Mesenteric Embolism Research Articles

Previous portal hypertension surgery negatively affects results of mesenteric to left portal vein bypass

The mesenteric to left portal vein bypass (MLPVB) has been successfully used to treat extrahepatic portal vein obstruction (EHPVO) in children. We examined the effect of failed prior surgical or radiological procedures intended to treat complications of portal hypertension on the success rate of subsequent MLPVB surgery. Sixty-two patients younger than 18 years with EHPVO underwent MLPVB between 1997 and 2006. Children were divided into 3 groups: those with no prior surgery related to portal hypertension, those with prior portosystemic shunts, and those with either splenectomy or mesenteric vascular embolization procedures. The effect of prior procedures on the patency rate of the MLPVB was then examined. Of 62 children, 11 (17.7%) had significant procedures to treat symptoms of portal hypertension: 6 had at least 1 portosystemic shunt attempt, 3 had isolated splenectomy, and 2 had embolization of the splenic artery or coronary and peripancreatic varices. Patients with previous portal hypertension surgery were significantly older and larger than those with no surgery. Patients with no prior interventions had a significantly higher MLPVB patency rate (88.2%, 45/51) than those with no prior interventions (63.6%, 7/11). Prior splenectomy alone was not found to adversely affect MLPVB. Patients with prior embolization procedures or unsuccessful shunts had significantly poorer successful outcomes (0% and 66.7%) than those with no prior interventions (88.2%; P < .005). The results demonstrate that prior portosystemic shunts or mesenteric embolizations have a deleterious effect on outcome after MLPVB and should be avoided whenever possible. This study suggests that patients with symptomatic EHPVO should undergo MLPVB as a primary intervention rather than as a rescue procedure to optimize MLPVB patency.

Acute parent artery dissection as a complication of mesenteric endovascular coil embolisation for pancreatic pseudoaneurysm

We wish to highlight arterial dissection as an unusual complication during endovascular coiling of a pancreatic pseudoaneurysm. Immediate recognition and prompt corrective measures prevented progression of this serious condition. In our patient, angioplasty prevented further propagation of the dissection and preserved coeliac artery patency.

Laparoscopic reversal of Hartmann's rectosigmoidectomy

The aim of this study was to analyse the outcome of laparoscopic restoration of bowel continuity post Hartmann's procedure. A prospectively electronic database of colorectal laparoscopic procedures between April 2001 and December 2006 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic reversal of an open Hartmann's procedure (LRH). Twenty-eight patients (11 males), median age 66 (32-89), median body mass index 26 have undergone an attempted LRH over a 5-year period. Twenty (71%) had undergone surgery for complicated diverticulitis, eight (29%) for cancer; two followed an anastomotic dehiscence post-laparoscopic high anterior resection. The median operation time was 80 min (40-255 min). Twenty-six procedures (93%) were completed laparoscopically. There was one late conversion (to release a small bowel loop from the pelvis). A small, fibrotic rectal stump split whilst attempting a stapled anastomosis - the procedure was abandoned. The median time to normal diet was 18 h and median hospital stay was 3 days (1-63). There were three (11%) readmissions; wound infection (two) and abdominal pain. There were two deaths (7%) - mesenteric emboli and anticoagulant induced upper gastrointestinal haemorrhage. We believe that in the hands of appropriately trained and experienced surgeons, laparoscopic 'reversal' of a Hartmann's procedure is a feasible, safe and largely predictive operation that allows for early return of gastrointestinal function and very early hospital discharge.

Giant left atrial myxoma in an elderly patient: Natural history over a 7-year period

We present the case of a 71-year-old woman with a 7-year history of a giant left atrial myxoma. The myxoma was attached to the atrial septum and occupied almost the entire left atrial cavity. The patient was hospitalized 4 times because of dyspnea on exertion, palpitations, fatigue, general asthenia, and weight loss. During prior hospitalizations, the patient had refused cardiac surgery. She developed several complications, including atrial fibrillation, mitral and tricuspid regurgitation, mesenteric embolism, pulmonary edema, and thrombotic stroke. We herein describe the natural history of left atrial myxoma in an elderly patient over a 7-year period.

