Endovascular Thrombolysis in Acute Mesenteric Vein Thrombosis: A 3-year follow-up with the rate of short and long-term sequaelae in 32 patients

Endovascular Management of Noncirrhotic Acute Portomesenteric Venous Thrombosis

Acute portomesenteric venous thrombosis (PVT) is a rare but potentially life-threatening condition in individuals without cirrhosis. Initial management typically involves anticoagulation therapy, but the optimal approach to interventional treatment remains a topic of ongoing research. This article explores both traditional and emerging endovascular techniques, providing an overview of the existing evidence supporting their use. Additionally, it delves into the significance of acute PVT in the context of contemporary pathologies, notably coronavirus disease 2019 infection, vaccine-induced immune thrombotic thrombocytopenia, and liver transplantation.

Mesenteric venous thrombosis in a young adult: A case report and review of the literature

BACKGROUND

Acute mesenteric vein thrombosis (MVT) accounts for only 2%-10% of all cases of acute mesenteric ischaemia, with an incidence rate of ~0.1% in Europe and the United States. It represents < 10% of mesenteric infarction cases and is seen predominantly in older adults. In younger individuals, MVT is uncommon, with 36% of cases having unidentified mechanisms and causes.

CASE SUMMARY

A 27-year-old man presented to the emergency department on February 29, 2024, with a chief complaint of intermittent abdominal pain for 3 day. He was previously in good health. As the abdominal pain was not alleviated by conventional treatment, an abdominal computed tomography (CT) scan was performed, which showed increased density in the portal and mesenteric veins. Further imaging, including portal vein ultrasound, mesenteric CT angiography, and enhanced abdominal CT, revealed widespread thrombosis of the portal vein system (including the main portal vein, left and right branches, proximal mesenteric vein, and splenic vein). After 10 day of thrombectomy and anticoagulation therapy, the patient's abdominal pain had improved significantly. Follow-up assessments indicated that portal venous blood flow had largely returned to normal. He was discharged on March 9, 2024. During a follow-up exam 2 months later, repeat abdominal enhanced CT showed that the previously detected thrombi were no longer visible.

CONCLUSION

Clinicians should remain vigilant for acute MVT in young patients presenting with abdominal pain, to prevent misdiagnosis of this fatal condition.

Association between PAI-1 4G/5G genotype and residual thrombus in acute mesenteric venous thrombosis

OBJECTIVE

Plasminogen activator inhibitor-1 (PAI-1) is the most important inhibitor of plasminogen activator. The functional 4G/5G polymorphism of the gene coding for PAI-1 may affect PAI-1 plasmatic activity, influencing the imbalance between coagulation and fibrinolysis cascades. In this study, we investigated the association between the PAI-1 4G/5G genotype and the development and residual thrombus of acute primary mesenteric venous thrombosis (MVT).

METHODS

The clinical data of 34 patients who underwent acute primary MVT were retrospectively reviewed. Fluorescence in situ hybridization was used to determine if patients had the 4G/5G polymorphism in the promoter of the PAI-1 gene. Patients were stratified according to the genotype of PAI-1.

RESULTS

11 patients (32.3%) were homozygous for the 4G genotype, 23 patients (67.6%) were non-homozygous for the 4G genotype (5G/5G). The extent of thrombosis was not correlated with the PAI-4G/5G polymorphism. After a mean follow-up of 16.6 ± 10.4 months, the 4G/4G genotype had a significantly larger thrombus burden (p < 0.05). 54% of patients in the 4G/4G genotype group had no lessening in the degree of mesenteric venous thrombosis, significantly higher than other patients (4G/5G + 5G/5G genotypes) (p < 0.05).

CONCLUSION

The PAI-1 4G/4G predicts residual thrombus of mesenteric veins after the acute phase.

Efficacy and safety of thrombolytic therapy for portal venous system thrombosis: A systematic review and meta-analysis

BACKGROUND AND AIMS

The role of thrombolytic therapy in patients with portal venous system thrombosis (PVST) remains ambiguous. This study aimed to systematically collect available evidence and evaluate the efficacy and safety of thrombolysis for PVST.

