Treatment outcomes in patients with acute thromboembolic occlusion of the superior mesenteric artery

OBJECTIVES

The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment.

METHODS

The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group.

RESULTS

Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency.

CONCLUSIONS

Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors.

Efficacy and safety analysis of AcoStream thrombus aspiration device in the treatment of acute superior mesenteric artery embolism

OBJECTIVE

Acute superior mesenteric artery embolism is a life-threatening disease caused by the abrupt interruption of mesenteric blood circulation, and the prognosis is very poor. Several studies have confirmed the efficacy and safety of percutaneous mechanical thrombectomy in acute superior mesenteric artery embolism, however, there are currently no literature reports on the latest percutaneous mechanical thrombectomy device-AcoStream™. In the present report, we summarize a series of cases and share our surgical experiences.

METHODS

The clinical data of 10 patients (six men and four women, mean age 77.6 ± 7.4 years) with acute superior mesenteric artery embolism treated by AcoStream™ in our center from December 2022 to December 2023 were retrospectively analyzed. Based on the literature, we summarized the diagnosis, therapy, and surgical experience of acute superior mesenteric artery embolism.

RESULTS

Percutaneous mechanical thrombectomy was performed for all the patients. The success rate of surgery reached 100% and no perioperative complications occurred. Abdominal pain was significantly relieved and the abdominal signs gradually disappeared in eight patients, while the other two patients still complained of abdominal pain during hospitalization, and eventually, they underwent resection of necrotic bowel. All the patients' symptoms were significantly relieved and they were smoothly discharged from the hospital.

CONCLUSIONS

As shown in the present study, percutaneous mechanical thrombectomy using AcoStream™ is minimally invasive, safe, and efficient in the initial stage of acute superior mesenteric artery embolism. We believe that percutaneous mechanical thrombectomy can be a promising alternative in selected cases.

Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review

It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.

Case report: ultrasound assisted catheter directed thrombolysis of an embolic partial occlusion of the superior mesenteric artery

Acute mesenteric ischemia (AMI) is a severe medical condition defined by insufficient vascular supply to the small bowel through mesenteric vessels, resulting in necrosis and eventual gangrene of bowel walls. We present the case of a 64-year-old man with recrudescence of prolonged epigastric pain at rest of few hours duration, cold sweating and episodes of vomiting. A computed tomography scan of his abdomen revealed multiple filling defects in the mid-distal part of the superior mesenteric artery (SMA) and the proximal part of jejunal branches, associated with small intestine walls thickening, suggesting SMA thromboembolism and initial intestinal ischemia. Considering the absence of signs of peritonitis at the abdominal examination and the presence of multiple arterial emboli was decided to perform an endovascular treatment with ultrasound assisted catheter-directed thrombolysis with EkoSonic Endovascular System-EKOS, which resulted in complete dissolution of the multiple emboli and improved blood flow into the intestine wall. The day after the procedure the patient's pain improved significantly and 5 days after he was discharged home asymptomatic on warfarin anticoagulation. After 1 year of follow-up the patient is fine with no further episodes of mesenteric ischemia or other embolisms.

Prediction of need for bowel resection in acute superior mesenteric artery occlusion: A retrospective study of 48 Japanese patients

Aim

This study aimed to predict cases of acute superior mesenteric artery (SMA) occlusion requiring bowel resection using occlusion site and time from symptom onset to diagnosis at five Japanese institutions. Advances in imaging, endovascular treatment, and perioperative management have improved the clinical outcomes of patients with acute SMA occlusion; however, in clinical practice it remains difficult to effectively determine patients requiring bowel resection.

Methods

We retrospectively analyzed the data of 48 patients (mean age: 82.5 y; male: 37.5%) diagnosed with acute SMA occlusion between June 2009 and August 2018. Background data of patients who required and did not require bowel resection were compared. A multivariable predictive model was developed using the time from symptom onset to diagnosis and whether SMA occlusion was proximal, including the origin of the middle colic artery.