Type 2 Endoleaks after Abdominal Aortic Aneurysm Stent Grafting with Systematic Mesenteric and Lumbar Coil Embolization

We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric artery (IMA) and/or lumbar arteries (LAs) prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). We retrospectively reviewed all patients undergoing EVAR over a 4-year period at one hospital. Results were analyzed using uni- and multivariate analyses. Fifty-five male patients with an average age of 71 years were evaluated. Follow-up averaged 15 +/- 13 months. The IMA was either coiled or occluded in 30 cases. One or more LAs were coiled in 29 patients. An average of 1.3 LAs per patients were coiled (range 0-6). There were no immediate or late complications from coiling. At last follow-up, 14 AAAs showed no change in diameter, one increased by 2 mm, and the remainder (n = 40) decreased by 7.5 +/- 6 mm in maximal diameter. Only five (9%) type 2 endoleaks were detected during follow-up. Three were associated with AAA size increase. Four of the five were treated with additional coiling, with good results. By logistic regression, neither endoleak occurrence nor AAA shrinkage correlated with LA or IMA coiling. However, by multivariate analysis, completeness of lumbar coiling correlated negatively with aneurysm shrinkage (p = 0.04) and IMA coiling correlated positively with aneurysm shrinkage (p = 0.04). Coil embolization of the IMA and/or LAs prior to EVAR can be safely accomplished in a large number of cases and is associated with a low incidence of type 2 endoleaks. We cannot at present demonstrate a benefit to LA embolization in terms of endoleak prevention or AAA shrinkage. However, IMA embolization may be of benefit in terms of AAA shrinkage.

Echocardiographically guided left atrial ablation: Characterization of a new technique

Several techniques for percutaneous catheter-based radiofrequency ablation of left atrial myocardium have been described. Each is potentially limited by anatomic inaccuracy, radiation requirement, cardiac/extracardiac collateral damage, proarrhythmia, lesion impermanence, or unclear procedural endpoint. The purpose of this study was to describe a new technique that may address some of these limitations. In 200 consecutive patients with atrial fibrillation (AF), complete ablative encircling of right and left pulmonary venous vestibules was performed using radiofrequency energy applied via a standard ablation electrode. Lesions were guided by a collaborative nonfluoroscopic imaging strategy involving intra-left atrial echocardiography and CARTO. A discrete procedural endpoint was sought: complete electrical isolation of all myocardium subtended by the encircling lesions. After a procedure in which the total fluoroscopy time averaged 6 minutes, isolation was achieved on the left and right sides in 198 and 199 patients, respectively. In addition to the vestibule-encircling lesions, isolation required one or more additional focal lesions within the subtended myocardial territory in the majority of left vestibules and in a minority of right vestibules. Significant procedural morbidity was observed, including cerebroembolism resulting in death and mesenteric embolism resulting in hemicolectomy. Procedural success, defined at 2 years after the initial procedure and requiring no interim procedure, antiarrhythmic drug therapy, or apparent arrhythmia burden, was observed in a significantly greater proportion of patients with a paroxysmal (87%) than persistent AF (60%) syndrome. Only a small proportion of patients with recurrent AF had recurrence of conduction in previously isolated zones. This technique may have advantages over those previously reported, including improved anatomic accuracy, improved lesion safety and efficacy, and diminished radiation exposure.

Percutaneous endovascular treatment of acute sequential systemic emboli

A 65-year-old woman was evaluated for acute right lower-extremity ischemia secondary to embolization from atrial fibrillation and subtherapeutic anticoagulation. Her symptoms quickly evolved in a dynamic fashion to involve multiple vascular beds, including a transient ischemic attack, abdominal pain secondary to mesenteric ischemia, and contralateral lower-extremity ischemia. Synchronous emboli were treated by using mechanical and pharmacologic thrombolysis via an endovascular approach under local anesthesia. This intervention allows prompt evaluation of multiple vascular beds with good short-term outcomes and minimal morbidity.

Splenic and mesenteric emboli in a patient with protruding aortic arch atheroma

Protruding atheromas in the thoracic aorta are an important cause of embolic disease. Transesophageal echocardiography (TEE) is the modality of choice for diagnosis of these lesions. We present a patient with splenic infarction in whom TEE revealed a large mobile atheroma in the aortic arch. A few hours following the disappearance of this mass from the aortic arch, the patient developed mesenteric artery embolism requiring subtotal small-bowel resection. We discuss the importance of the aortic arch as a source of peripheral emboli and the treatment modalities in these patients.

