Case Report

Use of the Palmaz Stent in Ostial Celiac Artery Stenosisl

Ira J. Finch, MD The author reports a case in which a 20-mm balloon-expandable Palmaz stent was used with percutaneous transluminal angioplasty to treat a stenosis of the proximal celiac artery in a patient with mesenteric isch-

Index terms: Arteries, celiac, emia. The stent was dilated to 9 mm, eliminating the stenosis. The pa- 951.1299 * Arteries, grafts and prosthe- tient made an uneventful recovery and remains asymptomatic at 4 ses, 95.1299 - Arteries, stenosis or ob- months. struction, 95.721

JVIR 1992: 3:633-637

From the Section of Inte~ent ional Radi- ology, Department of Radiology, John Muir Medical Center, 1601 Ygnacio Valley Rd, Walnut Creek, CA 94598. Received May 5, 1992; revision requested July 15; revision received July 28; accepted August 5. Ad- dress reprint requests to the author.

' SCVIR. 1992

VASCULAR endoprostheses have be- come a valuable adjunct to percutane- ous transluminal angioplasty (PTA) in the treatment of iliac artery lesions (1- 3). Recently, a preliminary investiga- tion of Palmaz stents placed in ostial stenoses of renal arteries was reported (4). Stent placement in these lesions is appealing since PTA alone has a rela- tively high failure rate (5,6) due to elas- tic recoil. Stent deployment in visceral branches of the aorta presents techni- cal challenges not encountered in iliac arteries or in large veins because the stent system must negotiate a signifi- cant curve, and the stent must be de- posited precisely at the junction of two vessels. This report details the place- ment of a Palmaz stent in the celiac artery of a patient with an ostial ath- erosclerotic stenosis. The technical con- siderations are discussed.

CASE REPORT

A 68-year-old man with known coro- nary artery disease and a history of bi- lateral femoral-popliteal bypass surgery presented with severe abdominal cramping precipitated by meals. A bi- plane abdominal aortogram revealed an 80% stenosis at the origin of the celiac artery (Fig l a ) and an occlusion of the inferior mesenteric artery (IMA). The superior mesenteric arteriogram dem- onstrated collateral flow to the IMA territory and retrograde filling of the gastroduodenal and hepatic vessels (Fig lb). The patient was considered a poor surgical risk. It was decided that PTA

and stent placement in the celiac artery would be attempted in an effort to re- duce the "steal" from the superior mesenteric artery (SMA) and improve mesenteric circulation. A fully in- formed patient consent was obtained in conjunction with approval from the hospital Investigational Review Board.

The patient was treated with a 5,000-U bolus of heparin and 10 mg of sublingual nifedipine. Through a 10- cm, 7-F vascular sheath (Cordis, Mi- ami) placed in the right common femo- ral artery, a 5.5-F C1 catheter (Medi- techIBoston Scientific, Watertown, Mass) and a 0.035-inch Bentson wire (Cook, Bloomington, Ind) were used to cross the celiac stenosis. The catheter was advanced over the wire into the distal splenic artery, and the wire was exchanged for a 180-cm Rosen wire (Cook). Under lateral fluoroscopic guid- ance, the lesion was dilated with a 5-F Ultrathin 4-mm x 2-cm balloon dila- tion catheter (Medi-techIBoston Scien- tific) to facilitate passage of the stent and decrease the inflation pressure needed for stent expansion. The deci- sion to place a stent across the stenosis was made based on its proximal loca- tion, which increases the chance of re- stenosis. The initial angioplasty was purposely performed with an "under- sized" balloon to ensure that the stent to be introduced would implant in the wall of the vessel and would not mi- grate.

A 45-cm, 7-F multipurpose A2 vascu- lar sheath (Cordis), which forms a 55" angle along its distal 3 cm, was sub-

634 Journal of Vascular and Interventional Radiology November 1992

jected to gentle heat to reduce the angle performed. This caused mild discom- with the stent in place. A superior to 10". Because of scarring in the pa- fort, which resolved following balloon mesenteric arteriogram was then ob- tient's groin, it was necessary to place a deflation. A final aortogram (Fig 3) tained by using the same contrast ma- 10-cm, 9-F vascular sheath (Cordis) in showed a widely patent celiac artery terial injection as was used for the diag- the femoral artery to permit introduc- tion of the 45-cm sheath. which was advanced over the Rosen wire and posi- tioned in the aorta just inferior to the celiac origin. A Palmaz stent (T204M; Johnson & Johnson, New Brunswick, NJ) crimped onto a 5-F, 7-mm x 2-cm PDMT balloon catheter (Medi-tech/ Boston Scientific) was introduced through the long sheath over the Rosen wire. The stent-loaded balloon catheter system was advanced easily into the proximal celiac artery. Proper position- ing was verified with several digital lat- eral aortograms obtained by injecting contrast material through the side-arm fitting of the long sheath. After the stent was expanded and the balloon was deflated, a gentle twisting accom- panied by a to-and-fro motion on the balloon catheter was used to withdraw it into the sheath. During this maneu- ver, negative pressure was maintained on the balloon.