METHODS

Eligible studies were searched via PubMed, EMBASE, and Cochrane Library databases. Among the cohort studies, meta-analyses were performed to assess the outcomes of PVST patients receiving thrombolysis. Pooled proportions were calculated. Among the case reports and case series, logistic regression analyses were performed to identify the risk factors for outcomes of PVST patients receiving thrombolysis. Odds ratios (ORs) were calculated.

RESULTS

Among the 2134 papers initially identified, 29 cohort studies and 131 case reports or case series were included. Based on the cohort studies, the pooled rates of overall response to thrombolytic therapy, complete recanalization of PVST, bleeding events during thrombolysis, further bowel resection, thrombosis recurrence, and 30-day mortality were 93%, 58%, 18%, 3%, 1%, and 4%, respectively. Based on the case reports and case series, acute pancreatitis (OR = 0.084), history of liver transplantation (OR = 13.346), and interval between onset of symptoms and initiation of thrombolysis ≤14 days (OR = 3.105) were significantly associated with complete recanalization of PVST; acute pancreatitis (OR = 6.556) was significantly associated with further bowel resection; but no factors associated with the overall response to thrombolytic therapy, bleeding events during thrombolysis, thrombosis recurrence, and 30-day mortality were identified or could be calculated.

CONCLUSION

Early initiation of thrombolysis should be effective for the treatment of PVST. But its benefits for PVST secondary to acute pancreatitis are weakened.

Acute superior mesenteric venous thrombosis results in high rates of readmission and morbidity

OBJECTIVE

Superior mesenteric venous thrombosis (MVT) is a poorly understood clinical entity, and as such, outcomes are poorly described. This study aimed to identify predictors of bowel ischemia after MVT and to compare outcomes for patients treated medically (group 1) with those for patients treated with bowel resection (group 2).

METHODS

This was a retrospective, single-institution study capturing all patients diagnosed with symptomatic acute MVT on computed tomography imaging from 2008 to 2018. Demographics, comorbidities, imaging, laboratory values, and treatment were included. Predictors of bowel resection were analyzed by univariate and multivariate statistics. Outcomes including mortality, readmissions for abdominal pain, and chronic mesenteric venous congestion were compared using χ² test.

RESULTS

There were 121 patients included in the study; 98 patients were treated medically (group 1), 19 patients were treated with bowel resection (group 2), and 4 patients were treated with endovascular recanalization (group 3). Group 1 and group 2 were compared directly. Patients requiring bowel resection tended to have higher body mass index (P = .051) and a hypercoagulable disorder (P = .003). Patients who required bowel resection were more likely to present with lactic acidosis (P < .001) and leukocytosis (P < .001) with bowel wall thickening on scan (P < .001). On multivariable analysis, a genetic thrombophilia was a strong predictor of bowel ischemia (odds ratio, 3.81; 95% confidence interval, 1.12-12.37). One-year mortality and readmission rates did not differ between groups. However, readmission rates for abdominal pain were high for both groups (group 1, 44.90%; group 2, 57.89%; P = .317), and a significant proportion of patients exhibited chronic mesenteric venous congestion on repeated scan (group 1, 42.86%; group 2, 47.37%; P = .104).

CONCLUSIONS

A genetic hypercoagulable disorder is a predictor of bowel ischemia due to MVT. Regardless of treatment, outcomes after MVT are morbid, with high rates of readmission for abdominal pain. An alternative approach to treat these patients is needed, given the poor outcomes with current strategies.

Incidence and risk factors of portomesenteric venous thrombosis after colorectal surgery for cancer in the elderly population

BACKGROUND

Although it is known that portomesenteric venous thrombosis (PMVT) is associated with total colectomy and proctocolectomy in young patients with inflammatory bowel disease, little is known about incidence and risk factors of PMVT among the elderly population undergoing colorectal surgery for cancer.

