasia. 2 Catheterinduced dissections have been reported; they m a y be associated with only a localized injury to the artery and occasionally m a y be followed by spontaneous resolution, but m o r e extensive dissections are likely to produce complete occlusion, a'4 D u r i n g an attempt to dilate a stenotic lesion at the orifice o f the right renal artery in the patient reported here, the catheter entered the superior mesenteric artery (SMA) and p r o d u c e d an extensive dissection that caused immediate occlusion. CASE REPORT
A 65-year-old woman was admitted to The New York Hospital with a diagnosis of renovascular hypertension of several months' duration. She had previously been in another hospital and was found to have a systemic blood pressure of 190/110 mm Hg. At that admission a rightsided hemiparesis had developed as a result of a small cerebral hemorrhage in the left hemisphere, but gradually the symptoms cleared. During that hospitalization a renal sonogram revealed a right kidney of only 7.5 cm in polar length. The patient received atenolol and captopril, but adequate control of the blood pressure was not achieved. In 1976 the patient had an aortobi-iliac Dacron bypass graft to control claudication. At that time she was noted to have a smaller than normal aorta below the renal arteries (diameter <1 cm). From the Division of Vascular Surgery, Cornell University Medical College. Reprint requests: Malcolm O. Perry, M.D., Professor of Surgery, Cornell University Medical College, 1300 York Ave., New York, NY 10021. 480
At the present admission the patient had a blood pressure of 200/120 mm H g in the supine position and 160/ 105 mm H g when sitting. She had recovered from the stroke. Renal vein blood samples were obtained via a transfemoral venous approach and there was significant lateralization of renin production from the small right kidney. Arteriography identified a severe stenosis at the origin of the right renal artery (Fig. 1). The patient was discharged from the hospital and 1 month later was readmitted for balloon dilation of the right renal artery via a right femoral artery approach. Dilation was attempted, but the renal artery was never entered, and during the procedure catheter trauma to the SMA caused an acute intramural dissection and occlusion of the second portion of the SMA (Figs. 2 and 3). Severe abdominal pain developed and immediate surgery was undertaken. When the SMA was exposed, the dissection was noted to include approximately 6 cm of the artery distal to the takeoff of the middle colic artery. There were no puls: ~°. palpable in the mesentery, and the small bowel was gray and ischemic. Systemic heparinization was obtained and a linear arteriotomy was made in the SMA over the area of dissection. The endarterectomy plane was entered and the proximal SMA was deared to the orifice; the endarterectomy plane was terminated at the junction of the plaque with the distal intima. The ledge of distal intima was tacked down with interrupted sutures of 6.0 polyp ropylene. There was no back-bleeding from the middle colic artery, and despite an attempted thrombectomy, flow could not be restored in the smaller branches of this vessel. The longitudinal arteriotomy was closed with an autogenous saphenous vcin graft and flow was restored to the SMA circulation. Distal flow in the SMA was excellent, and there was pulsatile flow in the distal arcades. The small and large bowel appeared to be viable. Postoperatively the patient was in a hemodynamically stable condition, alert and awake, but complained of intermitrent pain in the abdomen at 5- to 15-minute intervals. There was tenderness but no abdominal spasm. The
Volume 2 Number 3 May 1985
Intramural dissection of superior mesenteric artery 481
Fig. 1. Aortogram obtained prior to attempted balloon dilation reveals tight renal artery stenosis (arrow) and aortoiliac bypass graft. pain was mainly centered in the left upper quadrant and had a pleuritic component. She required more fluid replacement than usual; it was suspected that bowel ischemia might be present, although colonoscopy did not reveal ischemic colon mucosa. During the next 8 hours pain increased and the patient was returned to the operating room. The transverse colon and the hepatic and splenic flexures were ischemic and nonviable. The SMA repair was intact and there were visible pulsations m the small bowel mesentery. The transverse colon was resected and an ascending colostomy and a distal mucus fistula were constructed. The wounds were closed and the patient was returned to the intensive care unit. After a convalescence of I month the patient was returned to the operating room and the colostomy was closed. She also underwent cholecystectomy and common duct exploration to control cholelithiasis. Subsequently the patient had a rather prolonged convalescence because of a superficial wound infection, but her blood pressure remained in the range of 160 to 170/80 to 90 mm Hg. She required no antihypertensive medication. She declined to have additional diagnostic studies, but an abdominal sonogram was performed prior to discharge and was reported as being normal. Urinary fimction was normal as evaluated by urinalysis and measurements of blood creatinine levels. After the surgical wound had healed, she was discharged without medication, with a blood pressure of 160/90 mm Hg. The patient returned to the care of her
private physician in her out-of-state home; the blood pressure has remained relatively normal and no additional procedures have been required.