Results

Fifteen patients (31.3%) died during the hospital stay. Atrial fibrillation (83.3%) was the most common comorbidity. The median time from symptom onset to diagnosis was 13.0 (interquartile range, 4.75-24.0) h. Laparotomy, bowel resection, and thrombus embolectomy were performed in 41 (85.4%), 26 (54.2%), and 21 (43.8%) patients, respectively. A logistic regression model achieved 78.6% sensitivity in predicting cases not requiring bowel resection. Proximal occlusion was significantly associated with the requirement for bowel resection (P = .039).

Conclusion

The time from symptom onset to diagnosis and occlusion site contributed to high sensitivity in determining the need for bowel resection in patients with acute SMA occlusion. Further prospective studies are warranted to investigate the clinical impact of this model.

A single institutional experience with suction thrombectomy in acute mesenteric ischemia

Acute mesenteric ischemia (AMI) is typically treated by open surgery or hybrid techniques. Catheter-based aspiration thrombectomy represents another minimally invasive alternative with a potential additional safety benefit of minimizing the bleeding risk associated with thrombolytics. In this institutional case series, we present five clinical cases of aspiration thrombectomy for high-risk AMI using the Penumbra aspiration system. All patients underwent technically successful endovascular thrombectomy as demonstrated by intraoperative angiography results. However, bowel necrosis and sepsis adversely affected postoperative outcomes. Lack of intraoperative bowel assessment is a limitation of endovascular methods, highlighting the importance of patient selection.

Percutaneous mechanical thrombectomy in the management of early acute superior mesenteric artery embolism

PURPOSE

This study was performed to summarize our experience in the management of early-stage acute superior mesenteric artery embolism (ASMAE) by percutaneous mechanical thrombectomy (PMT).

METHODS

The clinical data of 12 patients with early-stage ASMAE treated by PMT in our institution from November 2019 to September 2021 were retrospectively analyzed. The patients had no obvious evidence of bowel infarction as shown by peritoneal puncture and computed tomography angiography. Thrombectomy of the superior mesenteric artery was performed using a 6F AngioJet catheter.

RESULTS

The emboli were completely removed in 10 (83.3%) patients. Six patients were treated only by the AngioJet device. The other six patients underwent combined treatment with a 6F multipurpose drainage catheter after PMT, including one patient who underwent simultaneous stent implantation. Two patients showed no significant improvement in their symptoms after the operation; one was found to have intestinal necrosis and underwent resection by exploratory laparotomy, and the other died of septic shock 3 days after PMT (further intervention had been discontinued because of complications with multiple underlying diseases). No other PMT-related complications occurred. Only one patient was found to have a pseudoaneurysm of the superior mesenteric artery 1 week after PMT and underwent resection by exploratory laparotomy. The 11 surviving patients were smoothly discharged from the hospital after their symptoms were relieved. At a mean follow-up of 13.2 months, computed tomography angiography showed smooth patency of the superior mesenteric artery. No patients developed serious symptoms during follow-up.

CONCLUSIONS

PMT by the AngioJet device is a minimally invasive, safe, and effective technique to remove ASMAE. Early application of PMT can avoid acute intestinal necrosis. Combining the AngioJet device with a 6F multipurpose drainage catheter might be more helpful to remove residual emboli.

Outcome Comparison of Endovascular and Open Surgery for the Treatment of Acute Superior Mesenteric Artery Embolism: A Retrospective Study

Background

Few centers have adopted endovascular revascularization for the treatment of superior mesenteric artery embolism (SMAE). We sought to evaluate the efficacy of endovascular therapy for the treatment of SMAE and identify post-treatment prognostic factors.

Methods

The clinical data of 41 patients with acute SMA embolism between 2013 and 2021 were retrospectively reviewed. Patients with mesenteric artery thrombosis, mesenteric venous thrombosis, and who had only conservative treatment were excluded.