METHODS

Data of elderly patients (> 70 years) undergoing surgery for colorectal cancer were retrospectively registered. The occurrence of PMVT was correlated with the patients' characteristics and operative variables. Data collected included age, sex, obesity, ASA score, tumor degree, type of surgical resection, surgical approach (laparoscopic or open), and duration of surgery (from skin incision to the application of dressings).

RESULTS

A total of 137 patients > 70 years who underwent surgery for colorectal cancer and developed an acute intraabdominal process with suggestive symptoms, needing a CT scan, were included. Three of these patients (2.1%) had portomesenteric venous thrombosis during the study period, which was proved with CT scan. There were no significant patients' characteristics or operative variables between patients with or without the occurrence of PMVT after surgery. Of interest, only operative time was significantly higher in patients with PMVT after surgery (256 ± 40 vs 140 ± 41, p < 0.001).

CONCLUSIONS

PMVT as a cause of abdominal pain after colorectal surgery for cancer in the elderly population is uncommon. An index of suspicion for PMVT in an elderly postoperative colorectal cancer patient with sudden onset of abdominal pain must be maintained.

Complex management of acute superior mesenteric venous thrombosis in the setting of metastatic ovarian cancer

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Superior mesenteric vein thrombosis (SMVT) is rare but seen in patients with hypercoagulable states.

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Prevention of mortality in patients with SMVT requires immediate diagnosis and complex management.

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A hierarchical approach to treatment progresses to more aggressive treatment as needed.

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Supportive care, medication, and endovascular and/or surgical interventions are available management options.

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In patients with underlying conditions, long-term treatment such as anticoagulation must also be initiated.

Acute mesenteric ischaemia: imaging and intervention

Acute mesenteric ischaemia (AMI) is an abdominal emergency in which an acute reduction in mesenteric arterial supply threatens bowel viability and may result in bowel infarction, perforation, and death. Despite improvements in diagnosis and treatment over recent decades, mortality rates in AMI remain very high. This article discusses the aetiological classification, pathophysiology, and clinical aspects of AMI. The specific imaging characteristics of each aetiological type of AMI are detailed and the role of different imaging methods in the diagnosis of AMI is discussed. Surgery is the established treatment of choice for AMI, but there is increasing use of endovascular techniques in treating AMI in cases where there are no clinical features of peritonism or radiological evidence of irreversible ischaemia. This article reviews the evidence for different diagnostic and management strategies for patients with AMI and discusses the advantages and disadvantages of surgical and endovascular treatments. Endovascular techniques have been reported to have high technical success rates and favourable outcomes when compared to open surgery; however, patient selection bias and a paucity of data limit the conclusions that can be drawn.

Contemporary Management of Acute Mesenteric Ischemia in the Endovascular Era

Objective:

Acute mesenteric ischemia is a rare disease entity associated with high morbidity and mortality. Disparate etiologies and nonspecific symptoms make the diagnosis challenging and often result in delayed diagnosis and intervention. Open laparotomy with mesenteric revascularization and resection of necrotic bowel has been considered the gold standard of care. With recent advances in percutaneous catheter-directed techniques, multiple retrospective studies have demonstrated the outcomes of endovascular therapy. Herein, we review the etiology, presentation, and diagnosis of acute mesenteric ischemia with contemporary outcomes associated with both open and endovascular treatments.

Methods:

The PubMed electronic database was queried in the English language using the search words mesenteric, acute ischemia, embolism, thromboembolism, thrombosis, revascularization, and endovascular in various combinations. Abstracts of the relevant titles were examined to confirm their relevance and the full articles then extracted. References from extracted articles were checked for any additional relevant articles. This systematic review encompassed literature for the past 5 years (between 2011 and 2016).

Results:

Early diagnosis and intervention improves acute mesenteric ischemia outcomes. Early restoration of mesenteric flow minimizes morbidity and mortality. In comparison to open laparotomy with mesenteric revascularization and resection of necrotic bowel, several retrospective studies using administrative data and single-center chart reviews demonstrate noninferior outcomes of an endovascular first approach in acute arterial mesenteric occlusion.