Localized Castleman's Disease Presenting as a Vascular Right Iliac Fossa Mass

Castleman's disease is a rare lymphoproliferative disorder of unknown aetiology. The presentation is varied, diagnosis is difficult, and optimum management is still unknown. We report our experience with a case of Castleman's disease in a 34-year old woman who presented with pallor, hepatosplenomegaly, and a right iliac fossa mass that was 5 cm in diameter. this was initially diagnosed as a soft tissue sarcoma and preoperative tumour embolization was planned before excision. Mesenteric arteriogram revealed that the feeder arteries arose from the superior mesenteric artery and embolization was aborted for fear of causing bowel ischaemia. On laparotomy, lymphoid enlargement was found between the leaves of the jejunal mesentery. The tumour was relatively avascular and the overlying mesenteric vessels contributed to teh duplex ultrasound and computerized tomography appearance of hypervascularity. The tumour with the mesentery and the overlying segment of jejunum was excised completely. Histopathology confirmed Castleman's disease. The purpose of this report is to present this rare case that caused a diagnostic dilemma and to review the management of this disorder.

Evidence for a central role for selective mesenteric angiography in the management of the major vascular complications of pancreatitis

Background Although mesenteric angiography and embolization are established radiologic procedures, the evidence-base to aid decision making regarding selection of these procedures in the emergent situation in patients with hemorrhagic complications of pancreatitis is limited. Methods A retrospective analysis of 19 patients with hemorrhagic complications of pancreatic inflammatory disease (acute pancreatitis, chronic pancreatitis, and pseudocyst) referred over a 4-year period and identified at the point of mesenteric angiography in order to determine the influence of interventional radiologic maneuvers on outcome. Results Mesenteric angiography localized bleeding in 15 (79%), with 11 (58%) embolizations undertaken. There was one (9%) procedure-related complication and 3 (27%) rebleeds. Of 11 patients undergoing embolization, 8 (73%) required no further intervention for bleeding and 8 (73%) survived. Conclusions Mesenteric angiography is valuable in localizing bleeding in patients with major vascular complications of pancreatic inflammatory disease. Angiographic embolization can achieve definitive hemostasis and stabilize a critically ill patient to permit disease reappraisal.

Paravisceral aortic thrombus as a source of peripheral embolization—Report of three cases and review of the literature

Spontaneous embolization resulting in peripheral arterial occlusion remains a significant cause of morbidity and limb loss. Accurate localization and correction of the embolic source is paramount for the prevention of further episodes and for the preservation of long-term patency and limb salvage. Common well-recognized embolic sources include intracardiac thrombus or myxoma, and thrombus within arterial aneurysms or complex atherosclerotic plaques. Less common is thrombus arising de novo in an otherwise normal aorta, possibly as a result of prior trauma, occult arteriopathy, and/or hypercoagulability. Reported herein are three cases of peripheral or mesenteric embolization arising from large thrombi within the visceral aortic segment, with minimal evidence for atherosclerosis or other aortic pathology. Each patient was treated with visceral aortic thrombectomy using a direct surgical approach.

Paravisceral aortic thrombus as a source of peripheral embolization—Report of three cases and review of the literature

Spontaneous embolization resulting in peripheral arterial occlusion remains a significant cause of morbidity and limb loss. Accurate localization and correction of the embolic source is paramount for the prevention of further episodes and for the preservation of long-term patency and limb salvage. Common well-recognized embolic sources include intracardiac thrombus or myxoma, and thrombus within arterial aneurysms or complex atherosclerotic plaques. Less common is thrombus arising de novo in an otherwise normal aorta, possibly as a result of prior trauma, occult arteriopathy, and/or hypercoagulability. Reported herein are three cases of peripheral or mesenteric embolization arising from large thrombi within the visceral aortic segment, with minimal evidence for atherosclerosis or other aortic pathology. Each patient was treated with visceral aortic thrombectomy using a direct surgical approach. (J Vasc Surg 2002;36:839-43.)

Hematochezia from the duodenum caused by superior mesenteric vein coil embolization

Hematochezia from the duodenum caused by superior mesenteric vein coil embolization

Superselective mesenteric embolization with microcoils in a porcine model.

