Acute superior mesenteric artery embolism: reperfusion with AngioJet hydrodynamic suction thrombectomy and pharmacologic thrombolysis with the EKOS catheter

Abstract

Acute mesenteric ischemia is commonly treated by surgical exploration and open thrombectomy. Very few reports describe using newer, minimally invasive methods which utilize catheter-based mechanical and pharmacological thrombolysis. Herein, we report a case of acute superior mesenteric embolism successfully treated with AngioJet hydrodynamic mechanical thrombectomy and EKOS catheter pharmacological thrombolysis. A 76-year-old man with new onset atrial fibrillation presented with abdominal pain of 48 hours duration. Subsequent contrast computed tomography scan of the abdomen revealed a filling defect in the superior mesenteric artery (SMA), suggestive of an acute embolus, which was confirmed by SMA angiogram. The AngioJet aspiration device was used for hydrodynamic suction thrombectomy. The repeat angiogram demonstrated only a partial restoration of blood flow, and thus the EKOS tissue plasminogen activator catheter was left in the SMA for continuous thrombolysis. The patient underwent continuous thrombolysis for two days, with two subsequent sessions of angiography. Thereafter, the patient improved symptomatically and serum lactate was normalized. In conclusion, the AngioJet suction thrombectomy and pharmaco-mechanical thrombolysis using the EKOS catheter is associated with minimal morbidity and can be rapidly performed. It may be used as an alternative to open surgical thrombectomy in selected cases of acute SMA embolism.

Percutaneous mechanical thrombectomy of superior mesenteric artery embolism

“…If there are clinical or CT signs of bowel necrosis, urgent surgery is needed. However, if there is no clear evidence of bowel necrosis, endovascular treatment can be a promising alternative11,12,16,17, as also confirmed in our series. Minimal bowel changes, such as circumferential wall thickening of cecum with normal, homogenous wall enhancement is not a contraidication for endovascular procedure.…”

“…One is the first case performed in our department19 and another is a case report of treatment with AngioJet ® hydrodynamic mechanical thrombectomy and EKOS ® catheter pharmacological thrombolysis 12. There are also some reports with a very high success rate (90%) for local fibrinolysis of the embolus in patients with SMA embolism 20,21.…”

“…The treatment of choice has been surgical laparotomy with thrombectomy 5. Alternatively, cases of percutaneous thrombectomy were reported 6–12. The two main percutaneous methods are aspiration thrombectomy, in which thrombus is removed by suction, and mechanical thrombectomy, using different automated devices to fragment and remove embolus.…”

Acute Superior Mesenteric Artery Embolism treated with Percutaneous Mechanical Thrombectomy: Preliminary application and Experience

“…The advantages of this procedure lie in its minimal invasiveness, clean the thrombus and restore the intestinal blood ow rapidly, reduce use of thrombolytic drugs and low complication rate 19 . The inadequacies include the possibility of vessel rupture and risk of bleeding, while such complications can be managed by operating carefully 20 . The most technical challenge is how to clean the distal arterial embolism.…”

Radiology and mesenteric ischaemia

“…Percutaneous transluminal angioplasty of the SMA in AMI has a poor long-term outcome and arterial dissection as a result of angioplasty would render subsequent stenting difficult. 45 As such, primary stenting for critically narrowed lesions is the approach of choice. The use of both balloon mounted and self-expanding stents have been described.…”