In Reply to: Case 797_03 -- SMA angioplasty/stent posted by Editor on July 17, 1997 at 17:11:10:
The comments already presented are interesting in their discrepancy. Ideally, a randomized prospective study would compare angioplasty/stenting vs. surgical bypass to answer some of the questions raised. My sense is that angioplasty/stenting would provide overall good initial results (with less periprocedural morbidity/mortality) but that the surgical results would be better long term. In this patient, who seems a poor surgical candidate, who has what appears to be a good lesion for angioplasty, and who (most importantly) has classic symptomatology, I believe an attempt at angioplasty (with stenting if the results are poor) is warranted after full discussion of the potential pros and cons of the various forms of therapy with the patient and referring physicians. I believe my vascular surgery colleagues would support this and would add that I would be reluctant to proceed without their support and backup.
I would echo the comments regarding sizing of the initial angioplasty and final stenting--if this was felt to be a 7 mm vessel,why was the lesion not dilated initially to 7 mm?
I think the arm is generally a good approach for the sma (we prefer a lower brachial puncture, although size considerations might come into play in a 70 yo woman). On the other hand, the location of this lesion and orientation of the sma are such that I probably would have attempted the lesion from the femoral approach.
I probably would not have approached the celiac lesion--feeling that one good mesenteric vessel should be enough to relieve the symptoms--but find the argument to do so (if one goes down you still have the other) interesting.
Very nice looking final result--please send a followup to the case club if one is obtained.