Microcatheter-Directed Thrombolysis Using Recombinant Tissue Plasminogen Activator for the Treatment of Acute Superior Mesenteric Artery Embolism: A Case Report.

Background: Acute mesenteric ischemia (AMI) is a life-threatening condition, and in 50% of patients, AMI is caused by acute superior mesenteric artery (SMA) embolism. Endovascular treatment is increasingly being considered the primary modality in selected cases. Many studies have reported that percutaneous aspiration embolectomy using a guiding catheter and thrombolysis with recombinant tissue plasminogen activator (rtPA) are effective in treating SMA embolism. However, no reports on treating SMA embolism using rtPA administered via a microcatheter exist. Case presentation: A 64-year-old man with underlying atrial fibrillation presented with acute SMA embolism revealed using computed tomography (CT). rtPA (total 3 mg) was carefully administered into the occluded SMA through a microcatheter. No complications occurred, and complete revascularization of the SMA was revealed on follow-up CT. Conclusions: Compared with previous reports, this case report reveals that successful revascularization can be achieved using rtPA administered via a microcatheter, with a low dose of rtPA and a short duration of thrombolysis.

Successful clinical management of mesenteric ischemia caused by superior mesenteric artery obstruction and celiac artery stenosis: a case report.

Acute mesenteric ischemia (AMI) is a rare, yet deadly thromboembolic accident that requires urgent surgery and or revascularization. We report the case of a 67-year-old male patient, who presented with severe abdominal pain and reduced oral intake, causing dehydration and impaired kidney function. The imaging evaluation including arterial Doppler and computed tomography (CT) scan showed AMI caused by superior mesenteric artery (SMA) obstruction and celiac artery stenosis, besides multiple atherosclerotic segments. Given the absence of guidelines in such an uncommon combination, a multidisciplinary management was initiated involving general medicine, general surgery, vascular surgery, and radiology. The agreed plan consisted of anticoagulation, exploratory laparotomy with necrosis resection and anastomosis, followed by percutaneous thrombectomy and angioplasty with stenting. The patient was discharged on day 7 postop with a highly satisfactory outcome and follow up. This case highlights the value of an early multidisciplinary approach in tailoring the management to the specific case of AMI.

The gastric double-stripe sign of chronic mesenteric ischemia: A case report.

RATIONALE: Atherosclerotic chronic mesenteric ischemia (CMI) is caused by stenosis or occlusion of mesenteric arteries and can progress to potentially life-threatening acute mesenteric ischemia if left untreated. However, correct diagnosis and timely treatment remain a challenge due to a lack of awareness, variable symptoms, and inconclusive diagnostic testing. PATIENT CONCERNS: An 82-year-old man with multiple cardiovascular risk factors, including chronic kidney disease, presented with dyspnea, anorexia, and oliguria. Laboratory results revealed severe renal dysfunction (raised serum blood urea nitrogen of 83.8 mg/dL, serum creatinine levels of 8.20 mg/dL, and decreased estimated glomerular filtration rate of 5.5 mL/min/1.73 m 2 ), hypoalbuminemia, and moderate anemia. A provisional diagnosis of acute exacerbation of chronic kidney disease was made and the patient required tentative intermittent hemodialysis, received blood transfusions, and was eventually placed on maintenance hemodialysis. However, the patient's symptoms did not improve. Esophagogastroduodenoscopy (EGD) revealed longitudinal gastric ulcers on the anterior and posterior walls of the stomach, which were named "a gastric double-stripe sign" because the lesions corresponded to the watershed areas of the stomach. No Helicobacter pylori infection or malignancy was identified, and increasing the dose of lansoprazole had no beneficial effects. Doppler ultrasound revealed high peak systolic velocity (270 cm/s) of the celiac artery (CA), suggesting CA stenosis, which was confirmed by magnetic resonance angiography. DIAGNOSIS: Final diagnosis of CMI was made based on patient's symptoms, EGD findings, Doppler ultrasound, and magnetic resonance angiography. INTERVENTIONS: Endovascular revascularization for CA stenosis was performed. OUTCOMES: The patient obtained symptomatic relief concomitant with the resolution of the gastric ulcers. The post-procedural course of the patient was uneventful and he remained healthy at the 1-year follow-up. LESSONS: This is the first case of CMI with EGD finding of a gastric double-stripe sign specific for gastric ischemia. This case highlights the clinical importance of this endoscopic finding in patients with suspected atherosclerotic CMI.