Conclusions:

For acute mesenteric arterial occlusive disease, both endovascular and open revascularization techniques are viable options. Although there is lack of level 1 evidence, single-center retrospective studies and administrative database studies demonstrated that an endovascular first approach may have improved outcomes in the immediate postoperative period. However, selection and other bias in these studies necessitate the need for definitive randomized prospective studies between endovascular and open mesenteric intervention. In contrast, mesenteric venous thrombosis may be treated with systemic anticoagulation without surgical revascularization. Catheter-directed thrombectomy and thrombolysis can be considered at the discretion of the clinician.

ACR Appropriateness Criteria® Radiologic Management of Mesenteric Ischemia

Mesenteric vascular insufficiency is a serious medical condition that may lead to bowel infarction, morbidity, and mortality that may approach 50%. Recommended therapy for acute mesenteric ischemia includes aspiration embolectomy, transcatheter thrombolysis, and angioplasty with or without stenting for the treatment of underlying arterial stenosis. Nonocclusive mesenteric ischemia may respond to transarterial infusion of vasodilators such as nitroglycerin, papaverine, glucagon, and prostaglandin E1. Recommended therapy for chronic mesenteric ischemia includes angioplasty with or without stent placement and, if an endovascular approach is not possible, surgical bypass or endarterectomy. The diagnosis of median arcuate ligament syndrome is controversial, but surgical release may be appropriate depending on the clinical situation. Venous mesenteric ischemia may respond to systemic anticoagulation alone. Transhepatic or transjugular superior mesenteric vein catheterization and thrombolytic infusion can be offered depending on the severity of symptoms, condition of the patient, and response to systemic anticoagulation. Adjunct transjugular intrahepatic portosystemic shunt creation can be considered for outflow improvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Treatment outcomes and risk factors for bowel infarction in patients with acute superior mesenteric venous thrombosis

OBJECTIVE

The prognosis of acute superior mesenteric venous thrombosis (SMVT) remains obscure. We aimed to investigate the treatment outcomes and possible risk factors for bowel infarction in these patients.

METHODS

We retrospectively included 66 patients with acute SMVT between January 2002 and June 2016. Each patient underwent contrast-enhanced computed tomography as part of the initial diagnosis. The standard protocol for management included a nonsurgical approach with early anticoagulation and selective exploration. For the analysis of the risk factors for bowel infarction, patients were divided into bowel resection (BR) and non-BR groups. Outcomes of interest were causes of SMVT, percentage of BR after nonsurgical treatment, and risk factors for BR.

RESULTS

Of 66 patients, 15 (23%) underwent BR; of these, 9 underwent urgent BR because of peritoneal signs and definite findings of bowel infarction on computed tomography scan, 4 underwent BR after failed anticoagulation, and 2 underwent BR because of delayed stricture. Clinically, vomiting (P = .003), abdominal distention (P = .003), rebound tenderness (P = .005), and leukocytosis (P = .001) were associated with BR. On radiologic examination, bowel wall thickening (P < .001), enhancement defects of the bowel wall (P < .001), and ascites (P = .007) were associated with BR. Twenty-seven (41%) patients presented with isolated SMVT, and the remaining patients demonstrated a coexisting portal vein (PV) thrombosis in addition to SMVT. All 15 BRs occurred in patients with combined PV thrombosis and SMVT (P < .001). Complete thrombosis of the superior mesenteric vein and PV was also associated with BR (P = .028 for superior mesenteric vein; P = .025 for PV). BR was performed in 1 (4%) of 24 patients with transient risk factors compared with 14 (33%) of 42 patients without transient risk factors (P = .006). Three patients (4.5%) died in the hospital.

CONCLUSIONS

In patients with acute SMVT, the extent of thrombus and etiology were associated with the severity of acute SMVT. Patients with transient risk factors and isolated SMVT tended to have a benign disease course. With early anticoagulation, acute SMVT does not seem to have the grave prognosis that is associated with arterial thrombosis.

Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty

Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits.

RESULTS

1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA.

