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Acute mesenteric ischemia and infarction is an emergent situation associated with high mortality, commonly due to emboli or thrombosis of the mesenteric arteries. Embolism to the mesenteric arteries is most frequently due to a dislodged thrombus from the left atrium, left ventricle, or cardiac valves. We report a case of 70-year-old female patient with an acute small bowel infarction due to a mesenteric artery embolism dislodged from a left atrial appendage detected by intraoperative transesophageal echocardiography and followed by anticoagulation therapy.

Paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt. It is a relatively rare phenomenon, representing about 2% of all cases of arterial embolism. We report a case of a 79-years-old woman admitted to hospital because of dyspnea and lower left limb pain. CT scan revealed multiple thrombi to kidney, lower limb and superior mesenteric artery during acute pulmonary embolism. Echocardiogram documented a patent foramen ovale with a right-to-left shunt. The patient was treated with thrombolytic therapy and heparin with progressive improvement of symptoms and resolution of pulmonary embolism and peripheral thrombosis. Patent foramen ovale closure was not performed because a life-long anticoagulation therapy was necessary, a tunnel-type patent foramen ovale may increases difficulty in realizing device implantation and there are no clear evidence-based guidelines to date addressing treatment in presence of a patent foramen ovale.

Objective

To investigate the risk profile of patients with thrombosis and emboli, and prognostic factors for death or amputation in patients presenting with acute limb ischemia in a tertiary care regional hospital in Brazil.

Methods

A prospectively planned cohort study was carried out in which 83 patients with acute limb ischemia, secondary to thrombosis, or embolism, classified in stages II and III of severity were evaluated. Univariate analysis and logistic regression models were used to explore the relationship between anthropometric and demographic characteristics, comorbidities, cardiovascular risk factors, duration of occlusion, and type of surgery with the incidence of amputation or death, which were evaluated in 30 days and 1 year thereafter.

Results

Male gender, smoking, and comorbidities were more frequent among patients with thrombosis, and atrial fibrillation was more common among patients with embolism. Occlusion longer than 24 hours (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.1–7.6) and a trend for diabetes (RR 2.6, 95% CI 0.9–7.5) were the characteristics associated with death or amputation in the multivariate analysis, which occurred in 15 (18.1%) and 24 (28.9%) of the participants, respectively. Reperfusion injury was a risk factor for death but not for amputation (OR 16.9, 95% CI 1.1–232.9) after adjustment for age, duration of occlusion, and diabetes.

Conclusions

Traditional and avoidable risk factors explain the occurrence of thrombosis and embolism in our region. Access to medical care is the most important and modifiable prognostic factor for death or amputation.

ABSTRACT

Mesenteric ischemia is classified as either acute or chronic. The former is a life-threatening emergency in which a sudden reduction in intestinal blood flow may ultimately result in bowel infarction. The most common causes are arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia, and mesenteric venous thrombosis. A high index of suspicion, early diagnosis and rapid intervention are necessary so that normal mesenteric perfusion is restored before fatal bowel infarction can occur. Chronic mesenteric ischemia is usually caused by stenotic or occlusive disease involving the proximal segments of the mesenteric arterial supply to the bowel, usually as a result of atherosclerosis. Intestinal angina is the classic presentation, defined as recurrent postprandial abdominal pain that subsides in 1 to 2 hours, with associated weight loss and aversion to food. When combined with the clinical presentation, physical examination, and laboratory data, imaging plays a key role in the diagnosis of either acute or chronic mesenteric ischemia. Recognition of pertinent imaging findings and various treatment options may aid in preventing the serious and possibly fatal sequelae that may occur in cases of mesenteric ischemia.

Acute occlusion of an abdominal aortic aneurysm is a rare phenomenon. Its possible complications include distal spasm followed by arterial thrombosis, ischemia of the distal limbs, distal embolization, acidosis, hyperkalemia, and the development of venous thrombosis of the lower limbs. Surgical correction is often complicated by cardiac decompensation, renal failure, fatal pulmonary embolism, and metabolic derangements related to toxins released from the revascularized limb. Unless contraindicated, immediate systemic heparinization must be undertaken when the diagnosis is first suspected.