Results

Forty-one consecutive patients were identified with SMAE (median age, [range] 35–86 years). Endovascular therapy was initiated in 14 patients with no clinical evidence of bowel necrosis, with mainly mechanical thrombectomy, and technical success was achieved in 93%. Endovascular therapy had advantages in duration surgery time, blood loss, bowel rest time, ICU time, and ventilator use. There was no difference in bowel necrosis, length of necrotic bowel resected, or in-hospital mortality between the two groups. An initial white blood cell (WBC) count >15 × 103/dl and neutrophil count >13 × 103/dl were associated with an increased risk of bowel necrosis, and an initial WBC count, renal function, American Society of Anesthesiologists (ASA >3) and necrotic bowel >2 m were associated with increased mortality.

Conclusions

Endovascular treatment has altered the management of SMAE, and it may be adopted in selected patients who are not at risk for bowel necrosis. Avoidance of bowel necrosis patients and close monitoring for bowel necrosis are important.

Endovascular Revascularization as Primary Treatment for Acute Embolic Mesenteric Ischemia: Stent Thrombectomy plus Aspiration versus Aspiration Alone

OBJECTIVE

This study aimed to investigate the outcomes of stent thrombectomy combined with aspiration versus aspiration alone in acute mesenteric ischemia (AMI).

METHODS

This was a single-center, retrospective cohort study. Between 1 May 2012 and 1 January 2021, 41 patients (mean age, 73.8±7.9 years) with AMI who underwent stent thrombectomy plus aspiration (Group 1, n=14) or aspiration alone (Group 2, n=27) were included. Patients' treatment regimens, clinical and follow-up outcomes were reviewed and analyzed. The group differences were compared using a Chi square test, Fisher's exact test, independent t test, or Mann-Whitney U test. The cumulative survival rate was calculated using a Kaplan-Meier curve.

RESULTS

The overall clinical success rate was 78.0% (32/41), and no significant difference was found between Group 1 and Group 2 (78.6% vs. 77.8%, p = 1.00). Whereas Group 1 was associated with a higher complete clearance rate (78.6% vs. 44.4%, p = 0.04), less adjunctive local thrombolysis (14.3% vs. 48.1%, p = 0.03), and shorter length of hospital stay (5.7±4.7 vs. 10.7±9.0 days, p = 0.03). The estimated survival rate at 1 month, 3 months, 6 months, 1 year, and 2 years was 73.2%, 72.5%, 71.4%, 65.3%, and 59.8%, respectively. No significant difference was found in survival rate between the groups (log-rank, p = 0.96). The recurrence rate for Group 1 and Group 2 were 8.3% (1/12) and 4.0% (1/25), respectively.

CONCLUSIONS

Compared with aspiration alone, additional stent thrombectomy showed superiorities in higher complete clearance rate, reduced adjunctive thrombolysis, and shorter length of hospital stay.

A multi-pillar piezoelectric stack transducer for nanodroplet mediated intravascular sonothrombolysis

We aim to develop a nanodroplet (ND)-mediated intravascular ultrasound (US) transducer for deep vein thrombosis treatments. The US device, having an efficient forward directivity of the acoustic beam, is capable of expediting the clot dissolution rate by activating cavitation of NDs injected onto a thrombus. We designed and prototyped a multi-pillar piezoelectric stack (MPPS) transducer composed of four piezoelectric stacks. Each stack was made of five layers of PZT-4 plates, having a dimension of 0.85 × 0.85 × 0.2 mm3. The transducer was characterized by measuring the electrical impedance and acoustic pressure, compared to simulation results. Next, in-vitro tests were conducted in a blood flow mimicking system using the transducer equipped with an ND injecting tube. The miniaturized transducer, having an aperture size of 2.8 mm, provided a high mechanical index of 1.52 and a relatively wide focal zone of 3.4 mm at 80 Vpp, 0.96 MHz electric input. The mass-reduction rate of the proposed method (NDs + US) was assessed to be 4.1 and 4.6 mg/min with and without the flow model, respectively. The rate was higher than that (1.3-2.7 mg/min) of other intravascular ultrasound modalities using micron-sized bubble agents. The ND-mediated intravascular sonothrombolysis using MPPS transducers was demonstrated with an unprecedented lysis rate, which may offer a new clinical option for DVT treatments. The MPPS transducer generated a high acoustic pressure (~3.1 MPa) at a distance of approximately 2.2 wavelengths from the small aperture, providing synergistic efficacy with nanodroplets for thrombolysis without thrombolytic agents.