Delayed bowel necrosis due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection.

Although inferior mesenteric artery occlusion due to acute aortic dissection sometimes occurs, it is usually not considered an important finding. Herein, we present an extremely rare case of delayed bowel ischaemia due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection that highlights the need for cardiac surgeons to be mindful of inferior mesenteric artery occlusion in patients with superior mesenteric artery dissection or vascular anomalies in the mesenteric arteries.

[Gas in superior mesenteric artery and celiac axis as a rare CT-sign of extensive bowel necrosis]. / Gaz v verkhnei bryzheechnoi arterii i chrevnom stvole kak redkii KT-priznak obshirnogo nekroza kishechnika.

The authors report endovascular treatment of acute thromboembolic occlusion of superior mesenteric artery in a 75-year-old patient whose postoperative period was complicated by massive reperfusion and translocation syndrome. Contrast-enhanced CT in 12 hours after successful thrombectomy from superior mesenteric artery revealed CT signs of irreversible bowel lesion, i.e. gas in hepatic veins, intestinal wall and mesenteric veins, bowel wall thinning. In addition, CT revealed extremely rare sign of severe acute mesenteric ischemia (gas in superior mesenteric artery and celiac axis). We found no description of gas in celiac axis following acute mesenteric ischemia in available literature.

Acute mesenteric ischemia as late complication of previous endovascular treatment in young woman. Case report and review of the literature.

BACKGROUND: Acute mesenteric ischemia (AMI) represents a severe complication of chronic mesenteric ischemia (CMI) which is a disorder caused by severe stenosis or occlusion of mesenteric arterial supply. If untreated, patients could face mesenteric infarction and death. CASE REPORT: A 41-year-old female smoker and drug abuser, previously treated with angioplasty and stenting of the superior mesenteric artery (SMA) for CMI four years before, was admitted to our institution suffering from acute abdominal pain due to complete occlusion of the stent. After a few hours of thrombolytic therapy, she experienced sudden worsening of clinical conditions, including AMI, due to complete rethrombosis of the SMA. Thereafter, she underwent urgent thrombectomy and a subsequent retrograde 6 mm prosthetic aorto-mesenteric bypass graft. The patient reported complete relief of symptoms afterwards. A CT scan at 1-month follow-up showed primary patency of the bypass in the absence of clinical recurrence. DISCUSSION: In cases of CMI, treatment options include surgical, endovascular or hybrid approaches. Endovascular therapy, based on percutaneous angioplasty with or without stenting, seems to be effective, although it can have worse midterm and long-term results. CONCLUSION: In patients already treated with an endovascular revascularization of the SMA or celiac trunk (CT), open surgical repair through a single retrograde aorto-mesenteric prosthetic bypass in cases of acute mesenteric ischemia, seems to offer a valid and safe approach in order to prevent bowel infarction. KEY WORDS: Acute mesenteric ischemia Angioplasty, Bypass, stent,Thrombolysis.

Occlusive Mesenteric Ischemia in Chronic Dialysis Patients.