We present a case of sudden occlusion of an abdominal aortic aneurysm complicated by venous thrombosis involving both lower extremities. After undergoing surgical revascularization, the patient sustained massive fatal pulmonary emboli. Prophylactic interruption of the inferior vena cava may be indicated in patients who present with this complication of abdominal aortic aneurysm.

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Introduction

Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery.

Case presentation

A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis.

Conclusion

Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.

Acute embolic occlusion of the common iliac artery is a rare medical emergency that is not only limb-threatening, but also potentially life-threatening. Several treatment options exist for acute limb ischemia, although no treatment is clearly best. We report a case of acute embolic occlusion of the left common iliac artery in a patient with atrial fibrillation who was treated successfully using mechanical thrombectomy following intra-arterial thrombolysis.

Introduction

Superior mesenteric artery syndrome is a rare cause of upper intestinal obstruction resulting from compression of the duodenum by the superior mesenteric artery and abdominal aorta.

Case presentation

We describe a case of superior mesenteric artery syndrome in a 61-year-old Japanese man with non-small cell lung cancer who had been treated with cisplatin-containing chemotherapy and had lost 7 kg in weight. The diagnosis was confirmed by the typical findings of abdominal computed tomography showing distended stomach resulting from compression of the third portion of the duodenum and reduction of an aortomesenteric distance and aortomesenteric angle.

Conclusions

This case highlights the importance of considering the possibility of superior mesenteric artery syndrome in patients treated with chemotherapy, especially those presenting with a low body mass index and showing weight loss during chemotherapy.

ABSTRACT

The Arc of Buhler (AOB) represents a persistence of the ventral anastomosis between the superior mesenteric artery (SMA) and the celiac arterial systems. The exact incidence of the AOB is not known, but it is believed to be ≤ 4%. Aneurysms of this rare anomaly are even more uncommon. We report a case of an aneurysm of the AOB with an intact pancreaticoduodenal artery arcade (PDAA) and near occlusive celiac origin stenosis. Stenoses or occlusions of the celiac origin have been reported in association with AOB aneurysms, as well as in patients with PDAA aneurysms. Transcatheter embolization (TCE) was successfully performed, thereby excluding the AOB aneurysm while preserving flow through the PDAA. To our knowledge, this is the first report of successful percutaneous treatment of an AOB aneurysm. The pathophysiology and management AOB and PDAA aneurysms are reviewed. Review of the literature suggests that TCE, when feasible, is at least as effective as conventional surgery in patients with PDAA aneurysms, but with lower morbidity and mortality. Based on this data and our experience, we believe that TCE should be the initial treatment of choice in patients with PDAA or AOB aneurysms.

Introduction

Ischemic bowel disease comprises both mesenteric ischemia and colonic ischemia. Mesenteric ischemia can be divided into acute and chronic ischemia. These are two separate entities, each with their specific clinical presentation and diagnostic and therapeutic modalities. However, diagnosis may be difficult due to the vague symptomatology and subtle signs.

Case presentation

We report the case of a 68-year-old Caucasian woman who presented with abdominal discomfort, anorexia, melena and fever. A physical examination revealed left lower quadrant tenderness and an irregular pulse. Computed tomography of her abdomen as well as computed tomography enterography, enteroscopy, angiography and small bowel enteroclysis demonstrated an ischemic jejunal segment caused by occlusion of a branch of the superior mesenteric artery. The ischemic segment was resected and an end-to-end anastomosis was performed. The diagnosis of segmental small bowel ischemia was confirmed by histopathological study.

Conclusion

Mesenteric ischemia is a pathology well-known by surgeons, gastroenterologists and radiologists. Acute and chronic mesenteric ischemia are two separate entities with their own specific clinical presentation, radiological signs and therapeutic modalities. We present the case of a patient with symptoms and signs of chronic mesenteric ischemia despite an acute etiology. To the best of our knowledge, this is the first report presenting a case of acute mesenteric ischemia with segmental superior mesenteric artery occlusion.