Pseudoaneurysm as a rare complication in the treatment of superior mesenteric artery embolism via percutaneous mechanical thrombectomy: a case report

Percutaneous mechanical thrombectomy is a safe and effective treatment for addressing thrombosis in various embolic diseases. In recent years, this approach has also been actively applied in the management of acute embolic occlusion of the superior mesenteric artery. A pseudoaneurysm as a complication of this operation is remarkably rare. This is the first case report of the diagnosis and treatment of a pseudoaneurysm that developed as a complication after the application of percutaneous mechanical thrombectomy via an AngioJet device for thrombolysis in the superior mesenteric artery.

Acute and Chronic Ischemic Disorders of the Small Bowel

PURPOSE OF REVIEW

Ischemic disorders of the small bowel represent a rare but highly morbid disease process which is often difficult to diagnose and has a complex management course involving multidisciplinary care. Given recent advances in radiologic modalities and surgical/endovascular techniques, this review seeks to provide a disease overview as well as a summary of emerging management strategies.

RECENT FINDINGS

In cases of acute mesenteric ischemia without evidence of frank bowel necrosis, an endovascular-first strategy employing thrombolysis, pharmacomechanical thrombectomy, and/or adjunctive angioplasty/stenting has been shown to have positive outcomes. In cases requiring open laparotomy, retrograde open mesenteric stenting may facilitate less dissection and more straightforward revascularization. While endovascular intervention for chronic mesenteric ischemia was historically limited by high rates of restenosis, use of covered stents in these vascular beds has been shown to have excellent patency rates. Ischemia of the small bowel can be acute or chronic in nature-endovascular treatment modalities have been shown to have excellent results given appropriate patient selection and should be an important tool in the armamentarium of management options for this complex disease process.

The role of endovascular therapy in acute mesenteric ischemia

Background

Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes.

Methods

An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016.

The following variables were extracted

number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel.

Results

Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively.

Conclusions

Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

Mechanical Recanalization for Acute Embolic Occlusion at the Origin of the Superior Mesenteric Artery

Purpose:

We report a combined technique consisting of thrombectomy and thromboaspiration for the treatment of acute embolic occlusion of the superior mesenteric artery (SMA) at the origin.

Case:

A 90-year-old female with chronic atrial fibrillation had a sudden onset of abdominal pain and hematochezia due to acute embolic occlusion at the origin of the SMA. Computed tomographic findings showed reversible bowel wall ischemia. We performed mechanical thrombectomy using the Solitaire FR revascularization device, a self-expanding and fully retrievable stent-based thrombectomy system for acute intracranial large artery occlusion, combined with manual aspiration through a 6F guiding sheath placed at the SMA origin via a right brachial approach. Prompt and complete recanalization of the SMA was obtained without distal embolism, and intestinal necrosis was avoided.

Conclusion:

Combined endovascular procedures of mechanical thrombectomy using the Solitaire FR with thromboaspiration may allow prompt recanalization, clot removal, and prevention of distal embolism and therefore would be a new therapy for acute embolic occlusion at the origin of the SMA.

Novel approach to percutaneous thrombolysis in large caliber clotted vascular access using ultrasound-accelerated thrombolysis

PURPOSE

End-stage renal disease has a high cost burden to the public. Surgical procedures such as hemodialysis (HD) access creation and transplant have high rates of vascular access complications, infections, and readmissions. Cost of HD care has increased to $19.4 billion in 2011; 30-day readmission rates are as high as 36%. There is a continuing need to preserve the route of vascular access for patients, given frequent thrombosis at a rate of 0.8 episodes per patient year at risk. We describe a novel method of thrombolysis using ultrasound-accelerated thrombolysis (USAT) technology for large caliber clotted vascular access.

