Mesenteric venous thrombosis

Endovascular Management of Acute and Chronic Mesenteric Ischemia

BACKGROUND

Mesenteric ischemia demands prompt and effective revascularization. Endovascular therapy (EVT) has become a well-established treatment modality with several benefits. This review examines current EVT options for managing acute and chronic mesenteric ischemia in contemporary practice.

METHOD

A comprehensive literature review was conducted to evaluate endovascular techniques for mesenteric ischemia, including angioplasty, stenting, thrombectomy, thrombolysis, pharmacological thrombectomy, local vasodilator infusion, and hybrid approaches. We also evaluated access sites and post-operative management.

RESULTS

EVT offers several advantages in the management of mesenteric ischemia, with various access sites and techniques available for single or combined use. EVT has largely replaced open revascularization for CMI and is increasing in use for AMI. The utility of each approach varies by disease chronicity, with different risk-benefit profiles. While short term outcomes are favorable, long-term patency rates and the need for re-interventions remain concerns. Further research is needed to compare open to endovascular revascularization.

CONCLUSION

EVT provides diverse revascularization options for mesenteric ischemia, particularly for high-risk patients. While it has favorable short-term outcomes, EVT may be associated with higher rates of restenosis and reintervention in the long term and the overall mortality rates for this disease process remain high, particularly for AMI. The choice between endovascular and open surgical approaches should be individualized on patient factors, lesion characteristics, and surgeon/interventionist expertise. Further prospective and randomized trials are needed to better elucidate outcomes from this approach and guide operative management.

Transhepatic Pharmacomechanical Thrombectomy of Symptomatic Acute Noncirrhotic, Nonmalignant Portomesenteric Venous Thrombosis: Midterm Results

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of transhepatic pharmacomechanical thrombectomy of symptomatic acute portomesenteric venous thrombosis. MATERIALS AND METHODS. Transhepatic pharmacomechanical thrombectomy (catheter-directed thrombolysis with mechanical thrombectomy) was performed in the treatment of nine patients with symptomatic acute noncirrhotic, nonmalignant porto-mesenteric venous thrombosis. The medical records, imaging examinations, technique of transhepatic pharmacomechanical thrombectomy, and clinical outcomes were reviewed. RESULTS. The mean follow-up period was 23.1 months (range, 8-34) months. Successful recanalization of the portomesenteric venous thrombosis, restoration of hepatopetal portal flow, clinically significant improvement in the signs and symptoms of acute mesenteric ischemia, and prevention of bowel resection were achieved in all patients. The most frequent minor complication (in three patients) was minor hemorrhage through the transhepatic access track. No procedure-related major complications occurred during hospitalization. No patient had rethrombosis or complications related to portal hypertension due to portomesenteric venous thrombosis. One patient died of massive pulmonary embolism on the 7th day after treatment. Cavernous transformation of the right portal vein occurred in one patient. CONCLUSION. Transhepatic pharmacomechanical thrombectomy is a safe and effective method of treatment of symptomatic acute portomesenteric venous thrombosis and prevention of bowel infarction.

Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route

OBJECTIVE

To assess the feasibility and effectiveness of transjugular intrahepatic route aspiration thrombectomy and catheter-directed thrombolytic therapy in patients with acute superior mesenteric venous thrombosis.

MATERIALS AND METHODS

During a period of 8 years, 12 patients with acute thrombosis of the superior mesenteric vein (SMV) were treated by transjugular intrahepatic approach. The mean age was 41.2 years. After access to the portal system via the transjugular approach, the pigtail catheter fragmentation of the thrombus, local urokinase injection, and manual aspiration thrombectomy were used for treatment of the SMV thrombosis initially, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for 2 to 6 days (4.2 ± 1.8 days). The adequacy of anticoagulation was performed during treatment, throughout hospitalization, and after discharge.

RESULTS

Technical success was achieved in all 12 patients. Substantial clinical improvement was seen in these patients after the procedure. Minor complications at the jugular puncture site were observed in 4 patients, but the thrombolytic therapy was not interrupted. Contrast-enhanced computed tomography (CT) scan before discharge demonstrated nearly complete disappearance of SMV thrombosis in all patients. The 12 patients were discharged 5-10 days (7.6 ± 2.0) after admission. Mean duration of follow-up after hospital discharge was 37.7 months, and no recurrent episodes of SMV thrombosis developed during that time period.

CONCLUSION

Catheter-directed thrombus aspiration, mechanical fragmentation, and local thrombolytic infusion via the transjugular intrahepatic route is a safe and effective therapy for the management of patients with acute symptomatic SMV thrombosis.

Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis

PURPOSE

The purpose of this study was to evaluate the utility of transcatheter thrombolytic therapy in 20 patients with acute or subacute (symptoms <40 days) portal and/or mesenteric vein thrombosis with severe symptoms, deteriorating clinical condition, and/or persistent symptoms despite anticoagulation.

MATERIALS AND METHODS

This retrospective study examined 12 male patients and eight female patients seen over a period of 11 years. The average age was 37.6 years. Four of the patients had previously undergone liver transplantation. An anatomic classification system was established to describe the extent of thrombus at the time of diagnosis. Patients were treated with thrombolytic therapy via the transhepatic route, common femoral vein route, and/or superior mesenteric artery route. Improvement in symptoms, avoidance of bowel resection, complications, and radiographic evidence of clot resolution were the main clinical outcomes.

RESULTS

Fifteen of the 20 patients exhibited some degree of lysis of the thrombus. Three patients had complete resolution, 12 had partial resolution, and five had no resolution. Eighty-five percent of patients (n = 17) had resolution of symptoms. Sixty percent of patients (n = 12) developed a major complication. No patients required bowel resection after thrombolytic therapy. One patient died with gastrointestinal hemorrhage and septic shock 2 weeks after thrombolytic therapy. Other major complications included bleeding and conditions requiring transfusion. No patients developed new portal or mesenteric thromboses. Two of the patients who received transplants eventually required repeat transplantation.

CONCLUSIONS

Transcatheter thrombolysis was beneficial in avoiding patient death, resolving thrombus, improving symptoms, and avoiding bowel resection. However, there was a high complication rate, indicating that this therapy should be reserved for patients with severe disease. Further evaluation of these techniques and outcomes should continue to be pursued.