BACKGROUND: Among dialysis patients, occlusive mesenteric vascular disease has rarely been reported. OBJECTIVES: To report on the experience of one center with regard to diagnosing and treating this complication. METHODS: The retrospective case-series involved six patients (3 females, 3 males; age 52-88 years; 5/6 were smokers) on chronic hemodialysis at a single center. All patients with symptoms suggestive of occlusive mesenteric disease and a subsequent angiographic intervention were included. Demographic, clinical, and laboratory data were collected from patient charts for the period before and after angioplasty and stenting of the mesenteric vessels. A Wilcoxon signed-rank test was used to compare the relevant data before and after the intervention. RESULTS: All participants had variable co-morbidities and postprandial abdominal pain, food aversion, and weight loss. CT angiography was limited due to heavy vascular calcifications. All underwent angioplasty with stenting of the superior mesenteric artery (4 patients) or the celiac artery (2 patients). All procedures were successful in resolving abdominal pain, malnutrition, and inflammation. Weight loss before was 15 ± 2 kg and weight gain after was 6 ± 2 kg. C-reactive protein decreased from 13.4 ± 5.2 mg/dl to 2.2 ± 0.4 mg/dl (P < 0.05). Serum albumin increased from 3.0 ± 0.2 g/dl to 3.9 ± 0.1 g/dl (P < 0.05). Two patients underwent a repeat procedure (4 years, 5 months, respectively). Follow-up ranged from 0.5-7 years. CONCLUSIONS: Occlusive mesenteric ischemia occurs among dialysis patients. The diagnosis requires a high degree of suspicion, and it is manageable by angiography and stenting of the most involved mesenteric artery.

Postoperative new-onset atrial fibrillation causing acute embolic occlusion of the superior mesenteric artery: A case report.

RATIONALE: Postoperative atrial fibrillation following noncardiac surgery increases mortality, length of hospital stay, and medical expenses; moreover, compared to nonvalvular atrial fibrillation, it poses a similar risk of thromboembolic complications. In this report, we discuss our decision-making process for diagnosis and treatment in case with unexpected postoperative new-onset atrial fibrillation causing acute mesenteric ischemia. PATIENT CONCERNS: A 78-year-old male patient received varicose vein stripping and ligation in his right leg. The patient was previously healthy with no known comorbidities. The next day after surgery, he complained of sudden epigastric pain unresponsive to conservative treatment, and new-onset atrial fibrillation was observed on electrocardiography. DIAGNOSES: An abdominal computed tomography scan revealed acute embolic occlusion of the superior mesenteric artery. INTERVENTIONS: Emergent surgical embolectomy was performed successfully. The time to operation from the recognition of abdominal pain was 6 h. Surgical critical care was performed for life-threatening ischemic reperfusion injury. OUTCOMES: The patient was discharged from the hospital on the 40th postoperative day. LESSONS: Atypical postoperative abdominal pain unresponsive to conservative treatment should be considered a surgical emergency, and a high level of clinical suspicion for acute mesenteric ischemia is required. Preoperative electrocardiography and postoperative telemetry might be helpful in some asymptomatic patients.

Acute mesenteric ischaemia due to superior mesenteric vein (SMV) thrombosis.

A 77-year-old male patient presented with a 5-day history of abdominal pain, coffee ground vomiting and blood-stained diarrhoea. CT scan of the abdomen and pelvis demonstrated a long segment thrombotic occlusion of the superior mesenteric vein (SMV) extending up to the proximal portion of the portal vein causing significant acute small bowel ischaemia. Patient's deteriorating clinical condition warranted surgical management. Successful surgical management required multidisciplinary teamwork between emergency, vascular surgeons, anaesthetists and intensivists. Emergency laparotomy revealed gangrene of an estimated 120 cm of small bowel segment starting from duodenojejunal junction and a long segment thrombotic occlusion of the SMV extending up to the portal confluence. Resection of gangrenous small bowel without anastomosis and thrombo-embolectomy of SMV along with laparostomy was done at the initial operation. Patient was admitted in the intensive care unit on systemic heparinisation through intravenous administration of unfractionated heparin. Second relook exploration was done after 48 hours followed by anastomosis of the small bowel and closure of the abdomen. Patient made a good recovery following anticoagulation therapy and was discharged on postoperative day 10.