There is a lack of data regarding the degree of ischemic change that may occur in small and large bowel after superselective arterial embolotherapy with platinum microcoils. The purpose of this study was to gain a clearer understanding of the ischemic complications of superselective embolization of peripheral mesenteric arteries with microcoils by gross and histologic examination of postembolectomy bowel specimens at several time intervals in an adult porcine model. Two-millimeter platinum microcoils with fibrils were superselectively deployed into six isolated mesenteric branch vessels in each of nine adult pigs. The animals were observed for two days (n = 3), one month (n = 3), or three months (n = 3) and then killed. At necropsy, intestines were examined for gross abnormalities. Sections of bowel containing microcoils were identified under fluoroscopy, resected, and evaluated histologically. A total of 54 microcoils were deployed into the distal arterial mesentery supplying the jejunum (n = 14), ileum (n = 26), and colon (n = 14) of nine adult pigs. Each animal received six microcoils. There were no clinical complications, and all pigs gained weight during their observation periods. Gross examination of the intestines did not reveal any evidence of acute or chronic ischemia. The coils were found in the distal arterial vasculature of the intestine. Histologic examination revealed mild superficial necrosis of villous tips in several samples; however, this finding is likely related to a fixation artifact rather than ischemic injury. There was no other histologic evidence suggestive of ischemic injury. Gross and histologic findings after superselective arterial embolotherapy demonstrated minimal changes in the bowel, and there were no significant clinical consequences to the animals. We conclude that transcatheter arterial embolotherapy in pigs is safe and may be applicable in the control of massive lower gastrointestinal hemorrhage in humans.

Conduite à tenir devant une suspicion d’ischémie mésentérique aiguë

Acute mesenteric ischemia (AMI) is a diagnostic and therapeutic emergency medicine. Its mortality remains high (30 to 95%), depending on both its etiologies and the rapidity of treatment. The term acute mesenteric ischemia is currently applied to a wide spectrum of bowel injuries within the distribution of the superior mesenteric vessels, ranging from reversible alterations in bowel function (acute mesenteric ischemia syndrome) to transmural necrosis of the bowel wall (mesenteric infarction). AMI may result from a superior mesenteric embolus, thrombosis of the superior mesenteric artery or vein, or non-occlusive mesenteric ischemia. The lack of specific clinical signs requires other diagnostic means. Abdominal computed tomographic scan is currently the most efficient diagnostic tool. It also helps to rule out diseases that may mimic AMI. Intravenous contrast injection may show mesenteric vascular occlusion and specific abnomalities of the bowel mucosae. Initial treatment consists of volume resuscitation and administration of appropriate doses of vasopressive drugs. The vasospasm treatment needs further clinical research. Diagnostic and therapeutic angiography is not easy to perform in regular practice, whereas a selective superior mesenteric artery catheter may allow a specific treatment for some patients. A multidisciplinary approach is needed for an accurate diagnosis and treatment.

Carbamazepine Diminishing the Effects of Warfarin and Leading to Mesenteric Embolism in a Patient with Atrial Fibrillation

LEARNING OBJECTIVE: 1). To know drugs that decrease warfarin levels CASE: A 66 year old woman, nursing home resident, with history of chronic atrial fibrillation, hemiplegia secondary to a stroke, congestive heart failure, hypertension and seizure disorder, presented to the hospital with worsening nausea and vomiting persisting for 3 weeks. Her medications included digoxin, warfarin and enalapril. The physical exam showed hemiplegia. Standard admission work up revealed an INR of 2.3 and a high serum phenytoin level of 42 mg/dl. The patient had phenytoin toxicity, so phenytoin was stopped and the patient observed. Two days later the patient developed generalized clonic-tonic seizures. At that time the phenytoin level was 22 mg/dl. It was decided to give the patient loading doses of carbamazepine oral suspension in order to prevent further seizures. The following evening the patient suddenly developed acute abdomen. The INR was 1.4. The patient developed mesenteric infarction secondary to embolism, as revealed by urgent exploratory laparotomy. The patient expired the next day. DISCUSSION: The event was brought on by inadequate anticoagulation secondary to a drug-drug interaction between warfarin and carbamazepine that resulted in a drop in INR. This, in our patient with atrial fibrillation, allowed for cardiac thrombi formation and their embolisation to the mesenteric circulation. Drug-drug interactions with warfarin are among the most common interactions seen in clinical practice. The following drugs decrease warfarin level and predispose to thrombosis (remember the acronym DECREASE): Diuretics: spironolactone Estrogen containing oral contraceptives Carbamazepine, Corticosteroides, Rifampin Ethchlorvynol Alcoholism, Aminogluthethimide Sucralfate Etc: barbiturates, griseofulvin, and vitamin K (broccoli and bananas).

