 Good morning members of the faculty and delegates of CT bus 2021. My name is Dr. Shubhangi Gupta. I'm a second year radiology resident from Maharishi Markandeshwar Institute of Medical Sciences and Research, Haryana. Today I'm going to present a paper on SMA angioplasty following a chronic mesentric ischemia. The aim is to re-vascularize your clouted or severely spin-off superior mesentric artery by stenting. Objective is to analyze the results and durability of angioplasty or stenting of the superior mesentric artery. Beginning with the introduction, a 45-year-old male patient presented to the OBD with complaints of abdominal pain for nine months located at the epigastric region, radiating to the back, aggravated after intake of food, increased in intensity of pain was seen for 10 days. He was on liquid diet at the time of admission and also gave a history of weight loss of over 20 kgs over a period of nine months. No history of nausea, vomiting or constipation. No history of fever was there. No significant past history was there. Personal history included presence of chronic smoking for 20 years and chronic alcoholism for the past eight years. Because of the presence of clinical riot of post-prandial abdominal pain, weight loss and food avoidance, possibility of mesentric ischemia was raised. However, abdominal radiographs and ultrasonography was inconclusive, so a CECT-abdominant pelvis was decided on. Ct-abdominant angiography was done and it showed presence of occlusion of celiac artery and stenosis of hepatic and spleenic arteries along with occlusion of the IMA. 90% stenosis of the SMA was seen. Multiple arterial collateral were seen in the perihepatic perigastric and perirectal regions. This is a Ct-sajaitan limit showing presence of occlusion of the SMA at the osteum. Again the coronal limit showing presence of 90% occlusion of the SMA. Now this is a Ct-sajaitan image also showing presence of diffuse atherosclerotic changes in the abdominal iota along with that there is presence of occlusion of the SMA at the osteum. A 3D reconstructed image also shows presence of stenotic segment at the origin of the SMA. Pre-procedural carotid doctor was performed and bilateral carotid bulge and distal common carotid artery showed atherosclerotic plaques with ulceration. Now predisposing factors for SMA occlusion includes history of heavy smoking, plaques at abdominal iota and bilateral carotids. Management options include SMA angioplasty. So this patient was diagnosed with chronic mesentic ischemia due to near total occlusion of the superior mesentic artery due to accelerated atherosclerosis of the iotic walls. Now patient was administered anti-platelets and statins and he was planned for revascularization of the superior mesentic artery. Material and methods required for the procedure includes guided catheters of different sizes, teriumo guide wires of different sizes, coronary balloons along with that we also need a balloon expanding stent and pigtail catheters. So in this procedure SMA stenosis was crossed with a guide wire, angioplasty of this stenosis was done with the balloon catheters which were negotiated with an expandable stent which was inflated up to its nominal pressure of up to 6 atmospheres. So this is an abdominal angiography which was performed and the later view of the iotogram shows presence of 90% stenosis of the superior mesentic artery at the osteum. Now this is an iotogram image showing a balloon expanding catheter in C2 at the place of the SMA occlusion. After the inflation of the catheter, again an iotogram was performed and it shows the presence of expandable catheter at the SMA occrusive site. Now post procedural iotogram image shows presence of an adequate opening with normal pacification of the occluded SMA. This image shows the presence of deployed catheter. Post procedural ultrasonography was performed which shows presence of catheter in C2 at the site of occluded SMA. Color flow Doppler shows presence of normal flow at the site of occlusion post procedure and also shows normal waveform. Now this is an axial CT and this is a coronal CT post procedure which shows presence of stent at the site of occlusion of the SMA. Along with that it also shows free flow of contrast post procedure which is indicative of normal flow in the SMA. Post procedural 3D reconstruction image shows presence of catheter in C2 at the site of SMA occlusion. So mesentic is chemia is a rare disease with nonspecific symptoms like abdominal pain which is out of proportion to physical examination and has a high mortality rate. Because due to decreased blood supply to this plankonic vasculature it is usually seen in age groups between 50 to 60 years where significant stenosis of two or more arteries are involved. Chronic mesentic is chemia is uncommon with incidence of up to 9 per 1 lakh people. Most common etiologies diffuse iotic atherosclerosis followed by stenosis of the proximal part of the celiac artery, the superior mesentic artery or the inferior mesentic artery. Because they remain of limited value being able to diagnose only late stages of the acute mesentic ischemia when the bowel necrosis has already been present. Ultrasound abdomen with Doppler waveform analysis can depict proximal mesentic thrombosis and secondary signs of bowel compromise but it is limited for the diagnosis of distal occlusion and non-occlusive mesentic ischemia and therefore is not recommended as the initial examination. CT angiography is emerging diagnostic tests with high sensitivity and specificity and should be considered the first line imaging modality. It also provides excellent anatomic mapping of the mesentic vasculature which is essential in the pre-operative planning, angiography is diagnostic as well as therapeutic. Management of mesentic ischemia depends on bowel viability. If the bowel has undergone infarction followed by necrosis then bowel rejection by open laparotomy is done and if the bowel viability is maintained then re-vascularization procedures are considered. In case of thrombosis thrombectomy is done while in case of embolism percutaneous trans-luminal balloon angioplasty with or without stenting gives a good outcome. So results in this particular case, stenosed area in the SMA was deployed with this tent and re-vascularization was achieved, patient improved symptomatically and post-procedure CT iotogram was performed which showed presence of satisfactory results. To conclude, angiography is the gold standard for occlusion or stenosis of the mesentic arteries because we have an advantage of direct visualization of the mesentic vasculature. Selective catheterization and pressure management measurements across stenosis areas can also be expertly evaluated. Following are the references for SMA angioplasty. Thank you very much.