Coeliac stent for mesenteric angina

Gabrielle Morris

45yo male for an aortogram, mesenteric angiogram +/- coeliac artery stent via R CFA +/- brachial approach. Interesting case for discussion.

Background

  • ? Mesenteric angina
    • Laparoscopic median arcuate ligament release 2021 due to weight loss, nausea, chest/abdominal pain.
    • Ongoing symptoms requiring admission to hospital in August – chest pain, SOB, 3 x syncopal episodes.
    • Weight loss now 25kg
    • Carotid dopplers, TTE, stress TTE, CTPA, CTB, troponins and ECG all negative.
    • ED presentation September with same symptoms after clopidogrel loading.
    • Abdominal angiography showed ongoing 90% coeliac artery stenosis
    • Plan for stent in lab 4.
  • Childhood asthma
  • Quit smoking 2020 (20PYH)
  • Depression and anxiety

Issues

  • Unusual symptoms: any concerning causes not fully elucidated?
    • Difficult to think of any investigation that hasn’t been done!
    • Possible vagal episodes (causing syncope) due to pain
  • Procedural risks?
    • At initial laparoscopic ligament release, substantial bleeding risk flagged to anaesthetist.
    • bleeding risk with this procedure?
  • Anaesthetic technique?
    • Tempting to avoid GA given history however conversion to GA in an emergency may be challenging. 
    • Also potential for long ++ procedure (from limited experience from the group) making light sedation challenging.

Discussion

  • What is median arcuate ligament syndrome? (from Uptodate)
    • A.k.a. coeliac axis syndrome, coeliac artery compression syndrome, Dunbar syndrome.
    • Recurrent abdominal pain related to compression of the coeliac artery by the MAL. 
    • Symptoms may be ischaemic or neuropathic.
    • Triad: post-prandial abdominal pain, weight loss, abdominal bruit.
    • 30yo+, 4 x more common in women
    • Careful patient selection for intervention needed, as may be an incidental finding in asymptomatic people, or not clearly related to symptoms due to another cause.
    • Treated initially with a laparoscopic ligament release. Second line treatments include ganglionectomy, percutaneous revascularisation or surgical revascularisation.  

  • Image

Plan

  • Procedural anaesthetist notified -> will discuss bleeding risks with surgeon on the day and have blood available in lab 4 if thought prudent (nil previous Abs)
  • GA thought to be safe and appropriate
  • Nil further Investiagtions