Mesenteric Embolism Research Articles

Ghost Passenger in the Heart: The Story of an Intracardiac Cyst Dancing with Coronary and Peripheral Embolisms

Cardiac localization of hydatid cyst, which is a parasitic disease, is rare. In this article, a case of mediastinal hydatid cyst invading the left atrium is presented. A 62-year-old male patient with risk factors for coronary artery disease presented with epigatric pain, nausea and vomiting. Coronary imaging was performed because ongoing epigatric pain was accompanied by ischemic changes and elevated troponin on electrocardiography. No occlusive lesion was observed in the epicardial coronary arteries. Mesenteric embolism was detected in the patient whose epigatric pain continued. The patient, who did not accept surgery after the initial diagnosis, developed peripheral and cerebral emboli in the following period, and the patient was referred for surgery.

Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries

PurposeTo evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR. Materials and MethodsBetween 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups. ResultsBetween the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (−5.2 vs −3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group. ConclusionsConcomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.

Blunt abdominal trauma managed with mesenteric embolization: case report

Blunt abdominal trauma managed with mesenteric embolization: case report

External validation of the Oakland score to assess safe hospital discharge among adult patients with acute lower gastrointestinal bleeding in an accident and emergency department in Hong Kong

Objective: To externally validate the use of the Oakland score in identification of low-risk lower gastrointestinal bleeding patients who can be safely managed without hospitalisation in an accident and emergency department in Hong Kong. Methods: This single-centre retrospective cohort study included adult patients who attended the accident and emergency department for lower gastrointestinal bleeding and were subsequently admitted to hospital from 1 January 2020 to 31 December 2020. Safe discharge was defined as absence of all of the following adverse outcomes after hospital presentation: blood transfusion; therapeutic colonoscopy, mesenteric embolisation, or laparotomy for bleeding; in-hospital death (all causes); and readmission with subsequent lower gastrointestinal bleeding within 28 days. The sensitivities, specificities and area under the receiver-operating characteristic curve of the Oakland score were calculated. Results: Among 376 patients who were included in this study, 114 (30.3%) of them experienced one or more adverse outcomes. The area under the receiver-operating characteristic curve for safe discharge was 0.88 (95% confidence interval, 0.84–0.91). Using an Oakland score threshold of ⩽8 points as in the original derivation study can achieve 100% sensitivity (95% confidence interval, 96.8%–100%) and 7.3% specificity (95% confidence interval, 4.4%–11.1%) for safe discharge. When the Oakland score threshold was extended to ⩽11 points, a much greater proportion of low-risk patients could be identified, with 97.4% sensitivity (95% confidence interval, 92.5%–99.5%) and 32.8% specificity (95% confidence interval, 27.2%–38.9%) for safe discharge. Conclusion: The Oakland score performed well in identification of lower gastrointestinal bleeding patients who were at low risk of experiencing adverse outcomes and could thus be safely managed without hospitalisation. Extension of the Oakland score threshold to ⩽11 points can allow identification of a greater proportion of low-risk patients while sensitivity is reasonably maintained.

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

Význam domácej parenterálnej výživy v klinickej praxi – vlastné skúsenosti z nášho centra

Home parenteral nutrition is an alternative route and form of nutrition in patients with irreversible intestinal failure in whom enteral nutrition is not possible or is insufficient in the long run with an increasing energy deficit. Starting parenteral nutrition at home improves the quality of patients’ life and consequently also the course of the underlying disease, with optimization of clinical manifestations of malnutrition. The most common indications for home parenteral nutrition include large reductions of the absorption area due to intestinal resections (Crohn’s disease surgical complications, ischemic small bowel necrosis due to thrombosis in the superior mesenteric vein or embolism or atherosclerotic occlusion of the superior mesenteric artery, but also intestinal failures of different aetiology and cancer with sufficient utilization of essential nutrients). Keywords home parenteral nutrition, short bowel syndrome, komplikácie

Manual Aspiration Thrombectomy for Embolic Acute Mesenteric Ischemia.