Coronary emboli are rare but devastating events. We present the case of a 31-year-old woman with peripartum cardiomyopathy and mural thrombus. She was admitted with an acute, non-ST elevation myocardial infarction. Two emboli were seen on the coronary angiogram: one in the left anterior descending coronary artery and a second in the left circumflex artery. Each embolus resolved after local infusion of eptifibatide at the time of angiography. There has been 1 report in the English-language medical literature of a similar coronary embolic event in the setting of peripartum cardiomyopathy; however, in that case, only 1 embolus was found. Our case further documents embolic coronary occlusion as a consequence of peripartum cardiomyopathy.

Isolated dissection of the superior mesenteric artery is a rare occurrence with a hitherto unknown exact etiology. Patients may present with abdominal symptoms or hemodynamic instability.

We herein present a case of spontaneous isolated superior mesenteric artery dissection in a 48-year-old man, who was admitted with epigastric pain. Due to an undiagnosed paced rhythm on the electrocardiogram, he was given fibrinolysis treatment for acute myocardial infarction. On further evaluation, angiography revealed that the cause of pain was the dissection of the superior mesenteric artery. The patient’s symptoms were diminished with conservative management, obviating the need for the angioplasty of the superior mesenteric artery.

INTRODUCTION

Vascular bullet embolism is a rare phenomenon with fewer than 200 cases reported in the literature.

PRESENTATION OF CASE

A 22 year-old male presented with a gunshot wound to the right lower quadrant. Imaging demonstrated a bullet lodged in his left lower quadrant. Upon operative exploration, a single hole was found in the right external iliac vein without injury into the left lower quadrant. The bullet was found to have migrated intravascularly from the right external to the left common iliac vein, and was subsequently removed endovascularly.

DISCUSSION

Bullet embolism occurs infrequently, with arterial more common than venous. Arterial embolization usually requires emergency operative intervention due to ischemia. While venous embolization is often asymptomatic, removal of the bullet is recommended to avoid delayed complications when possible.

CONCLUSION

Venous bullet emboli should be removed endovascularly whenever technically possible.

Background. Hemobilia is a rare, jeopardizing complication of laparoscopic cholecystectomy coming upon usually within 4 weeks after surgery. The first-line management is angiographic coil embolization of hepatic arteries, which is successful in the majority of bleedings: in a minority of cases, a second embolization or even laparotomy is needed. Case Presentation. We describe the case history of a patient in which laparoscopic cholecystectomy was complicated 3 weeks later by massive hemobilia. The cause of haemorrhage was a pseudoaneurysm of a right hepatic artery branching off the superior mesenteric artery; this complication was successfully managed by one-stage angiographic embolization with full recovery of the patient.

A 5 1/2-year experience of 147 patients with arterial embolism of the limbs is reported. The mean age was 66.9 years, range 24-90 years and the male to female ratio was 1.07 to 1. Two distinct types of embolic episode with very different clinical consequences were recognised. Type I (64%) in which large emboli occluded the proximal arteries of the lower limb. They were usually treated by embolectomy and were followed by death or permanent disability in 63% of patients. Type II (36%) in which small emboli occluded the arterial supply of the upper limb or the arteries of the distal lower limb. Embolectomy was performed in only 60% of cases. Death was unusual and disability occurred largely as a consequence of non-surgical management. After occlusion of the aorta, iliac or femoral arteries embolectomy is necessary to save both life and limb while after embolism of the arm or distal lower limb it is essential for the preservation of function.