DISCUSSION Although iatrogenic arterial injuries during the course o f diagnostic and therapeutic procedures with arterial catheters are uncommon, on occasion they are responsible for serious complications. 1,4 Arteriography performed by the Seldinger technique via the c o m m o n femoral artery is remarkably free of complications despite being used most often in patients with atherosclerotic arterial disease? More extensive manipulations such as may be required during balloon dilation would appear to be more likely to produce arterial injury and thus predispose to intramural dissection. F r o m June 1978 to September 1981 at The N e w York Hospital 104 renal artery dilations in 89 patients were performed, s There were no deaths caused by the procedure, but 14 significant complications were seen. These included transient renal failure (two) and myocardial ischemia (one). A m o n g the patients with atheromatous lesions (70 arteries) four renal artery dissections occurred; three were successfully treated by surgical repair, and one kidney was
Journal of VASCULAR SURGERY
482 Perry
Fig. 2. Dissection in SMA is clearly seen (large arrow). There is localized, nonobstructing dissection in aorta (small arrow). lost. Two renal artery dissections complicated balloon dilation of fibrous dysplastic lesions (34 arteries). One was repaired with an aortorenal bypass, and nephrectomy was needed in the other patient. Three other patients required surgical repair of the arterial puncture site. The complication rate in this series (15%) compares with the 9% rate reported by Martin and Cassarella. 6 The only nonrenal arterial dissection in this series is the subject of this report, but iliac and femoral artery dissections have been observed by others. 7 A computer search of the world literature failed to reveal other cases of SMA dissection as a complication of attempted balloon dilation of renal arteries, but widespread embolization of the mesenteric and peripheral circulation resulting in death has been reported. 7 Intramural dissection complicating such maneuvers would appear to be more likely in patients who have advanced atheromatous disease, especially when there are compound intimal plaques that might be more susceptible to injury by a catheter. Although the exact mechanisms causing the SMA dissection in
this patient are not known, the angiographers experienced difficulty in manipulating the catheter into the small renal artery orifice, and it went into the SMA on several occasions during the attempt to enter the renal artery. The dissection was easily diagnosed by the routine arteriography being performed durin~ the procedure. The direct surgical approach to the mesenteric artery was chosen because the arteriographic pictures showed the area of dissection clearly. The dissection occurred in the plane normally developed for a standard endarterectomy. Although distal disease was present within the artery, there was sufficient transition from abnormal to relatively normal intima to permit ending the endarterectomy under direct vision, but the distal ledge of intima was secured with interrupted sutures. Despite several attempts the middle colic artery could not be reopened because of its small size and extensive clots. Vein patch graft angioplasty was performed to widen the area of arteriotomy, particularly over the distal ledge ofintima. This technique may be useful especially in preservation of patency in small arteries. The bowel ap-
Volume 2 Number 3 May 1985
Intramural dissection of superior mesenteric artery 483
Fig. 3. Delayed film shows dissection and complete obstruction of SMA (arrow). peared viable and the visible pulsations in the small bowel mesentery indicated there was adequate blood flow to the intestines. Apparently because of loss of the inferior mesenteric artery with the previous aortic grafting procedurc, and perhaps because of a reduction in flow from the hypogastric and the middle hemorrhoidal vessels, there was inadequate blood flow to the transi,~rse colon. The importance of the middle colic artery is well known, especially when other collateral pathways have been interrupted during previous operations. The hypogastric circulation (contributing the middle hemorrhoidal artery), the open SMA, and celiac arteries appeared to be adequate at the initial procedure. The colon was normal in color, and although no pulsations were visible in the colon mesentery, artcrial Doppler signals werc prescnt. Despitc these assurances of viability, delayed ischemia of the colon occurred. There were no hypotensive episodes in the immediatc postoperativc period. Perhaps thromboembolism or distal propagation of clot from the occluded middle colic artcry was the cause of the subsequent ischemic colon. Additional systemic anticoagulants were not added after completion of the vascular repair.