A 65-year-old woman was admitted with diffuse abdominal pain, diarrhea, and hematochezia of one day's duration. Her medical history included surgical repair of an anterior mitral valve cleft and an associated ostium primum atrial septal defect, implant of a single-chamber pacemaker programmed in VVIR mode for complete atrioventricular block, and stroke despite appropriate anticoagulant therapy for paroxysmal atrial fibrillation (AF). At admission, the patient had been on chronic anticoagulant therapy with acenocoumarol (target international normalized ratio, 3.0). Mesenteric arterial embolization was highly suspected.Abdominal computed tomographic angiograms revealed a large thrombus in the first 5 cm of the superior mesenteric artery (SMA) distal to its ostium (Fig. 1). Within 6 hours, this finding was confirmed on a mesenteric angiogram (Fig. 2A). Access was obtained by introducing a 6F angiographic catheter into the right brachial artery and advancing it to the SMA. Next, the 6F angiographic catheter was exchanged for a 6F multipurpose guiding catheter. Under fluoroscopic guidance, the multipurpose catheter was passed through the thrombotic segment several times. A large amount of thrombotic material was manually aspirated from the SMA and its branches by means of suction from a large-bore 50-mL syringe connected externally to the guiding catheter (Fig. 2B). A final postprocedural mesenteric angiogram confirmed thrombus removal (Fig. 2C), which was accompanied by prompt relief of symptoms and normalization of laboratory values.The thrombotic event was considered embolic, given the patient's history of stroke despite anticoagulant therapy, incomplete occlusion of the SMA just distal to its ostium, and the absence of ostial calcified atherosclerosis. The patient's anticoagulation regimen was switched from acenocoumarol to apixaban 5 mg 2×/d and clopidogrel 75 mg/d. Four days after the thrombectomy and an uncomplicated course of recovery, she was discharged from the hospital. At one-year follow-up, she had experienced no recurrent cardioembolic events.Acute mesenteric ischemia is typically caused by SMA emboli and, despite advances in endovascular therapy, is associated with high morbidity and mortality rates.1 Early diagnosis and revascularization are essential to prevent intestinal complications. However, because acute mesenteric ischemia is rare and often associated with nonspecific abdominal pain, diagnosis is difficult. This is particularly relevant in patients with AF, in whom early evaluation by computed tomographic angiography is crucial.2 The development of thrombosis despite appropriate anticoagulation for comorbid AF puts patients at high risk for bleeding during surgery and thus poses additional therapeutic challenges. For patients who are promptly diagnosed and show no signs of advanced bowel ischemia, percutaneous revascularization is a viable option.3 If an aspiration catheter is not available, manual aspiration thrombectomy is feasible.Section editor: Raymond F. Stainback, MD

940 Mesenteric Haematoma Complicated by A Perforated Sigmoid Diverticulum Following Extracorporeal Shockwave Lithotripsy

Abstract A 78 year old female presented with sudden onset lower abdominal pain, vomiting and fresh rectal bleeding. She had undergone extracorporeal shockwave lithotripsy (ECSL) for a left renal stone two weeks earlier and was taking Rivaroxaban for atrial fibrillation. A CT Abdomen &amp; Pelvis revealed a large mesenteric haematoma and a contained sigmoid perforation secondary to compressive forces of the haematoma on the sigmoid artery, resulting in ischaemia. While mesenteric angiogram-guided embolisation initially controlled the active sigmoid artery bleed, the patient clinically deteriorated the following day warranting a laparotomy. This revealed an ischaemic sigmoid colon with contained faeculent material within the mesentery. An extended left hemi-colectomy with end-colostomy was performed. Despite optimal critical care input, the patient developed multi-organ failure and passed away one week later. Mesenteric haematoma should be considered as a rare complication in patients with sudden onset abdominal pain following ECSL; especially with concurrent anti-coagulation use.

Predictors and risk factors for intestinal necrosis in patients with mesenteric ischemia.