Role of angiography and embolization for massive gastroduodenal hemorrhage

The role of mesenteric angiography and embolization for massive gastroduodenal bleeding is unclear. We reviewed the records of patients who underwent angiography for acute, nonmalignant, and nonvariceal gastric or duodenal hemorrhage that was documented but not controlled by endoscopy. Fifty patients were identified over a 7-year period ending in March 1998. Only 17 patients (34%) were originally admitted to the hospital with gastrointestinal bleeding. All required treatment in the intensive care unit (mean 15 days) with a mean APACHE III score of 79 (29% predicted hospital mortality), and 32 (64%) had organ failure. A mean of 2.1 endoscopies were performed to locate the source of acute duodenal bleeding in 37 (74%) and gastric bleeding in 13 (26%). An average of 24.3 units of packed red blood cells were transfused per patient. Twenty-five patients (50%) were found to have active bleeding at angiography; all were treated by embolization as were 22 who underwent empiric embolization. Twenty-six patients (52%) were successfully treated by embolization and thus spared imminent surgery. Multiple variables were compared between those who were successfully treated by embolization and those considered failures. Time to angiography was considerably shorter (2.5 vs. 5.8 days, P <0.017) and fewer total units of packed red blood cells were used (14.6 vs. 34, P <0.003) in those who were successfully treated. There was also a strong trend toward using fewer units of packed red blood cells for transfusion prior to angiography (11.2 vs. 17.1, P <0.08). No differences were found that could be attributed to gastric vs. duodenal sources, number of comorbid diseases, organ failure, APACHE score, age, or whether active bleeding was found at angiography. A total of 20 patients (40%) died including 9 of 17 patients operated on in an attempt to salvage angiographic failure. In summary, angiographic embolization should be performed early in the course of bleeding in otherwise critically ill patients.

INTESTINAL (MESENTERIC) VASCULOPATHY I: Acute Superior Mesenteric Arteriopathy and Venopathy

Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.

A case report : Successful treatment for intractable fundic variceal hemorrhage by direct catheterization of the mesenteric vein and embolization

A case report : Successful treatment for intractable fundic variceal hemorrhage by direct catheterization of the mesenteric vein and embolization

Local Infusion of Fibrinolytic Agents for Acute Renal Artery Thromboembolism: Report of Ten Cases

Management of acute renal artery occlusion remains a therapeutic challenge. We report our experience with 10 cases of acute renal artery occlusion treated primarily by local infusion of fibrinolytic agents. Renal artery occlusion occurred as a result of thrombosis of a stenosed vessel in three cases, from renal artery embolism in two cases, as a complication of percutaneous transluminal angioplasty in four cases, and in association with aortic occlusion in one case. Flank pain was present in all cases and hematuria in four cases. Acute renal failure was seen at the time of presentation in four cases (one case from bilateral occlusion and three cases from an associated nonfunctioning contralateral kidney). Diagnosis was confirmed by renal isotope scanning and arteriography in all cases. All patients were treated by selective infusion of streptokinase or urokinase into the occluded renal arteries. In five cases this was combined with balloon catheter angioplasty. Therapy was initiated within 24 hours from the onset of symptoms in three cases, within 3 days in four cases, within 6 days in two cases, and after 5 weeks in one case. Successful revascularization was initially achieved in 7 of the 10 cases by arteriographic criteria. Rethrombosis occurred in one patient after 3 days and fibrinolytic therapy was repeated successfully. Renal function was restored in one of the four patients presenting with acute renal failure. One complication necessitating resection occurred as a result of fibrinolytic therapy in the form of acute mesenteric embolism with descending colon infarction. No major bleeding complications were encountered and there were no deaths in this group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)