The patient continued to have a relatively normal blood pressure throughout the postoperative period despite not receiving any antihypertensive medication. This may be because the right renal artery was occluded, and the kidney was no longer elaborating renin; but since she declined additional studies, this can only be speculative. It is clear that most of these angiographic procedures can be performed safely. If local injury to the artery does occur, and if it culminates in occlusion, expeditious repair is likely to be successful if it is not delayed beyond the time when clots can be successfully extracted, and blood flow can be reestablished. 8 An attempt should be made to open all major collateral vessels, because, as was seen in this patient who had previous aortic surgery, removal of another significant collateral artery may result in severe ischemia. 9 Vigorous early attempts to restore normal flow are appropriate in these patients. REFERENCES 1. Dean RH. Renovascular hypertension: An overview. In Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saundcrs Co, 1984:1100-8. 2. Pcrry MO. Spontaneous renal artery dissection. J Cardiovasc Surg 1982; 23:54-8.
484
Journal of VASCULAR SURGERY
Perry
3. Lang EK. A survey of the complications of percutaneous retrograde arteriography. Radiology 1963; 81:257-63. 4. Charlesworth PM, Brewster DC, Darling RC. Renal artery injury from a Fogarty balloon catheter, J VASC SURG 1984; 4:573-6. 5. Sos TA, Picketing TG, Sniderman .K, Saddekni S, Case DB, Silane MF, Vaughan ED, Laragh JH- Percutaneous transluminal renal angioplasty in renovascular hypertension due to atherorna or fibromuscular dysplasia. N Engl J Med 1983; 309:274-9. 6. Martin EC, Casarella WJ. Percutaneons transluminal anglo-
plasty in renovascular hypertension. In: Stanley JC, Ernst C~s, Fry WJ, eds. Renovascular hypertension. Philadelphia: WB Saunders Co, 1984:254-74. 7. Connolly JE, Kwaan JH, McCort PM. Complications after percutaneous transluminal angioplasty. Am J Surg 1981; 142:60-6. 8. Sachs SM, Morton JH, Schwartz SI. Acute mesenteric ischemia. Surgery 1982; 92:646-53. 9. Bergan JJ, Dean RH, Coma J, Yao JST. Revascularization in treatment of mesenteric infarction. Ann Surg 1975; 182: 430-8.
B O U N D VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOURNAL OF VASCULARSURGERY for 1985 are available to subscribers only. Active members of the two sponsoring societies will automatically receive a complimentary bound volume. They may be purchased from the publisher at a cost of $26.00 ($38.40 international) for Vol. 2 (January to December). Price includes shipping charges. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the voltmle. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Circulation Fulfillment, The C. V. Mosby Company, 11830 Westlinc Industrial Drive, St. Louis, M O 63146, USA. In the United States call toll free: (800)325-4177, ext. 351. In Missouri call collect: (314)872-8370, ext. 351. Subscriptions must bc in force to qualify. Bound volumes are not available in place o f a regular JOURNAL subscription.