BackgroundMesenteric ischemia results in blood flow that is insufficient to meet metabolic demands and subsequent dysfunction of visceral organs, including arterial obstruction and venous thrombosis. Sustained mesenteric ischemia exhausts the ability of capillaries to provide oxygen and initiate an inflammatory reaction, and eventually leads to intestinal mucosal necrosis, a serious and potentially life-threatening condition. Therefore, it is essential that the predictors and risk factors for intestinal necrosis in patients with mesenteric thrombus are explored.MethodsThis study retrospectively enrolled 41 patients with mesenteric ischemia (including mesenteric vein embolism, mesenteric artery thrombosis, and portal vein thrombosis) who were admitted to the Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital between May 2016 and October 2019; of the patients, 18 were further diagnosed with intestinal necrosis. Comparisons of symptoms, computed tomography angiography (CTA) features, and laboratory examination results were performed between mesenteric ischemia patients with and without intestinal necrosis.ResultsWhite blood cell count showed an excellent predictive ability for intestinal necrosis in patients with mesenteric ischemia, with an area under the receiver operating characteristic (ROC) curve of 0.772 (P=0.009). The four CTA features [pneumatosis (P=0.016), intestinal swelling (P=0.006), ascitic fluid (P<0.001), and decreased intestinal wall enhancement (P=0.004)] differed significantly between patients with and without intestinal necrosis. Peritonitis showed a strong association with intestinal necrosis (P=0.006) in the univariate analysis, and multivariate analysis further showed their association [odds ratio (OR): 8.53; 95%CI: 1.46–49.81; P=0.017].ConclusionsWhite blood cell count is a potential predictor of intestinal necrosis. Peritonitis is a possible risk factor for intestinal necrosis in patients with mesenteric ischemia. A multi-center prospective study with a larger sample size needs to be performed to further investigate these findings.

S3527 Hepatic and Gastrointestinal Complications of Chronic Schistosomiasis: A Case Report on the Importance of Treatment Confirmation

INTRODUCTION: Schistosomiasis affects millions worldwide and can have devastating hepatosplenic and intestinal consequences. Though it is well-known to providers in tropical and subtropical parts of the world, those in non-endemic areas are often unfamiliar with the disease and its complications. CASE DESCRIPTION/METHODS: A 76-year-old Filipino female with a history of schistosomiasis complicated by portal hypertension presented to a tertiary care center for shortness of breath. In the emergency department, she was found to be hypoxic with increased work of breathing. Chest x-ray demonstrated a recurrent hepatic hydrothorax that required emergent thoracentesis. On admission, she reported subacute on chronic abdominal pain previously attributed to symptomatic cholelithiasis. Physical exam was notable for tachycardia to the 120s and a mildly, diffusely tender abdomen. Relevant laboratory tests included: white blood cell count 11,200/mm3 without eosinophilia, AST 44 U/L, ALT 21 U/L, alkaline phosphatase 172 IU/L, total bilirubin 1.2 mg/dL, and direct bilirubin 0.4 mg/dL. Imaging studies revealed a chronic portal vein thrombus (PVT), a 20–30 cm loop of severely thickened distal ileum, multiple inferior mesenteric arteriovenous malformations (AVMs), calcifications in the sigmoid colon, and cholelithiasis. Review of prior records showed that when she was 48 years old, the patient had a liver biopsy with Schistosoma japonicum ova in the portal tracts. Despite this, she never received treatment for schistosomiasis. After diagnosis, she had seen multiple providers in various specialties (hepatology, surgery, primary care) at different institutions. It was always assumed that she had been treated. This patient’s initial management included praziquantel, inferior mesenteric AVM embolization, prophylactic enoxaparin for PVT, a percutaneous cholecystostomy tube for symptomatic cholelithiasis, and diuresis for hepatic hydrothorax. She was admitted twice more within a month of discharge due to further complications of her disease. Ultimately, she was discharged with home hospice care. DISCUSSION: This case demonstrates the importance of confirming schistosomiasis treatment in previously diagnosed patients. This patient had seen multiple specialists prior to a provider realizing she had never received treatment. Ultimately, the complications of chronic schistosomiasis became life-limiting but may have been prevented if treatment had occurred at the time of diagnosis.