A lateral aortogram revealed an an- ticipated residual 30% stenosis (Fig 2). A 5~ Ultrathin 9-mm x 4-cm ango- a. b. plasty catheter (Medi-tech/Boston Sci- Figure 1. (a) Subtracted lateral abdominal aortogram shows an irregular 80% steno- entific) was then introduced over the sis of the celiac origin. The SMA is widely patent. (b) Subtracted anteroposterior supe- Rosen wire and positioned in the ex- rior mesenteric arteriogram shows retrograde filling of the gastroduodenal and hepatic panded stent. A single inflation was arteries (arrows).

2. 3a. 3b. Figures 2,3. (2) Digital lateral aortogram obtained following stent deployment. A 30% residual stenosis of the celiac origin is present. (3a) Early, nonsubtracted lateral digital aortogram obtained following expansion with a 9-mm balloon shows the proximal aspect of the stent flush with the aortic wall. (3b) Midstream subtracted image from the same run demonstrates expansion of the stenosis.

Finch 635

Volume 3 Number 4

nostic study. This showed a decrease in the degree of retrograde filling of the celiac branches (Fig 4). Intravascular pressure measurements were not ob- tained. Postprocedural anticoagulation was not used.

The patient made an uneventful re- covery and over the course of the next 4 days was advanced to a full solid food diet, which he tolerated without pain. The patient has been followed up by his gastroenterologist and remains asymp- tomatic at 4 months.

DISCUSSION

In approaching this stenosis, the femoral route was chosen over the axil- lary to minimize the distance between the puncture site and the target vessel (reducing the required length of the guiding sheath) and to avoid the bend at the junction of the aorta and left subclavian artery. For placement of stents in renal arteries, Rees et a1 (4) introduced the balloon-loaded stent through a backloaded 9-F guiding cath- eter. The use of the long 7-F sheath eliminates the need to backload the stent and, in most cases, should reduce the size of the arterial puncture to 7 F. It is extremely important to make sure the stent is securely "crimped" on the balloon, and in this case, the stent- loaded balloon catheter was passed

through the long sheath outside of the patient first.

Proper stent selection was considered critical in this case. As the stenotic seg- ment was short, a 20-mm-long stent was chosen with the thought that it would be easier to advance around the bend than a 30-mm stent. In addition, the shorter stent would be less likely to interfere with placement of a bypass graft should the procedure fail. Because the proximal celiac artery and SMA measured 10.5 mm in diameter, a stent expandable to 10 mm was selected. A 20-mm articulated stent is available and might have been easier to advance into the celiac artery, but it is only ex- pandable to 8 mm (manufacturer rec- ommends 7 mm). A 5-F balloon cathe- ter with a diameter smaller than that of the artery was used to minimize cathe- ter resistance at the aortic-celiac junc- tion. In fact, there was no difficulty ad- vancing the stent over the relatively stiff Rosen wire into the celiac artery. Based on this experience, the use of an angled guiding catheter to engage the origin of the artery may not be neces- sary. It was actually slightly more diffi- cult to withdraw the balloon catheter through the expanded stent, but this was easily accomplished with a gentle twisting motion as described.

Proper positioning was verified with digital runs obtained through the sheath. The position of the stent is evi-

Figure 4. Antero- posterior digital su- perior mesenteric arteriogram obtained immediately follow- ing stent placement shows diminished filling of the common hepatic artery. The maximum degree of retrograde filling is demonstrated on this image. The same in- jection parameters as in Figure lb were used; catheter posi- tion is slightly more selective.

dent from the opaque markers on the balloon catheter, but one must allow for contraction of the stent length with expansion (approximately 4 mm for a 9-mm deployed diameter). The stent was placed flush with the edge of the aortic wall. Since the proximal portion of the stent expanded fully, it was not flared with another balloon. The stent was not overdilated, as inflation to 9 mm caused the patient mild discomfort. The optimal expansion parameters and medical regimen to minimize restenosis have yet to be determined.

References 1. Giinther RW, Vorwerk D, Bohndorf

K, Peters I, El-Din A, Messmer B. Iliac and femoral artery stenoses and occlusions: treatment with intravas- cular stents. Radiology 1989; 172: 725-730.

2. Bonn J , Gardiner GA, Shapiro MJ, Sullivan KL, Levin DC. Palmaz vas- cular stent: initial clinical experience. Radiology 1990; 174:741-745.

3. Long AL, Page PE, Raynaud AC, et al. Percutaneous iliac artery stent: angiographic long-term follow-up. Radiology 1991; 180:771-778.

4. Rees CR, Palmaz JC, Becker GJ, et al. Palmaz stent in atherosclerotic steno- ses involving ostia of the renal arter- ies: preliminary report of a multi- center study. Radiology 1991; 181: 507-514.

5. Schwarten DE. Percutaneous trans- luminal angioplasty of the renal ar- teries: intravenous digital subtraction angiography for follow-up. Radiology -.

1984;-150:369-373. Dean RH, Callis JT, Smith BM, Meacham PW. Failed percutaneous transluminal renal angioplasty: expe- rience with lesions requiring opera- tive intervention. J Vasc Surg 1987; 6:301-307.

Perspective follows