Superior Mesenteric Artery Embolism Research Articles

Imaging in Intestinal Ischemic Disorders

Intestinal ischemia and infarction are a heterogeneous group of diseases that have as their unifying theme hypoxia of the small bowel and/or colon. The incidence of bowel ischemia is increasing for a number of reasons: the aging of the population, the ability of intensive care units to salvage critically ill patients, and heightened clinical awareness of these disorders. Improvements in diagnostic imaging techniques have contributed greatly to the earlier diagnosis of intestinal ischemia, which can have a positive influence on patient outcomes. In this review, advances in multidetector computerized tomography, magnetic resonance, and ultrasound in the detection of intestinal ischemia are highlighted and placed in the context of expeditious patient management.

Experience in the management of acute superior mesenteric artery ischemia

To study the management of acute superior mesenteric artery (SMA) ischemia and to improve its prognosis. The clinical data of 37 patients treated from January 1996 to August 2007 was retrospectively reviewed. Of the cases, 19 (51.4%) patients were diagnosed with acute SMA embolism, 15 (40.5%) with acute SMA thrombosis, 2 (5.4%) with spontaneous isolated dissection of SMA and 1 (2.7%) with SMA aneurysm. Nineteen (51.4%) patients were misdiagnosed in emergency. Eighteen (48.6%) patients died in the hospital, and most of them died of severe infection and multiple organ failure. Three cases of the survived 19 patients experienced severe complications (2 with short gut syndrome, 1 with cerebral hemorrhage). Nine cases were followed-up for a mean period of 15 months, and 5 died during that term. Acute SMA ischemia has multiple etiological factors. Early intervention can improve the prognosis.

Experimental Study on Acute Ischemic Small Bowel Changes Induced by Superselective Embolization of Superior Mesenteric Artery Branches with N-Butyl Cyanoacrylate

To evaluate the degree of ischemic changes of the small bowel after superselective embolization of superior mesenteric artery (SMA) branches at the vasa recta level with N-butyl cyanoacrylate (NBCA) in dogs. In six dogs, superselective embolization was performed with NBCA in five isolated branches of the SMA at the vasa recta level. All dogs were sacrificed 24 hours after embolization. According to the extent of the NBCA mixtures on radiographs of the specimen, embolized segments were divided into group A (embolization of three or fewer vasa recta) or group B (embolization of four or more vasa recta). Histologic evaluation of the mucosal, submucosal, and muscle layers of the embolized segments was performed by a pathologist. In group A (n=15), histologic findings were normal in seven segments (47%). Mild ischemic changes were noted in the mucosal layer in eight segments, the submucosal layer in four segments, and the muscle layer in one segment. In group B (n=15), ischemic changes were noted in the mucosal layer in all 15 segments, the submucosal layer in 14 segments, and the muscle layer in 10 segments. The difference in ischemic damage between groups A and B was statistically significant. Superselective embolization involving three or fewer vasa recta of the SMA was relatively tolerable, and embolization involving four or more vasa recta carried an increased risk of substantial ischemic bowel damage. Further studies are necessary to determine the clinical implications of our findings in human subjects.

Emergency Embolectomy For Synchronous Embolism In A Patient With Cirrhosis And Dilated Cardiomyopathy

Background: Correct and quick diagnosis of superior mesenteric artery embolism with subsequent adequate therapy can save a patient's life. Methods: We describe a 43-year-old male with potentially fatal synchronous embolism, secondary to dilated cardiomyopathy, affecting the superior mesenteric and femoral artery treated with staged embolectomy. Conclusions: This case should heighten the awareness of embolic events in non-anticoagulated patients with dilated cardiomyopathy.

Regarding “Floating thrombus in the ascending aorta”

1We congratulate them on their excellent result. We thoroughly agree with their prompt and aggressive workup, including transesophageal echocardiography, to detect a source of embolism. There are several points to be discussed. First, we believe that the context may be misunderstood. They commented that the neurological event was suspected to be a transient ischemic attack, not a stroke/cerebral hemorrhage, which was confi rmed by magnetic resonance imaging. Therefore, the last sentence of the discussion is not consistent with their position. Second, the timing of the operation is a matter of concern. The operation was performed 5 days after admission despite evidence of splenic embolization during the clinical course. 1 Even though the size of the thrombus was getting smaller with anticoagulation, we believe that surgery should have been performed earlier. Some previous reports have shown catastrophic consequences of a fl oating thrombus in the ascending aorta, such as acute myocardial infarct (AMI) and cerebrovascular accident (CVA). 2–4 In reviewing those 12 reports, a fl oating thrombus in the ascending aorta had been associated with three AMIs (25%), three CVAs (25%), three peripheral embolisms (25%), and two visceral embolisms (17%) including one fatal superior mesenteric artery embolism. 2–4 We strongly suggest surgical removal of the fl oating thrombus in the ascending aorta as soon as possible when no contraindication for cardiopulmonary bypass exists, such as a cerebral infarct or hemorrhage (or both) and lethal liver dysfunction. To avoid the worst scenario, one should not procrastinate about surgery for this entity.

