In Reply to: Case 797_03 -- SMA angioplasty/stent posted by Editor on July 17, 1997 at 17:11:10:
I would have handled this case a little differently. I prefer the high brachial approach for these cases, since in these patients who are often skinny, the tight downward angle of the SMA makes passing balloons and stents from below difficult.
Given that you stented to 7 mm, it is not surprising that PTA to 4 and 5 mm was ineffective, since the vessel was significantly under-dilated. A 7 mm PTA might have given you an adequate result.
I would have treated the celiac stenosis also. The principle of revascularizing the gut is to treat all culprit lesions; a surgeon would have done supra-celiac bypass to both the celiac and SMA. Given the predictably limited patency of small stents, you double your chances of sustained clinical benefit by fixing both inflow vessels. That way if one stent restenoses, the other will continue to provide perfusion to the bowel.
Finally, this patient had both HTN and CAD. I would also have stented the renals and the coronaries, then shot the carotids to see what could be done there. After all, if the scumbag cardiologists can do it, why not? [to HCFA -- just kidding. (Not about the cardiologists.)]