Splenoportal-mesenteric axis thrombosis and splenic artery occlusion as initial presentations of COVID-19 disease.

OBJECTIVE: Although pulmonary involvement represents the primary and most characteristic presentation of Sars-Cov-2 infection, due to its innate tropism for endothelium, it is also associated with systemic pro-coagulative changes and thromboses. This paper describes a COVID-19 atypical presentation with massive thrombotic occlusion of the splenoportal-mesenteric axis and the splenic artery in the absence of clinical or radiological manifestation of pulmonary involvement. PATIENTS AND METHODS: Female patient, with no history of disease, trauma or fever in the last 30 days, was admitted to ER for persistent left subcostal pain. Laboratory exams, including inflammation, coagulation markers and Sars-CoV-2 serology, were requested. Whole-body CT with contrast media injection was performed. RESULTS: Laboratory exams showed elevated reactive C-protein, bilirubin, γ-GT and D-dimer. Whole-body CT showed: splenic artery occlusion, thrombosis of splenic, mesenteric and portal veins with portal intra-hepatic branches ectasia, juxta-hilar portal cavernomatosis of probable acute onset (absence of signs of chronic hepatopathy and of varices), a hypodense area in the spleen indicating ischemic parenchymal suffering. The patient resulted positive for Sars-CoV-2 IgG, thus in the absence of typical clinics or pulmonary parenchymal abnormality at chest CT. CONCLUSIONS: A case of acute venous thrombosis and arterial occlusion as primary manifestations of COVID-19.

Superior Mesenteric Arterial and Venous Thrombosis in COVID-19.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 has been reported in literature, combined superior mesenteric arterial and venous thrombosis is rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection. CASE REPORT: We report a case of a 45-year-old man who was a health care worker who presented to the emergency department with severe abdominal pain. The clinical examination was unremarkable, but imaging revealed acute mesenteric ischemia caused by superior mesenteric artery and superior mesenteric vein occlusion. Imaging of the chest was suggestive of COVID-19 infection, which was later confirmed with reverse transcription polymerase chain reaction of his nasopharyngeal swab. To date, only 1 case of combined superior mesenteric artery and superior mesenteric vein thrombosis caused by COVID-19 has been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding high-resolution computed tomography of the chest to abdominal imaging should be considered in patients with acute abdomen because it can help to identify COVID-19 immediately. © 2020 Elsevier Inc.

Risk factors for ischemic antiphospholipid syndrome: A case-control study.

OBJECTIVE: The objective of this study was to identify clinical and laboratory risk factors for ischemic stroke (IS) in primary antiphospholipid syndrome (APS) patients. MATERIALS AND METHODS: We performed a case-control study with consecutive primary APS patients divided into two groups, those who presented with IS, vs. those with no history of stroke. Demographics, vascular risk factors, therapeutic approaches, laboratory, imaging and functional outcomes were recorded. RESULTS: Fifty-three confirmed primary APS patients with IS and sixty-six non-stroke primary APS controls were recruited. Most patients were female (65.5 %), with a median age of 33 years. The main vascular risk factors for primary APS-associated stroke were hypertension (11.3 %), diabetes (11.3 %) and hypercholesterolemia (9.4 %). Among patients with stroke, median NIHSS score was 6; 15.1 % of these patients presented a recurrent stroke, and 88.8 % had a good functional outcome at the final follow-up. Positive lupus anticoagulant (OR = 6.1, 95 %CI 2.7-13.5), anti-ß2 glycoprotein IgG (OR = 3.6, 95 %CI 1.7-7.9), and anticardiolipin IgG (OR = 2.8, 95 %CI 1.3-5.9) were more prevalent in non-stroke primary APS, with a triple-positive antibody presence in 46.4 % of controls vs. 22.2 % of patients with stroke (OR = 3.0, 95 %CI 1.3-6.7). At the time of the index event (arterial or venous), 14 known primary APS patients were using vitamin K antagonists, but only 35.7 % of them had achieved therapeutic INR. CONCLUSION: Patients with primary APS and IS have similar vascular risk factors and lower antibody positivity than those with extracranial thrombosis.