L-Lactate After Embolization of the Superior Mesenteric Artery

Plasma markers for intestinal ischemia have not proven to be accurate. The value of L-lactate is unclear. Experimental models based on open surgery confound the effects of surgical trauma with that of ischemia. The aim was to create an endovascular model for acute superior mesenteric artery thromboembolism, and then to study L-lactate and lactate dehydrogenase (LD) activity in plasma and peritoneal fluid in pigs with extensive, high-grade intestinal ischemia. Nine pigs underwent full superior mesenteric artery embolization with 4 h of intended intestinal ischemia, whereas six were control animals. Sampling of central venous and arterial blood was performed throughout the experiment, ending with laparotomy to collect peritoneal fluid and segmental intestinal biopsies. A pathologist, blinded to the performed interventions, graded the ischemic lesions. There were no differences in plasma L-lactate (P = 0.61) or LD activity levels (P = 0.69), measured at different time points from baseline to end of study, between animals with extensive, high-grade intestinal ischemia and sham. Intraperitoneal L-Lactate (P = 0.005) and LD activity (P = 0.018) levels were elevated compared with sham. There were differences in grades of ischemia in the duodenum (P = 0.003), small intestine (P < 0.001), proximal (P < 0.001), and sigmoid (P = 0.032) colon between experimental animals and sham. The grade of small bowel ischemia (n = 15) correlated to intraperitoneal fluid L-lactate (r = 0.80; P < 0.001) and LD activity levels (r = 0.72; P = 0.003). This endovascular study in a porcine model showed that L-lactate and LD activity levels in peritoneal fluid, not in plasma, reflect intestinal ischemia. The study suggests that plasma L-lactate not is a useful early marker in patients with suspicion of intestinal ischemia.

Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome

Acute mesenteric ischaemia remains a serious condition requiring emergency, surgical management. The mortality rate still remains high, due to the unspecific and delayed diagnosis and ranges from 59% to 100%. Purpose of our study is to present our experience in the management of the disease. This is a retrospective study of 61 patients treated surgically for acute mesenteric ischaemia, between 1988 and 2004. All patients underwent a laparotomy. 75% of the patients were operated within the first 24 hours and the rest within 48 hours. Superior mesenteric artery embolism occurred in 36 (59%), thrombosis in 21 (34%) and superior mesenteric vein thrombosis in 4 (7%) cases. In 49 (80%) cases, embolectomy or thrombectomy of the superior mesenteric artery with resection of the necrotic segment of the bowel was performed. Twelve cases (20%) were considered inoperable because of massive bowel necrosis. According to our study mortality and morbidity rate amounts to 75% and 80% respectively. No significant difference in the mortality rate between patients with embolism (75%) and thrombosis (76%) was found. However a significant increase of mortality rate was observed when the surgical intervention became afterwards the first 24-hour period. (72% versus 87%). Patients who underwent embolectomy or thrombectomy with bowel resection presented an improved survival rate compared with patients that underwent only bowel resection. (p = 0.019) Acute mesenteric ischaemia has the characteristics of a highly lethal condition and only early recognition and appropriate treatment can reduce the potential for a devastating outcome. The reduction of time interval from the beginning of symptoms up to the treatment remains the main critical important factor.

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.

Isolated Left Ventricular Noncompaction of the Myocardium as a Cause of Embolic Superior Mesenteric Artery Occlusion

Isolated noncompaction of the left ventricular (LV) myocardium is a rare congenital disorder resulting from an arrest of the compaction process of the myocardial trabeculae during normal embryogenesis. It is characterized by the presence of prominent LV myocardial trabeculations and deep intertrabecular recesses that are in continuity with the LV cavity. The most common clinical presentation includes progressive LV dysfunction, life-threatening tachyarrhythmias, and the risk for severe cardioembolic events. We describe a case where isolated noncompaction of the LV myocardium was diagnosed after an embolic occlusion of the superior mesenteric artery in a 40-year-old Caucasian woman.

