case_images: PMC11514322_01
case_images: Preoperative imaging from computed tomography angiography suggested that the pancreaticoduodenal arcade, located between the celiac axis (CA) and the superior mesenteric artery (SMA), had undergone compensatory hypertrophy.
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case_images: Preoperative CTA revealed an occlusion at the SMA's opening, extending approximately 2 cm, with compensatory hypertrophy of the pancreaticoduodenal artery arch between the CA and SMA (Figure 1).
case_images: Intraoperative angiography. (a) Abdominal aorta angiogram showing SMA origin occlusion, (b) gastroduodenal artery catheterization revealing compensatory hypertrophy in the pancreaticoduodenal arch between CA and SMA.
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case_images: Hand-injected angiography through this setup revealed significant compensatory hypertrophy of collaterals between the CA and SMA (Figure 2).
case_images: Intraoperative angiography depicting retrograde passage through the pancreaticoduodenal artery arch. (a) Deployment of a multipurpose angiographic (MPA) catheter in conjunction with a V-14 guidewire and microcatheter, facilitated by roadmap navigation into the pancreaticoduodenal artery arch, (b) targeting the SMA stenotic segment, (c) translesional entry into the abdominal aorta.
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case_images: A microcatheter (Boston Scientific, Marlborough [https://www.bostonscientific.com/en-US/products/embolization/Renegade_HI-FLO_Microcatheter.html]), accompanied by a V-14 guidewire (Boston Scientific, Marlborough, MA, USA) and guided by the roadmap, navigated retrogradely through the pancreaticoduodenal artery arch, crossing the occluded segment into the abdominal aorta (Figure 3).
case_images: Angiography post-balloon dilation and stent implantation. (a) Balloon dilation of the occluded segment, (b) utilizing the pre-dilated channel for antegrade passage through the SMA with placement of a V-18 guidewire, (c) implantation of a 6 mm x 25 mm VIABAHN covered stent and post-dilation, with angiography via a pigtail catheter placed in the femoral artery.
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case_images: Following this, a 3 mm x 30 mm pre-dilation (ClearStream Technologies, Enniscorthy County Wexford, Ireland) was performed, and a V-18 guidewire (Boston Scientific, Marlborough, MA, USA) was antegradely placed through the SMA using the post-dilation vascular channel (Figure 4A and B). Subsequent angiography confirmed the stent's optimal placement, with the SMA remaining patent and distal vessels clearly visualized (Figure 4C).
case_images: Retrograde approach diagram. The green section depicts the retrograde route starting from the celiac trunk, progressing through the common hepatic artery to the gastroduodenal artery, and extending to the pancreaticoduodenal arterial arc which connects to the superior mesenteric artery.
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case_images: The main retrograde approach during the treatment process is shown in Figure 5.
case_images: CTA at 6-month post-operative follow-up.
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case_images: A 6-month follow-up CTA showed the SMA stent well-maintained, with clear imaging of the distal SMA, confirming the success of the intervention (Figure 6).