Cocaine-induced mesenteric ischaemia requiring small bowel resection.

Cocaine use causes profound vasoconstriction leading to various systemic complications. Gastrointestinal complications such as mesenteric ischaemia are difficult to recognise and may result in serious consequences if not treated promptly. We report on the case of a 47-year-old man presenting with mesenteric ischaemia on a background of acute on chronic cocaine consumption, where diagnosis was not evident until second presentation. He underwent an emergency laparotomy with small bowel resection and jejunostomy formation and made a good recovery with eventual reversal surgery. The literature on cocaine-induced bowel ischaemia shows significant variability in presentation and outcome. Laboratory investigations are non-specific, and early recognition is vital. Given the increasing recreational use of cocaine in the UK, it is imperative to have a high clinical index of suspicion for mesenteric ischaemia in patients presenting with non-specific abdominal pain, and to ensure a detailed social history covering recreational drug use is not forgotten.

The impact of endovascular treatment on clinical outcomes of stable symptomatic patients with spontaneous superior mesenteric artery dissection.

OBJECTIVE: To evaluate the efficacy and clinical outcomes of endovascular treatment for superior mesenteric artery dissection (SMAD) and its effect on superior mesenteric artery (SMA) remodeling compared with medical management alone after successful initial medical management. METHODS: In this retrospective analysis, all patients with spontaneous SMAD at a single institution were identified from March 2007 to August 2019. The primary outcomes were freedom from major adverse events (MAEs, a composite of dissection-related death, the recurrence of mesenteric ischemia symptoms, and a requirement for intervention). The secondary outcomes were morphologic remodeling of the dissections and stenosis or occlusion of the SMA. RESULTS: A total of 94 patients with SMAD who underwent successful initial medical management (91 males; mean age, 50.4 ± 6.3 years) were enrolled in the study. Fifty-seven (60.6%) received medical management alone, and 37 (39.4%) underwent endovascular repair after initial medical management. In the endovascular group, the technical success rate was 86.5% (32 of 37). During a mean follow-up period of 33.6 ± 26.2 months (range, 1-120 months), nine (9.6%) patients experienced a recurrence of abdominal pain, and six had additional interventions for SMAD. The patients in the endovascular group showed more complete or partial remodeling (22 [81.1%] vs 24 [44.4%]; P < .0001) or unchanged dissections (5 [13.5%] vs 23 [42.6%]; P = .0001) than those in the conservative group. Survival analysis showed that the estimated MAE-free survival rates were 95.6%, 88.9%, and 85.4% at 1, 3, and 5 years, respectively. There was a higher freedom from SMA stenosis or occlusion in the endovascular group (log rank P = .046). CONCLUSIONS: Endovascular treatment and medical management alone result in similar MAE-free survival for patients with SMAD after successful initial medical management. Moreover, endovascular therapy is associated with a higher complete remodeling rate and greater freedom from SMA stenosis or occlusion.

A Peculiar Case of Small Bowel Stricture in a Coronavirus Disease 2019 Patient with Congenital Adhesion Band and Superior Mesenteric Vein Thrombosis.

BACKGROUND: There is increasing evidence supporting coronavirus disease 2019 (COVID-19)-related coagulopathy. In the available literature, only 2 cases of superior mesenteric vein thrombosis have been described. METHODS: We present a peculiar case of high-grade small bowel obstruction in a patient with COVID-19 infection. RESULTS: Exploratory laparotomy revealed a congenital adhesion band with associated focal bowel ischemia contributed by superior mesenteric vein thrombosis and positive lupus anticoagulant. CONCLUSIONS: It is important to consider the rare differential of mesenteric vein thrombosis and its related sequelae of mesenteric ischemia in a patient with COVID-19 who presents with abdominal pain.