Review article: diagnosis and management of mesenteric ischaemia with an emphasis on pharmacotherapy

Mesenteric ischaemia results from decreased blood flow to the bowel, causing cellular injury from lack of oxygen and nutrients. Acute mesenteric ischaemia (AMI) is an uncommon disorder with high morbidity and mortality, but outcomes are improved with prompt recognition and aggressive treatment. Five subgroups of AMI have been identified, with superior mesenteric artery embolism (SMAE) the most common. Older age and cardiovascular disease are common risk factors for AMI, excepting acute mesenteric venous thrombosis (AMVT), which affects younger patients with hypercoaguable states. AMI is characterized by sudden onset of abdominal pain; a benign abdominal exam may be observed prior to bowel infarction. Conventional angiography and more recently, computed tomography angiography, are the cornerstones of diagnosis. Correction of predisposing conditions, volume resuscitation and antibiotic treatment are standard treatments for AMI, and surgery is mandated in the setting of peritoneal signs. Intra-arterial vasodilators are used routinely in the treatment of non-occlusive mesenteric ischaemia (NOMI) and also are advocated in the treatment of occlusive AMI to decrease associated vasospasm. Thrombolytics have been used on a limited basis to treat occlusive AMI. A variety of agents have been studied in animal models to treat reperfusion injury, which sometimes can be more harmful than ischaemic injury. Chronic mesenteric ischaemia (CMI) usually is caused by severe obstructive atherosclerotic disease of two or more splanchnic vessels, presents with post-prandial pain and weight loss, and is treated by either surgical revascularization or percutaneous angioplasty and stenting.

Surgical therapy for acute superior mesenteric artery embolism

Background Acute mesenteric artery embolism has a high rate of morbidity and mortality. Early diagnosis and appropriate treatment are the most important factors associated with morbidity and mortality. Methods During the period between 1997 and 2002, 24 patients underwent superior mesenteric artery embolectomy. The patients were divided into three groups according to the onset of symptoms and operation time. Group I (n = 12) patients were operated on in the first 6 hours after onset of symptoms; group II (n = 9) patients were operated on between 6 and 12 hours after onset; and group III (n = 3) patients underwent embolectomy after 12 hours. Low-dose (5 to 10 mg) local tissue-type plasminogen activator (t-PA) administration directly into the superior mesenteric artery was an additional procedure with the embolectomy in all patients. Results The macroscopic view of the intestine was normal in 15 patients (12 patients in group I and 3 patients in group II) 30 minutes after the administration of local t-PA. Segmental resection was necessary in 4 patients in group II. Extended resection was necessary in 2 patients in group II and 3 patients in group III, and all of the patients died during the early postoperative period. Conclusions We suggest that explorative laparotomy should be done in patients with sudden abdominal pain, nausea, vomiting, mild leukocytosis, and metabolic acidosis who have previous valvular heart disease or atrial fibrillation. Ultimately, selective low dose t-PA (5 to 10 mg) administration reduces the length of intestinal portion to be resected.

肺癌術後に上腸間膜動脈血栓塞栓症を発症し救命し得た１例

症例は凝固系, 循環器系に異常のない57歳男性.検診にて左上肺野に異常陰影を指摘され当院を受診.肺癌にて左肺上葉切除, リンパ節郭清を施行した.術後第4病日に突然の腹痛が出現.精査の結果, 上腸間膜動脈血栓塞栓症と診断した.緊急開腹術で, 上腸間膜動脈血栓を除去し, 開腹術後21病日に軽快退院した.極めて稀な肺癌術後合併症を経験したので報告する.

Acute Superior Mesenteric Artery Embolism: Rapid Reperfusion With Hydrodynamic Thrombectomy and Pharmacological Thrombolysis

Acute Superior Mesenteric Artery Embolism: Rapid Reperfusion With Hydrodynamic Thrombectomy and Pharmacological Thrombolysis

SUPERIOR MESENTERIC ARTERIAL EMBOLISM: A RETROSPECTIVE STUDY OF LOCAL THROMBOLYTIC TREATMENT WITH UROKINASE IN WEST CHINA

SUMMARYEmbolism of the superior mesenteric artery (SMA) is a rare disorder. To explore the selective criteria of local thrombolysis, evaluate its efficacy and discuss the therapeutic protocol of SMA embolism, a retrospective case control study was undertaken. Sixteen cases were divided into two groups: nine cases (group A) from May 1995 to April 1999 were given traditional treatment, while seven cases (group B) from November 1999 to June 2002 received comprehensive therapy including local thrombolysis. The local thrombolytic treatment was performed without procedure‐related complications and the embolus was successfully lysed in four patients. The time between admission and diagnosis (or treatment) was shorter in group B than in group A (2.3 ± 1.2 vs 12.3 ± 9.2 hr, p=0.013). Gangrenous bowel segments in group A were much longer than in group B (159.4 ± 87.7 vs 45.7 ± 61.6 cm, p=0.009). However, mortality between the two groups was the same (p=0.282, OR=0.32, 95% Cl=0.039, 2.618) perhaps because of the small sample size. Angiography could shorten the duration from the onset of SMA embolism to therapy and certainly lowers the risk of mortality. Local fibrinolytic infusion may be an effective alternative to embolectomy in patients with SMA embolism but without intestinal infarction.

