Patient A, a 40-year-old female, suffered from episodes of upper abdominal and back pain accompanied by vomiting since a year before presentation. Initially, complaints presented predominantly postprandial but eventually even in the absence of any provocative factors. She had lost 9 kg (15% total body weight). Her medical history mentioned fibromyalgia. Furthermore, she had been smoking cigarettes for 20 years (ten pack years) but quitted 8 months before presentation. Her medication consisted of oral contraceptives and isosorbide mononitrate 50 mg daily on trial during 3 months which appeared to have a positive effect on her complaints.
The diagnosis of chronic splanchnic ischemia was by the exclusion of several other diseases and after numerous other investigations. Computed tomography angiography (CTA) revealed a high-grade stenosis at the ostia of the superior mesenteric artery (SMA), the celiac trunk, and the inferior mesenteric artery [Figure 1].
The patient was presented for splanchnic revascularization. After retrograde duplex-guided puncture of the right femoral artery, a diagnostic angiography confirmed a pinpoint stenosis of the celiac trunk and SMA. Subsequently, the right brachial artery was punctured. The stenosis in the celiac trunk was passed easily, and a 5 mm x 19 mm self-expandable stent was placed. Subsequently, a 5 mm x 15 mm self-expandable stent was placed in the SMA. Postballooning was performed after the stent placements. The procedure was uncomplicated resulting in a technical successful revascularization [Figure 2].
During the procedure, the patient experienced an increased abdominal tension, pain, and nausea. Angiography, however, showed a patent SMA and celiac trunk, without evidence of distal embolization, dissection, or thrombosis of the target vessels.
Approximately 7 h after the procedure, a CTA was performed because of persisting significant abdominal complaints in the epigastric region despite administration of substantial amounts of analgesics. CTA revealed patent stents in the SMA and celiac trunk and adequate peripheral blood flow. No laboratory abnormalities were detected (serum lipase level 16 U/l, C-reactive protein 2 mg/l).
The day after the procedure pain persisted in the epigastric region. No hepatosplenomegaly was observed. A gastroscopy showed no abnormalities. Serum lipase levels as well as liver function tests and infection parameters remained low. Serum lactic acid level was 1.0 mmol/l.
Even more than 50 h after the initial procedure, complaints did not diminish. Once again CTA was repeated, showing patent splanchnic arteries [Figure 3a]. However, an impressive hyperperfusion state of liver and spleen was visualized, accompanied by ascites (Figure 3b).
Symptoms were considered to be due to splanchnic reperfusion and diminished spontaneously after a few days