Limits...
Endovascular recanalisation of an acute superior mesenteric artery occlusion. A case report and review of the literature.

McGarry JG, McEvoy SH, Brophy DP - Ann Med Surg (Lond) (2014)

Bottom Line: A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography.Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion.However, laparotomy is often required to accurately determine bowel viability and the need for resection.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

ABSTRACT

Introduction: Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%.

Presentation of case: A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis.

Discussion: We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI.

Conclusion: Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection.

No MeSH data available.


Related in: MedlinePlus

(A) Three-dimensional volume rendering of arterial phase computed tomography (CT) angiography showing a segmental thromboembolic occlusion of the SMA immediately distal to the right colic branch. (B) Selective catheterisation and angiography of the SMA occlusion. (C) Successful revascularisation of the SMA following catheter-directed thrombolysis, angioplasty and thromboaspiration.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4372641&req=5

fig1: (A) Three-dimensional volume rendering of arterial phase computed tomography (CT) angiography showing a segmental thromboembolic occlusion of the SMA immediately distal to the right colic branch. (B) Selective catheterisation and angiography of the SMA occlusion. (C) Successful revascularisation of the SMA following catheter-directed thrombolysis, angioplasty and thromboaspiration.

Mentions: A 78-year old male presented with a 20-hour history of acute onset severe sharp central abdominal pain and vomiting. On arrival to the emergency department he was pale, tachycardic and hypertensive, with mild central abdominal tenderness. Abnormalities in his blood tests included mild acute renal impairment, leucocytosis and a raised arterial lactate (3.3 mmol/L; normal range 0.5–1 mmol/L). His medical history included atrial fibrillation, ischaemic heart disease and hypertension. An urgent CT mesenteric angiogram was performed and a complete thromboembolic occlusion ∼4 cm distal to the origin of the SMA was evident on arterial phase images (Fig. 1A). He was promptly fluid resuscitated and commenced on empirical antibiotics but his clinical condition continued to deteriorate with severe abdominal pain and uncontrolled tachycardia, and an urgent laparotomy was performed at 05:00 h. At laparotomy there were no signs of free fluid or perforation, and the bowel was determined to be viable. It was decided, based on local expertise and facilities available, to transfer the patient to the interventional radiology suite for urgent endovascular revascularisation. Access was established via the right common femoral artery and a 6-French introducer sheath system (Terumo Corporation, NJ, USA). Selective SMA angiography confirmed a segmental thromboembolic occlusion ∼4 cm from its origin (Fig. 1B). Selective catheterisation of the SMA was performed using a 0.0014-inch guidewire and SOS Omni® selective catheter (Angiodynamics, NY, USA). The thrombus was initially laced with a 20 mg bolus of tissue plasminogen activator (tPA), followed by angioplasty with a 4 × 20 mm balloon under fluoroscopic control. Remaining fragments of thrombus were removed by thromboaspiration until the occluded segment was fully recanalised. A 6-French closure device (Angioseal®, St. Jude Medical, MN, USA) was used for haemostasis at the femoral access site. The procedure duration was one hour and there were no complications. The patient was then recommenced on a heparin infusion to maintain the activated partial thromboplastin time ratio between 1.5 and 2.5. Within hours his abdominal pain had improved dramatically and the arterial lactate had normalised. Despite this initial improvement over subsequent days his clinical condition continued to deteriorate with progression of sepsis. A repeat CT abdomen 6 days post-intervention demonstrated normal bowel without any secondary signs of intestinal ischaemia (Fig. 1C). In addition to worsening renal impairment he developed acute respiratory distress syndrome (ARDS) requiring ventilation, and unfortunately died 10 days later.


Endovascular recanalisation of an acute superior mesenteric artery occlusion. A case report and review of the literature.

McGarry JG, McEvoy SH, Brophy DP - Ann Med Surg (Lond) (2014)

(A) Three-dimensional volume rendering of arterial phase computed tomography (CT) angiography showing a segmental thromboembolic occlusion of the SMA immediately distal to the right colic branch. (B) Selective catheterisation and angiography of the SMA occlusion. (C) Successful revascularisation of the SMA following catheter-directed thrombolysis, angioplasty and thromboaspiration.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4372641&req=5

fig1: (A) Three-dimensional volume rendering of arterial phase computed tomography (CT) angiography showing a segmental thromboembolic occlusion of the SMA immediately distal to the right colic branch. (B) Selective catheterisation and angiography of the SMA occlusion. (C) Successful revascularisation of the SMA following catheter-directed thrombolysis, angioplasty and thromboaspiration.
Mentions: A 78-year old male presented with a 20-hour history of acute onset severe sharp central abdominal pain and vomiting. On arrival to the emergency department he was pale, tachycardic and hypertensive, with mild central abdominal tenderness. Abnormalities in his blood tests included mild acute renal impairment, leucocytosis and a raised arterial lactate (3.3 mmol/L; normal range 0.5–1 mmol/L). His medical history included atrial fibrillation, ischaemic heart disease and hypertension. An urgent CT mesenteric angiogram was performed and a complete thromboembolic occlusion ∼4 cm distal to the origin of the SMA was evident on arterial phase images (Fig. 1A). He was promptly fluid resuscitated and commenced on empirical antibiotics but his clinical condition continued to deteriorate with severe abdominal pain and uncontrolled tachycardia, and an urgent laparotomy was performed at 05:00 h. At laparotomy there were no signs of free fluid or perforation, and the bowel was determined to be viable. It was decided, based on local expertise and facilities available, to transfer the patient to the interventional radiology suite for urgent endovascular revascularisation. Access was established via the right common femoral artery and a 6-French introducer sheath system (Terumo Corporation, NJ, USA). Selective SMA angiography confirmed a segmental thromboembolic occlusion ∼4 cm from its origin (Fig. 1B). Selective catheterisation of the SMA was performed using a 0.0014-inch guidewire and SOS Omni® selective catheter (Angiodynamics, NY, USA). The thrombus was initially laced with a 20 mg bolus of tissue plasminogen activator (tPA), followed by angioplasty with a 4 × 20 mm balloon under fluoroscopic control. Remaining fragments of thrombus were removed by thromboaspiration until the occluded segment was fully recanalised. A 6-French closure device (Angioseal®, St. Jude Medical, MN, USA) was used for haemostasis at the femoral access site. The procedure duration was one hour and there were no complications. The patient was then recommenced on a heparin infusion to maintain the activated partial thromboplastin time ratio between 1.5 and 2.5. Within hours his abdominal pain had improved dramatically and the arterial lactate had normalised. Despite this initial improvement over subsequent days his clinical condition continued to deteriorate with progression of sepsis. A repeat CT abdomen 6 days post-intervention demonstrated normal bowel without any secondary signs of intestinal ischaemia (Fig. 1C). In addition to worsening renal impairment he developed acute respiratory distress syndrome (ARDS) requiring ventilation, and unfortunately died 10 days later.

Bottom Line: A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography.Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion.However, laparotomy is often required to accurately determine bowel viability and the need for resection.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

ABSTRACT

Introduction: Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%.

Presentation of case: A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis.

Discussion: We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI.

Conclusion: Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection.

No MeSH data available.


Related in: MedlinePlus