Spontaneous Retroperitoneal Hemorrhage Secondary to Chronic Celiac Axis Compression Treated with Embolization Utilizing Cone Beam CT

Median arcuate ligament syndrome (MALS) is a rare and often misdiagnosed vascular pathology. In this paper, we discuss a 51-year-old female with MALS presenting with hypotension due to retroperitoneal hemorrhage. Currently, there is no consensus regarding the optimal treatment approach for such patients. This case report demonstrates the utility of conventional mesenteric angiography, cone beam CT with 3D reconstruction, and selective mesenteric transarterial embolization as an effective treatment approach for patients with spontaneous aneurysm rupture in MALS.

Exclusion Technique for Entire Shaggy Aorta Followed by One-Stage Repair of the Aortic Arch and Descending Aorta

A shaggy aorta is defined as a very extensive atheromatous disease with diffuse ulcers in combination with fragile and mobile debris, and actual thrombus. Multiple embolisation - resulting in permanent neurological deficits, paraplegia and a large area of mesenteric embolisation - attributed to cholesterol atheromatic mobile plaque caused by shaggy aorta needs to be prevented. Complete exclusion of the shaggy aorta from the distal aortic arch to the end of the descending aorta was presented in two cases: a 71-year-old male and a 51-year-old male. Successful one-stage repair of the extended aortic arch and descending aorta was performed using an isolated selective cerebral perfusion technique via sternotomy and left anterior thoracotomy. There were no neurological or embolic events in the present cases. Contrast-enhanced computed tomography showed good reconstruction of the aortic arch and descending aorta. The patients are still being followed up in the outpatient clinic and have shown no atheromatic embolisation for the past 6 years. The exclusion technique for an entire shaggy aorta followed by one-stage repair of the aortic arch and descending aorta is a durable and feasible operation for preventing atheromatous embolisation.

Super-Selective Mesenteric Embolization as Guide for Surgical Resection in Bleeding Small Bowel Angiodysplasia

We present the case of a 79-year-old woman and of a 43-year-old man with no relevant past medical history. Both patients were admitted to the emergency department for anemia and rectal bleeding. After resuscitation, the two patients underwent colonoscopy and gastroscopy, both negative. Computed tomography angiography revealed active bleeding from the small bowel in both cases. The first patient underwent angiography and mesenteric embolization with surgical glue, obtaining a complete stop of the bleeding. After 2 days, a small bowel resection was performed under the guidance of the segmental bowel ischemia secondary to embolization. In the second patient, the angiography revealed a large jejunal angiodysplasia. Therefore, a mesenteric super-selective embolization was carried out. The intraoperative identification of the coils allowed to guide the following bowel resection. The postoperative course was uneventful in both patients. Small bowel angiodysplasia is a rare cause of lower gastrointestinal bleeding. In most patients, bleeding stops spontaneously. However, patients with ongoing active bleeding non-responding to conservative treatment may need invasive procedures. The use of super-selective mesenteric embolization is highly successful and relatively safe. When surgery is necessary, identification of the bleeding site is troublesome. In this setting, angioembolization could help to identify the correct site of bleeding, thus allowing to perform a segmental small bowel resection.

Monocyte High Density Lipoprotein Cholesterol Ratio as a New Prognostic Factor for Mesenteric Embolism.

To determine the effectiveness of the ratio of monocyte count to high density lipoprotein cholesterol in predicting in-hospital mortality. Descriptive study. Intensive Care Unite, Adana Numune Research and Training Hospital, Turkey, from January 2018 to December 2019. Patients admitted to the intensive care unit with the diagnosis of mesenteric embolism were included in the study. Monocyte count and high-density lipoprotein cholesterol (HDL) values were determined. Monocyte HDL Ratio (MHR) values of the patients were calculated. SPSS 26 package programme was used to investigate the effectiveness of MHR in predicting mortality. The mean age of the 81 patients was 69.9 ±10.6 years. In the group with mortality, the number of monocytes and MHR were significantly higher than the group without mortality (p<0.05). In the mortality group, HDL value was significantly lower (p<0.05) than the non-mortality group. Sensitivity of the MHR cutoff value of 19 was 81.8%, positive predictive value was 96.4%, specificity value was 97.9%, negative predictive value was 88.7%. For patients diagnosed with acute mesenteric embolism, the use of predictors in terms of mortality estimation is very important for the faster implementation of treatment modalities. MHR value can be used as a strong predictor. Key Words: Mesenteric embolism, Monocyte, HDL cholesterol, MHR, Mortality.

