Hybrid Retrograde Celiac Artery Stenting for Acute Mesenteric Ischemia after Gastric Surgery

Background: Celiac artery (CA) occlusions/stenosis is infrequently associated with liver ischemia due to its unique vascularization, where portal vein provides about 75% of liver's perfusion. Collateral flow from gastroduodenal artery also provides, in most cases, enough blood supply to prevent ischemic hepatitis. In cases where these collateral pathways are compromised, severe liver ischemia can occur. Methods: We present a case of acute mesenteric ischemia following gastric surgery that was treated with a hybrid retrograde CA stenting. Results: We report a case of a 72-year-old male, who underwent gastric surgery for gastric cancer. On fourth postoperative day, he presented with acute abdomen, and on laparotomy, a partial duodenal suture dehiscence was found and suture closed. Owing to worsening of patient's clinical condition, with associated ischemic hepatitis, 2 days later, a computed tomography angiography was performed that showed a superior mesenteric artery (SMA) occlusion at its origin with an associated, severe, ostial stenosis of the CA. On laparotomy, irreversible visceral ischemia was found, which led to total colectomy, resection of 50 cms of small bowel, and splenectomy. Liver ischemia was also confirmed. Femoral access was used to try to cannulate the CA and cross its stenosis, without success. Taking advantage of the open abdomen, we then opted to place a 5F sheath in the splenic artery stump. From this retrograde approach, stenosis traversal was easy, and the CA was ballooned and stented with reperfusion of almost all the liver. Despite these efforts, patient died because of multiorganic failure, 8 days later. Conclusions: Ischemic hepatitis is a rare but serious complication of CA/SMA occlusive disease. Its occurrence is at increased risk after surgeries, where collateral flow is compromised. The endovascular treatment is currently the preferred approach to treat visceral arteries occlusive disease; however, antegrade CA cannulation can be tricky, and in an open abdomen scenario, retrograde approach from the splenic artery can be an additional resource. This case demonstrates the flexibility of endovascular techniques and that they can provide useful solutions even during open surgery.