METHODS

Consecutive patients with thrombosis of their dialysis vascular access that involved large caliber conduits or those that extended into large and/or central veins (axillary, subclavian, innominate) were chosen to undergo catheter-directed thrombolysis with the EKOS EndoWave system.

RESULTS

Twelve patients underwent a total of 14 procedures. Complete thrombolysis was achieved after seven procedures at the time of repeat fistulogram. Four patients required percutaneous balloon thombectomy to resolve remaining clot at the arterial anastomosis, and three required rheolytic thrombectomy in the aneurysmal segment of the arteriovenous fistula (AVF). All patients had an associated procedure (percutaneous transluminal angioplasty and/or stent placement) to treat the cause of thrombosis.

CONCLUSIONS

USAT is a safe and effective percutaneous method of thrombolysis in patients who have large clot burden.

Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience

PURPOSE

Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA).

MATERIALS AND METHODS

From 2003 to 2014, we analysed the in-hospital mortality of 37 patients with acute mesenteric embolism who underwent primary endovascular therapy with subsequent on-demand laparotomy. Transcatheter embolus aspiration was used in all 37 patients (19 women, 18 men, median age 76 years) with embolic occlusion of the SMA. Adjunctive local thrombolysis (n = 2) and stenting (n = 2) were also utilised.

RESULTS

We achieved complete recanalization of the SMA stem in 91.9 %. One patient was successfully treated by surgical embolectomy due to a failed endovascular approach. Subsequent exploratory laparotomy was performed in 73.0 % (n = 27), and necrotic bowel resection in 40.5 %. The total in-hospital mortality was 27.0 %.

CONCLUSION

Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0 %.

Radiology and mesenteric ischaemia

This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.

Percutaneous mechanical thrombectomy of superior mesenteric artery embolism

Background

The present series present three consecutive cases of successful percutaneous mechanical embolectomy in acute superior mesenteric artery ischemia. Superior mesenteric artery embolism is a rare abdominal emergency that commonly leads to bowel infarction and has a very high mortality rate. Prompt recognition and treatment are crucial for successful outcome. Endovascular therapeutic approach in patients with acute SMA embolism in median portion of its stem is proposed.

Case reports.

Three male patients had experienced a sudden abdominal pain and acute superior mesenteric artery embolism in median portion of its stem was revealed on computed tomography angiography. No signs of intestinal infarction were present. The decision for endovascular treatment was made in concordance with the surgeons. In one patient 6 French gauge Rotarex^® device was used while in others 6 French gauge Aspirex^® device were used. All patients experienced sudden relief of pain after the procedure with no signs of intestinal infarction. Minor procedural complication – rupture of a smaller branch of SMA during Aspirex^® treatment was successfully managed by coiling while transient paralytic ileus presented in one patient resolved spontaneously. All three patients remained symptom-free with patent superior mesenteric artery during the follow-up period.

Conclusions

Percutaneous mechanical thrombectomy seems to be a rapid and effective treatment of acute superior mesenteric artery embolism in median portion of its stem in absence of bowel necrosis. Follow-up of our patients showed excellent short- and long-term results.

Successful recanalization of acute superior mesenteric artery thromboembolic occlusion by a combination of intraarterial thrombolysis and mechanical thrombectomy with a carotid filter

Acute superior mesenteric artery (SMA) occlusion is a life-threatening disease, and acute intestinal ischemia develops from the sudden decrease in perfusion to the intestines. The key to saving the patient's life is early diagnosis, and prompt revascularization of the SMA can prevent intestinal infarction and decrease the risk of bowel segment necrosis. Computed tomographic angiography may be useful for rapid diagnosis. We report recanalization of an SMA occlusion in an 80-year-old man with a combination of intraarterial thrombolysis and mechanical thrombectomy with a carotid filter.