CONCLUSIONS

It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT.

Mesenteric venous thrombosis

OBJECTIVE

This review explores the current literature on the natural history, diagnosis, and management of mesenteric venous thrombosis (MVT) in the modern era.

METHODS

A review of the contemporary literature from 1997 to 2016 on MVT and its pathogenesis, diagnosis, and treatment was performed.

RESULTS

MVT is an insidious and lethal disease associated with acute mesenteric ischemia. The prevalence of MVT has increased sharply during the past two decades commensurate with an increase in radiographic imaging for abdominal complaints. The optimal treatment of and approach to MVT is controversial, given the poorly understood natural history of this rare disease. Both endovascular and open surgical strategies in addition to systemic anticoagulation have been used as adjuncts to treat MVT with limited success. Despite advances in treatment, mortality associated with MVT is still high. Furthermore, recent studies have shown that failure to recanalize the portomesenteric venous system leads to an increased risk for development of sequelae of portal hypertension.

CONCLUSIONS

MVT is a challenging disease to treat, given the difficulty in establishing a prompt initial diagnosis and the inability to reliably monitor patients for evidence of impending bowel infarction. Careful selection of patients for endovascular, open, or hybrid approaches is key to achieving improved outcomes. However, the paucity of prospective data and our evolving understanding of the natural history of MVT make consensus treatment strategies difficult to ascertain.

Mesenteric vein thrombosis can be safely treated with anticoagulation but is associated with significant sequelae of portal hypertension

BACKGROUND

Mesenteric venous thrombosis (MVT) is a relatively uncommon but potentially lethal condition associated with bowel ischemia and infarction. The natural history and long-term outcomes are poorly understood and under-reported.

METHODS

A single-institution retrospective review of noncirrhotic patients diagnosed with MVT from 1999 to 2015 was performed using International Classification of Diseases, Ninth Revision and radiology codes. Patients were excluded if no radiographic imaging was available for review. Eighty patients were identified for analysis. Demographic, clinical, and radiographic data on presentation and at long-term follow-up were collected. Long-term sequelae of portal venous hypertension were defined as esophageal varices, portal vein cavernous transformation, splenomegaly, or hepatic atrophy, as seen on follow-up imaging.

RESULTS

There were 80 patients (57.5% male; mean age, 57.9 ± 15.6 years) identified; 83.3% were symptomatic, and 80% presented with abdominal pain. Median follow-up was 480 days (range, 1-6183 days). Follow-up radiographic and clinical data were available for 50 patients (62.5%). The underlying causes of MVT included cancer (41.5%), an inflammatory process (25.9%), the postoperative state (20.7%), and idiopathic cases (18.8%). Pancreatic cancer was the most common associated malignant neoplasm (53%), followed by colon cancer (15%). Twenty patients (26%) had prior or concurrent lower extremity deep venous thromboses. Most patients (68.4%) were treated with anticoagulation; the rest were treated expectantly. Ten (12.5%) had bleeding complications related to anticoagulation, including one death from intracranial hemorrhage. Four patients underwent intervention (three pharmacomechanical thrombolysis and one thrombectomy). One patient died of intestinal ischemia. Two patients had recurrent MVT, both on discontinuing anticoagulation. Long-term imaging sequelae of portal hypertension were noted in 25 of 50 patients (50%) who had follow-up imaging available. Patients with long-term sequelae had lower recanalization rates (36.8% vs 65%; P = .079) and significantly higher rates of complete as opposed to partial thrombosis at the initial event (73% vs 43.3%; P < .005). Long-term sequelae were unrelated to the initial cause or treatment with anticoagulation (P = NS).

CONCLUSIONS

Most cases of MVT are associated with malignant disease or an inflammatory process, such as pancreatitis. A diagnosis of malignant disease in the setting of MVT has poor prognosis, with a 5-year survival of only 25%. MVT can be effectively treated with anticoagulation in the majority of cases. Operative or endovascular intervention is rarely needed but important to consider in patients with signs of severe ischemia or impending bowel infarction. There is a significant incidence of radiographically noted long-term sequelae from MVT related to portal venous hypertension, especially in cases of initial complete thrombosis of the mesenteric vein.