Abstract No. 614 Intranodal intraoperative mesenteric lymphangiography and embolization for chylous ascites: technical and safety features

Abstract No. 614 Intranodal intraoperative mesenteric lymphangiography and embolization for chylous ascites: technical and safety features

Multicentre randomised controlled trial to evaluate the efficacy of pre-emptive inferior mesenteric artery embolisation during endovascular aortic aneurysm repair on aneurysm sac change: protocol of Clarify IMA study

IntroductionType II endoleak (EL) is frequently seen after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) and is often considered responsible for aneurysm sac enlargement if it persists. In...

PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE IN A PATIENT WITH ATRIAL FIBRILLATION AND OSLER-WEBER-RENDU DISEASE

We present a case report of a 79-year-old woman with permanent atrial fibrillation and Osler-Weber-Rendu disease who underwent percutaneous closure of left atrial appendage. The patient had a history of small bowel resection due to mesenteric embolism and recurrent episodes of gastrointestinal bleeding, epistaxis and hemarthrosis. Bleeding episodes were exacerbated by anticoagulation therapy causing severe anemia that required repeated red blood cells transfusions. Left atrial appendage occlusion with Watchman 30 mm LAA Device was successfully performed. In long-term observation no thromboembolic event, epistaxis or severe bleeding have occurred.

Management of per rectal bleeding is resource intensive

Haematochezia or per rectal (PR) bleeding is the most common presentation of lower gastrointestinal bleeding. This study analyses the hospital resources used in the management of patients with PR bleeding. A retrospective analysis was performed on patients who presented with PR bleeding from June 2012 to December 2013 to a single tertiary centre in Sydney, Australia. Age, gender, comorbidities, use of antiplatelet or anticoagulant medications, vital signs, and haematological data were recorded. The objective factors available on initial patient assessment were analysed for their relationship with the following outcomes: use of computed tomography mesenteric angiogram, formal angiography and embolization, transfusion of blood products, endoscopy, operative management and length of stay. There were 523 confirmed presentations of PR bleeding. Four hundred and fifty-two of these presented directly to emergency department, while 71 were referred from another hospital. One in five patients had blood transfusion (19%), 13% had computed tomography mesenteric angiogram, 4% had embolization and 13% underwent diagnostic and/or therapeutic colonoscopy. Patients referred from other facilities were more comorbid (55% versus 30%), more likely to be on antiplatelet or anticoagulant (69% versus 33%) with a higher rate of embolization (28% versus 4%), more packed cell transfusions (2.1 versus 0.7 units) and longer length of stay (7.9 versus 5.7 days) but mortality was the same (1%). The management of patients with PR bleeding is resource intensive. Better identification and allocation of resources in patients who present with PR bleeding may lead to better efficiency in managing this growing clinical problem.

An unsuspected bleeding Meckel's diverticulum in an adult detected on mesenteric angiography.

Meckel's diverticulum is usually asymptomatic and found in almost 2% of the population. Haemorrhage from a Meckel's diverticulum is common in children but rare in adults. Here we report a case of 20 years old male with recurrent gastrointestinal bleeding. Meckel's diverticulum was diagnosed due to abnormal vascularity on mesenteric angiography and embolization was performed. Diagnosis was correlated with other radiological imaging and later elective resection was performed. This case is reported to emphasize the potential role of mesenteric angiography in the detection and management of bleeding Meckel's diverticulum and correlation with other radiological imaging.

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis

Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies. To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques. A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017. Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work. Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic. The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm. In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.