Angioplasty and Stenting

The author’s preference is to use a brachial artery approach. This offers excellent support with a small profile system and precise stent deployment in patients with an acute SMA angle. Percutaneous access is established with a micropuncture set using ultrasound guidance. Full systemic heparinization (80 mg/kg) is achieved before catheter manipulations to produce an activated clotting time of more than 250 seconds. A 6-Fr 90-cm Shuttle Select sheath (Cook Medical, Bloomington, IN) is positioned in the descending thoracic aorta above the celiac artery origin. A 5-Fr MPA catheter is ideal for selective catheterization of the mesenteric arteries. In patients with classic symptoms and suitable lesions by CTA, abdominal aortogram is not needed and the intervention is directed to the target vessel. The initial selective angiography should demonstrate the severity of the stenosis and document the distal branches for comparison with postintervention views.

The target SMA lesion is initially crossed using a 0.035-inch soft Glidewire, which is exchanged for the interventional wire of choice after confirmation of true lumen access (Figure 1). The author’s preference is to use a small-profile (0.014- or 0.018-inch) stiff guidewire for most interventions. It is important to visualize the tip of the guidewire, which should be positioned within the main trunk of the SMA rather than within smaller side branches to avoid an inadvertent perforation or dissection. The author’s preference is to use embolic protection (e.g., 320-cm Spider RX filter wire) in patients with occlusions, long lesions (>30 mm), severe calcification, thrombus, and acute or subacute symptoms. If a longer 0.035-inch stent is used, the 0.014-inch filter wire is combined with a 0.018-inch buddy wire, and the stent is introduced via both wires for better support and to facilitate subsequent retrieval of the embolic protection device.

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