ESTES guidelines: acute mesenteric ischaemia

PURPOSE

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.

METHODS

A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.

RESULTS

The resultant recommendations are presented in this paper.

CONCLUSIONS

The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Mesenteric Ischemia

Acute mesenteric ischemia (AMI) is a rare disease that most commonly affects the elderly. The vague symptoms often lead to delayed diagnosis and consequent high mortality. Physical exam and laboratory findings lack the sensitivity and specificity to exclude AMI, but computed tomography angiography can rapidly and accurately confirm the diagnosis. Survival improves with prompt restoration of perfusion and resection of nonviable bowel. Advances in imaging, operative techniques, and critical care have led to a steady decline in overall mortality; however, long-term survival is limited because of the comorbidities in this patient group.

Mesenteric ischemia

PURPOSE OF REVIEW

Diagnosis of acute mesenteric ischemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischemia may be treated with urgent intestinal revascularization.

RECENT FINDINGS

The establishment of a hybrid operation room is most important to be able to perform explorative laparotomy for evaluation of the extent of mesenteric ischemia and successful intestinal revascularization. Endovascular recanalization and stenting has become an important alternative, especially in patients with both acute and chronic thrombotic superior mesenteric artery (SMA) occlusion. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. The concept of damage-control surgery is recommended after intestinal revascularization.

SUMMARY

Intestinal revascularization in patients with arterial occlusive mesenteric ischemia reduces bowel morbidity and mortality. Observational studies report that both endovascular and open vascular therapy options are effective, but endovascular technique may be preferred in these often elderly and fragile patients.

Modern treatment of acute mesenteric ischaemia

BACKGROUND

Diagnosis of acute mesenteric ischaemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischaemia may be treated with urgent intestinal revascularization.

METHODS

This was a review of modern treatment strategies for acute mesenteric ischaemia.

RESULTS

Endovascular therapy has become an important alternative, especially in patients with acute thrombotic superior mesenteric artery (SMA) occlusion, where the occlusive lesion can be recanalized either antegradely from the femoral or brachial artery, or retrogradely from an exposed SMA after laparotomy, and stented. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. Laparotomy is needed to evaluate the extent and severity of visceral organ ischaemia, which is treated according to the principles of damage control surgery.

CONCLUSION

Modern treatment of acute mesenteric ischaemia involves a specialized approach that considers surgical and, increasingly, endovascular options for best outcomes.

Special indications for vitamin K antagonists: a review

In this review, we present some different and special conditions that are generally being treated with anticoagulants such as cerebral vein thrombosis (CVT), mesenteric vein thrombosis (MVT), Budd-Chiari syndrome (BCS), and Pulmonary Hypertension (PH) despite the lack of controlled clinical trials. While either low molecular weight heparins (LMWHs) or unfractioned heparin (UFH) are used in the acute phase of the first three conditions, the potential chronic use of warfarin in PH is controversial. What is not completely known in the management of CVT, MTV, and BCS is whether (a) LMWHs are similar to UFH in terms of efficacy and safety, and (b) a fibrinolytic drug could be employed in the acute phase. The timing at which warfarin should be started, and the duration of its employment are two additional crucial points that deserve to be examined. In the course of PH, the role of warfarin is controversial, but it could be employed after a careful balance of the hemorrhagic and thromboembolic risk. In conclusion, we tried to simplify the approach to this sometimes problematic task considering the available literature with the aim of providing some practical skills to be used by physicians in their daily clinical practice. Since it is improbable that in the future controlled clinical trials will be designed to find the optimal anti-thrombotic management of these conditions, we believe that a physician should be aware of the lack of solid data in the field but at the same time should always exert clinical judgment when considering an aggressive anticoagulant approach. The duration of oral anticoagulant treatment is left to the clinical judgment of the balance between the hemorrhagic and thrombotic risks in any single patient.