Multiple detector-row CT angiography of the renal and mesenteric vessels

Computed tomography angiography (CTA) of the abdomen with multiple detector-row computed tomography (MD-CT) is an effective technique for minimally invasive imaging of the renal arteries and the visceral vasculature. This article reviews the clinical and technical aspects of MD-CT angiography in terms of image acquisition and reconstruction parameters, contrast medium application, and three-dimensional visualization with special attention to renal and mesenteric vascular imaging. Because of its high sensitivity to detect renal artery stenosis on the one hand, and because a normal renal CTA virtually excludes the presence of a significant renal artery stenosis on the other hand, renal CTA plays a useful role in the management of patients with suspected renovascular hypertension. Mesenteric CTA is a useful tool for visualizing normal vascular anatomy and its variants—particularly in the setting of organ transplantation. Vascular pathology, e.g. atherosclerotic disease (abdominal angina), or aneurysms of the visceral arteries are reliably assessed with CTA. Mesenteric CTA is an invaluable adjunct to abdominal CT in the setting of abdominal emergencies, because of its ability to detect the causes of acute intestinal ischemia (superior mesenteric artery embolism or thrombosis, superior mesenteric vein thrombosis). Accurate timing of the CTA acquisition and the subsequent parenchymal phase acquisition relative to the contrast medium transit time is critical to obtain excellent image quality in double-pass abdominal CT acquisitions.

A Case of Superior Mesenteric Arterial Embolism Treated with Vascular Reconstruction Alone

A Case of Superior Mesenteric Arterial Embolism Treated with Vascular Reconstruction Alone

胸部大動脈血管内膜肉腫による上腸間膜動脈腫よう塞栓症の１例

胸部大動脈血管内膜肉腫による上腸間膜動脈腫よう塞栓症の１例

ISCHEMIC BOWEL DISEASE IN THE ELDERLY

The ischemic bowel diseases are a heterogeneous group of disorders usually seen in elderly individuals. They represent ischemic damage to different portions [figure: see text] of the bowel and produce a variety of clinical syndromes and outcomes. Colonic ischemia is the commonest of these disorders and has a favorable prognosis in most cases. In contrast, acute mesenteric ischemia, most commonly caused by a superior mesenteric artery embolus, is a disease with a poor prognosis. Acute mesenteric ischemia secondary to nonocclusive mesenteric ischemia usually is a [figure: see text] catastrophic complication of other severe medical illnesses, most notably atherosclerosis. Proper diagnosis and management of patients with ischemic bowel disease requires vigilance on the part of the physician and a willingness to embark on an aggressive plan of diagnosis and management in the appropriate setting.

Evaluation of stapling technique in surgical treatment of esophageal and cardiac cancer

Objective: To investigate an effective method to prevent anastomotic leakage and stenosis, evaluating the role of stapling technique in surgical treatment of esophageal and cardiac cancer. Methods: The stapling technique was used in end-to-side esophagogastromosis in surgical treatment of esophageal and cardiac cancer. Results: 128 patients were so treated. One patient died of superior mesenteric artery embolism, and the operative mortality was 0.78%. No anastomotic leakage or stenosis was found in this series. The other complications included postoperative thoracic cavity bleeding in 1 (0.78%), myocardial infarction in 2 (1.56%), stress ulcer of stomach in 1 (0.78%), and gastroparsis in 4 (3.12%). The overall morbidity rate was 4.7%. Conclusion: Using stapler to perform end-to-side esophagogastromosis has the advantages of being simple and safe, cutting short the operation time, and preventing leakage and stenosis. It is an ideal technique in the treatment of esophageal and cardiac cancer.

SUPERIOR MESENTERIC ARTERIAL EMBOLISM CURED BY VASCULAR RECONSTRUCTION ONLY-A CASE REPORT-

A patient with acute superior mesenteric artery (SMA) embolism, who received an early diagnosis, was cured by vascular reconstruction alone. A 77-year-old woman with atrial fibrillation and old myocardial infarction visited to our hospital with a complaint of acute abdominal pain. The combination of poor abdominal findings and her past history indicated the diagnosis of SMA embolism. Two hours after onset, emergency angiographic was performed. Angiographic findings revealed a shadow defect in the appearance of the main trunk of the SMA in an area peripheral to the middle colic artery bifurcation, therefore Urokinase was infused directly into the SMA. Because the abdominal pain disappeared, continuous intravenous infusion of anticoagulant and fibrinolysis therapy were selected. Because the abdominal pain redeveloped and blood analysis showed a white cell count of 49300 after ten days from onset, and laparotomy was performed. Laparotomy revealed no evidence of necrosis of the small and large intestine, and embolectomy with a 3Fr Fogarty catheter alone was performed. The rest of the hospital stay was uneventful and the patient was discharged eight weeks after the operation.