Endovascular Treatment of a Stenosed Anomalous Left Gastric Artery: Unique Open Artery of the Gastrointestinal Tract

Case report. We report the case of a 46-year-old male who presented with an 18-month history of postprandial abdominal pain that had worsened during the previous two months, diarrhea, and a 12 kg weight lost. His previous medical history included surgical revascularization of an aortic-iliac occlusion (Leriche syndrome) five years before, and previous admission due to ischemic cardiopathy. He was a three-pack per day smoker. Diagnosis at admission was chronic intestinal ischemia. An angiography with lateral and anterior-posterior views of the aorta, and a selective view of the left gastric artery demonstrated an occlusion at the origin of the superior and inferior mesenteric arteries and at the celiac trunk as well. The origin of the left gastric artery (LGA) was found at the aorta artery, isolated from the celiac trunk. The LGA was the unique open splanchnic vessel and presented severe stenosis at the proximal segment (without ostium involvement). Important collateral vascularization was found in the gastric fundus, with opacification of the short gastric, left gastro-omental, splanchnic and gastroduodenal, superior mesenteric, and hepatic arteries (Figure 1). In addition, the angiography showed stenosis of the left subclavian artery and coronary lesions in three vessels. Endovascular treatment was considered. We achieved access through the right common femoral artery with an 8 Fr introducer under local anesthesia. We used an 8 Fr guide catheter through which we progressed with a hydrophilic 0.035 guide to the distal segment of the LGA. The angioplasty was performed using a 4/40 mm balloon. The angiographic control showed partial dilation of the lesion. We implanted a 6/20 mm Bare Palmaz Stent. The post-stenting angiography showed absence of residual lesions. The patient, however, continued to complain of post-prandial abdominal pain after food intake was restarted. A new angiography revealed an acute angulation in the LGA distal to the stent. A flexible self-expandable 7/20 mm Symphony Stent (NMT Medical, Inc., Boston, Massachusetts) was superposed to the distal end of the first stent. The angiographic control demonstrated good correction of the angulation (Figure 2). Abdominal pain did not relapse after restarting food intake, and the patient was discharged three days after the procedure. He remained asymptomatic for six months. He died in the seventh month due to a coronary event. Discussion. Chronic visceral ischemia results from occlusion or severe stenosis of the major visceral arteries. In the vast majority of cases, this is due to arteriosclerosis of the proximal portion of these arteries. Undoubtedly, the ability of the visceral circulation to tolerate occlusions and stenosis of its major arterial trunks reflects the slow progression of the atherosclerotic process, allowing enough time for the development of gradual enlargement of collateral circulation pathways. In the rare cases of patients developing clinically evident intestinal ischemia, symptoms do not usually appear until at least two of the three major splanchnic arteries are highly stenosed or occluded.¹ Finch reported in 1992 the use of a stent in the proximal celiac artery stenosis.² Since then, many authors have published successful cases with the endovascular stenting of the celiac and mesenteric arteries for the treatment of mesenteric ischemia.^3–8 Today, bypass grafting surgery remains the primary option for chronic mesenteric ischemia secondary to atherosclerotic disease. This is particularly true in patients with classic symptoms, angiographic findings and low operative risk. Peripheral transluminal angioplasty is a second-line therapy, although it can be the elective procedure for patients with high operative risk.⁵ In our case report, the patient had a clear history of atherosclerotic disease. We concluded that the progression of aortic-iliac disease occluded the inferior mesenteric artery and that the origin of the superior mesenteric artery and the celiac artery were gradually occluded, allowing the development of an important collateral vascularization. The images of the arteriography clearly showed the proximal occlusion with an open distal vessel, which is typical of chronic visceral ischemia. The independent origin of the left gastric artery is an anatomic variation that allowed it to initially avoid the occlusion of the celiac artery and the patient remained asymptomatic. However, progression of the arteriosclerosis was evident due to the severity of the lesion of the proximal third of the artery that threatened the vascularization of the entire gastrointestinal tract, and was responsible for the visceral arterial disease of our patient. The distal angulation of the first stent placed shows the ductility of the splanchnic arteries; for this reason, we encourage the use of flexible stents. Clinical evolution and the recovery of our patient indicate that minimally invasive percutaneous treatment is a valid alternative for lesions that do not involve the ostium, especially in patients with high surgical risk.

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