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Thrombosis of the celiac artery trunk is a rare cause of acute abdominal pain. Thrombosis of the celiac artery carries a high mortality and morbidity when the diagnoses and treatment are delayed. It is frequently associated with other cardiovascular events. The most common etiology is atherosclerosis. 20–30% of cases may have symptoms of chronic mesenteric ischemia. Main goal of the treatment is to reestablish the diminished or stopped mesenteric blood flow and to avoid end-organ ischemia. Essential thrombocythemia is a chronic myeloproliferative disorder characterized by marked increase in thrombocyte number and clinical presentation may be with thrombotic episodes, hemorrhage, or both. To our knowledge this is the first report of celiac artery thrombosis and superior mesenteric artery stenoses in a patient with essential thrombocythemia. The patient was managed successfully with surgical treatment.

An extrahepatic arterioportal fistula (APF) involving the gastroduodenal artery and superior mesenteric vein is rare and mostly results from iatrogenic injuries. The clinical symptoms associated with APFs may include abdominal pain, gastrointestinal bleeding, ascites, nausea, vomiting, diarrhea, or even congestive heart failure. We present the case of a 70-year-old man who presented with chronic abdominal pain and gastrointestinal bleeding secondary to APF and portal vein thrombosis. The endovascular embolization of APF was accomplished successfully, and symptoms of portal hypertension resolved immediately after intervention. Unfortunately, the patient did not respond well to anticoagulation therapy with warfarin. Therefore, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt, and the complications of portal hypertension resolved. In conclusion, the embolization of APF is technically feasible and effective and can be considered the first-choice therapy in selected patients.

To report a case of acute superior mesenteric artery (SMA) embolism successfully treated with aspiration and pharmacological thrombolysis. A 74-year-old female was admitted to the hospital with acute abdominal pain 5 hours in duration. Computed tomography angiography revealed a complete embolic occlusion distal to the first jejunal branch of the SMA. Aspiration and local continuous thrombolysis with urokinase resulted in near complete revascularization of the mesenteric flow after 4 hours and almost complete restoration after 20 hours. The patient made a complete recovery and continues to do well on warfarin therapy after treatment. Aspiration and thrombolytic therapy can be an alternative treatment modality in surgical high risk patient.

Paradoxical emboli occur when venous embolic material passes into the arterial circulation (via a right-to-left cardiac shunt). The association of paradoxical emboli and arterial ischaemia has been described previously, especially with respect to cerebral infarcts. We describe a case in which double paradoxical emboli following a long haul flight, resulted in emergency amputation of an upper limb. Amputation resulting from a paradoxical embolus has not previously been described.

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A case of celiac artery embolism in a patient with factor V Leiden thrombophilia is reported. The embolism was likely due to an undetected cardiac thrombus, causing an abdominal aortic embolism. The patient underwent emergency surgery for the abdominal embolism. The celiac artery embolism was treated nonsurgically due to the presence of collateral circulation through the gastroduodenal artery from the superior mesenteric artery. The patient fully recovered and was discharged from the hospital one month after his first referral.

Introduction

Acute pulmonary embolism has varied presentations ranging from asymptomatic, incidentally discovered emboli to massive embolism, causing immediate death. Tumor embolism is a rare but unique complication of malignancies. This uncommon catastrophe of a malignant tumor in a young patient, culminating as a pulmonary embolism, is being reported for the first time.

Case presentation

A 19-year-old Asian man presented to the emergency service at our hospital with acute onset dyspnea. His clinical examination led to the suspicion of an acute pulmonary embolism with a lower lumbosacral radiculopathy. A magnetic resonance imaging scan of the pelvis demonstrated a chondrosarcoma arising from the right iliac wing, eroding into the common iliac vein and creeping up the inferior vena cava to lodge in the pulmonary artery, thus producing a saddle embolus.

Conclusion

The importance of exploring for malignancies in the event of an idiopathic pulmonary embolism is highlighted. Early detection of such malignancies can substantially affect the outcome in young patients.

