Keywords
atherosclerosis - endovascular procedures/stents - except PCI - imaging (all modalities)
- perfusion - stents - esophagectomy - complications
Introduction
Patients undergoing esophagectomy are at risk of morbidity and even mortality due
to perioperative complications. Leakage of the anastomosis between the proximal esophagus
and the gastric conduit is a common complication. An important risk factor for anastomotic
leakage (AL) is ischemia of the gastric conduit, and is entirely dependent on the
patency of the gastroepiploic arcade for its perfusion. On routine computed tomography
(CT) scans, calcification of the aorta and its visceral branches can be detected.
However, for estimating the presence of significant stenosis, a CT angiography (CTA)
of the abdominal aorta and visceral branches is required.[1] This report presents two patients evaluated for esophageal cancer, both with significant
calcifications in the celiac trunk detected on routine CT scanning.
Case Reports
Case 1
A male patient, age 76, was diagnosed with cT2–3N0–1M0 distal esophageal cancer. Cardiovascular
risk factors included diabetes mellitus and hypertension. The routine staging CT scan
of the neck, chest, and abdomen demonstrated abundant calcifications both in the descending
aorta, celiac artery (CA), and the superior mesenteric artery (SMA). Surprisingly,
additional CTA did not reveal significant stenosis in the CA and SMA.
After neoadjuvant chemoradiotherapy, the patient underwent a minimally invasive Ivor
Lewis esophagectomy with an uncomplicated postoperative course.
Case 2
A male patient, age 65, was diagnosed with cT3-N2-M0 distal esophageal cancer. Cardiovascular
risk factors included hypertension, diabetes mellitus type II, a transient ischemic
attack, coronary artery disease (percutaneous transluminal coronary angioplasty),
and morbid obesity that was treated with a gastric bypass. The staging CT scan showed
severe calcifications of the CA. Additional CTA demonstrated a subtotal occlusion
of the CA without significant occlusion of the SMA ([Figs. 1] and [2A] and [B]).
Fig. 1 Transversal standard computed tomography (CT) of the celiac trunk.
Fig. 2 (A) Sagittal computed tomography (CT) angiography; subtotal occlusion of the celiac
artery. (B) Transversal CT angiography; subtotal occlusion of the celiac artery.
The patient was discussed in the multidisciplinary working group on mesenteric ischemia
and angioplasty was advised. After neoadjuvant chemoradiotherapy and 6 weeks prior
to the esophagectomy, percutaneous stent angioplasty ([Figs. 3A] and [B]) of the CA was performed. Antithrombotic drugs (carbaspirin calcium 100 mg and clopidogrel
75 mg) were prescribed. The patient underwent a total minimally invasive Ivor Lewis
esophagectomy with continuation of carbaspirin calcium. After a rapid recovery, the
patient was discharged 6 days after operation. One year postoperatively the stent
was still patent.
Fig. 3 (A) Digital subtraction angiography (DSA) before stenting. (B) DSA 1 day after percutaneous angioplasty with stenting.
Discussion
AL after esophageal surgery is a life-threatening complication. This case report demonstrates
that risk assessment and treatment of a potentially impaired perfusion of the gastric
conduit is feasible. To our knowledge, this is the first report describing stent angioplasty
prior to esophagectomy in a high-risk patient for AL due to significant calcifications.
Recently, atherosclerosis of the descending aorta and celiac trunk has been identified
as a strong risk factor for AL.[2]
[3] The relationship between calcifications and AL likely reflects a complex pathophysiological
mechanism in generalized atherosclerosis.[4] Notwithstanding, reducing this risk factor by assessing and quantifying the grade
of the celiac trunk stenosis, and treating it when necessary with modern percutaneous
endovascular techniques, appears to be possible within the waiting time between chemoradiotherapy
and esophagectomy. Although larger patient data sets are needed to estimate the actual
risk reduction of this strategy for AL, this report shows that it is highly important
to identify patients at risk. We propose to classify patients with a stenosis in the
CA > 70% detected by duplex or CT scan (arterial phase), as patients at risk, and
advise to perform preventive percutaneous mesenteric artery stenting.[1]
[5]
[6]
In conclusion, patients with severe calcifications of the mesenteric arteries on routine
preoperative CT scanning can benefit from further assessment and treatment to reduce
the risk of AL. CTA can accurately estimate the existence and the grade of a stenosis,
and endovascular treatment can be performed in the waiting time for esophagectomy.