A previously fit 37-year-old man developed superior mesenteric venous thrombosis after undergoing a laparoscopic Nissen fundoplication. Despite receiving thrombo-embolic prophylaxis on postoperative day 16, he presented with a gradual onset of vague, but severe, umbilical and epigastric pains. Laboratory tests, abdominal ultrasound scan and gastroscopy were all unremarkable. Contrast enhanced abdominal spiral computerised tomography (CT) revealed a partial occlusion of the superior mesenteric and portal vein due to a thrombus; abnormal flow was confirmed on colour Doppler ultrasound. A predisposing hyper-coagulable condition was excluded. The patient responded rapidly to expectant management and a repeat spiral CT scan, 3 weeks after the initial presentation, demonstrated complete re-canalisation of the vessel. Although rare, superior mesenteric venous thrombosis is probably underdiagnosed due to the vague nature of the symptoms, the lack of clinical signs, a low index of suspicion on the part of the clinician, and then subsequent failure to request the optimal investigation--namely contrast enhanced abdominal spiral CT scan. We discuss the possible mechanisms by which laparoscopic surgery may increase the risks of developing superior mesenteric venous thrombosis, the pitfalls in diagnosis and treatment options.

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Intravascular migration of bullets and other foreign bodies is a rare but known complication of penetrating trauma. Missile embolization can represent a diagnostic challenge because it may present in various and unexpected ways. We present the case of a 54-year-old female who sustained shotgun pellet emboli to the pulmonary arteries following a left upper extremity gunshot wound and related vascular surgery. The case illustrates bilateral embolization, and the embolic events occurred following surgery. Embolization should be considered in evaluating patients with gunshot wounds, particularly if there are anomalous symptoms or the projectile is not found in the original, or expected, location. Close attention to the location of the foreign bodies on serial radiographs may reveal the diagnosis of intravascular embolization.

Summary

Neonates presenting with intractable cardiac failure due to vein of Galen aneurysmal malformations (VGAMs) rapidly progress to multisystem organ failure and death if left untreated. Currently the only viable treatment option is endovascular embolization. Although intracranial embolization of a neonate is a high-risk procedure, successful treatment can reverse cardiac failure and prevent neurological complications associated with VGAMs. Embolization via the arterial route is thought to have a better outcome than embolization via the venous system. However, multiple transarterial embolizations in different sessions may well be contraindicated in neonates, because repeat access via the femoral artery, carries a risk of arterial trauma which, in turn, can jeopardize lower limbs. With this case study we show that after repeat failure of arterial embolization, the transcranial placement of an Amplatzer PFO occluder (AGA Medical, Plymouth, USA) in the aneurysm can effectively reduce intrafistular pressure and venous outflow velocity. We also propose a mathematical model that can be used to calculate flow velocity through the aneurysm, which, in turn, could be used to aid clinical decision-making. Unlike some conventional techniques, the placement of an Amplatzer occluder does not pose the risk of completely obstructing venous drainage and therefore does not increase the risk of venous breakthrough hemorrhage. We propose this endovascular technique as a treatment option for high risk neonates in need of emergency embolization of VGAMs, where multiple arterial embolizations failed to control the condition sufficiently.

Due to a lack of early symptoms, pancreatic cancers of the body and tail are discovered mostly at advanced stages. These locally advanced cancers often involve the celiac axis or the common hepatic artery and are therefore declared unresectable. The extended distal pancreatectomy with en bloc resection of the celiac artery may offer a chance of complete resection. We present the case of a 48-year-old female with pancreatic body cancer invading the celiac axis. The patient underwent laparoscopy to exclude hepatic and peritoneal metastasis. Subsequently, a selective embolization of the common hepatic artery was performed to enlarge arterial flow to the hepatobiliary system and the stomach via the pancreatoduodenal arcades from the superior mesenteric artery. Fifteen days after embolization, the extended distal pancreatectomy with splenectomy and en bloc resection of the celiac axis was carried out. The postoperative course was uneventful, and complete tumor resection was achieved. This case report and a review of the literature show the feasibility and safety of the extended distal pancreatectomy with en bloc resection of the celiac axis. A preoperative embolization of the celiac axis may avoid ischemia-related complications of the stomach or the liver.