Treatment of superior mesenteric and portal vein thrombosis with direct thrombolytic infusion via an operatively placed mesenteric catheter

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.     

Portal vein thrombosis after laparoscopic colectomy: thrombolytic therapy via the superior mesenteric vein

Portal vein thrombosis is a rare but well-reported complication after laparoscopic surgery. We present a case of portomesenteric venous thrombosis that occurred 8 days after a laparoscopic-assisted right hemicolectomy. Systemic anticoagulation failed to improve symptoms. The early postoperative state precluded the use of transarterial thrombolytic therapy. Transjugular intrahepatic catheter-directed infusion of urokinase into the superior mesenteric vein resulted in clearance of thrombus and resolution of symptoms. The published data on laparoscopy-induced splanchnic venous thrombosis and transjugular intrahepatic intramesenteric thrombolysis are discussed.     

急性肠系膜上静脉血栓形成的手术及介入治疗

目的 探讨急性肠系膜上静脉血栓形成的治疗方法.方法 2006年10月至2012年2月共收治31例急性肠系膜上静脉血栓形成的患者,分别做了坏死小肠切除及肠系膜上静脉切开取栓或经肠系膜上动脉置管间接肠系膜上静脉溶栓治疗,分析2种治疗方式的疗效及适应证.结果 外科手术治疗9例,其中6例术后痊愈,3例因消化道出血无法抗凝、溶栓,术后仍有腹胀,造影可见肠系膜上静脉内血栓残留;介入治疗22例中有17例术后72h内症状明显改善,其余症状改善时间为术后5～7d.2例置管溶栓过程中并发少量消化道出血,终止溶栓治疗;1例置管溶栓48 h后腹痛症状加重,中转开腹手术.本组随访25例(81％),随访时间5 ～35个月,平均(19±5)个月.20例无腹胀、腹痛,3例有饱食后腹部胀满感.结论 合理选择急性肠系膜上静脉血栓治疗适应证是取得良好疗效的关键,肠系膜上动脉置管间接肠系膜上静脉溶栓是一种操作简单、风险较小、疗效确切的方法.     

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.     

Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator

Portal and mesenteric venous thrombosis is an uncommon condition that is usually treated with systemic anticoagulation. Catheter-directed thrombolysis via the superior mesenteric artery may be a viable adjunct to treatment of this potentially morbid condition. We present a case of portal and mesenteric venous thrombosis treated with systemic anticoagulation and catheter-directed infusion of tissue plasminogen activator via the superior mesenteric artery.     

急性和亚急性肠系膜上静脉-门静脉血栓的介入治疗

目的评价介入技术治疗急性和亚急性肠系膜上静脉（superior mesenteric vein，SMV）-门静脉（portal vein，PV）血栓形成的疗效。方法对21例急性和亚急性SMV—PV血栓形成患者进行介入治疗。选择经颈静脉途径经肝穿刺门静脉[即通过经颈静脉肝内门脉系统分流术（transjugular intrahepatic portosystemic shuntapproach，TIPS途径）]介入治疗（12例）和经导管肠系膜上动脉（superior mesenteric artery，SMA）溶栓治疗（9例）。结果治疗成功19例，无严重并发症。11例经TIPS途径治疗的患者于治疗结束时造影显示大部分血栓被清除，门静脉系统有血流通过，临床症状缓解。1例虽然SMV—PV恢复血流，但12d后死于腹腔脓肿、MODS。经导管SMA内溶栓治疗9例，术后症状逐渐改善8例，无效1例。结论经TIPS途径介入技术和经导管SMA溶栓是治疗急性和亚急性SMV—PV血栓形成的有效方法。     

Lysis therapy of thrombosis of the superior mesenteric artery

INTRODUCTION: For surgeons the acute intestinal ischaemia is still a diagnostic and therapeutic challenge. If clinically suspected, the diagnostic procedures such as duplex sonography and arterial angiography should be carried out immediately. Although the diagnosis is often quickly clear, perioperative mortality rate remains high. We report the acute local thrombolytic therapy as an alternative treatment. CASE REPORT: A 80-year-old male patient was referred to our hospital with a complete occlusion of the superior mesenteric artery. Duplex sonography and the arterial angiogram confirmed the clinical diagnosis. Because the patient was assessed to be at high risk we decided to avoid an operation and local thrombolytic therapy using rt-PA and urokinase was carried out. RESULT: The local thrombolytic therapy was successful and led to a complete restoration of the arterial flow within the superior mesenteric artery. The clinical symptoms subsided and no complications were observed. CONCLUSION: Local thrombolytic therapy appears to be a suitable therapeutic option in patients suffering of mesenteric arterial occlusion. Although the duplex sonography often confirms the diagnosis with high accuracy the angiography remains the diagnostic gold standard.     

急性肠系膜上静脉血栓形成的诊断与治疗

目的 加深对急性肠系膜上静脉血栓形成(AMVT)导致急腹症严重性的认识,探讨提高疗效的措施。方法 对13例AMVT临床特点、治疗方法和效果进行分析比较。结果 入院均诊断为急腹症,但术前能确诊仅2例,拟诊1例,行小肠部分切除11例,其中小肠广泛切除3例,仅作剖腹探查2例。治愈10例,死亡3例。随诊3个月～14年,无复发,无短肠综合征发生。结论 AMVT临床表现无特异性,术前确诊困难。腹痛与腹部体征不符、WBC大于20×10~9/L时应警惕本病。彩色多普勒对诊断有较大帮助。充分认识此病,争取早期诊断及时手术是提高疗效关键,术后抗凝溶栓可防止复发。     

肝移植中门静脉-内脏曲张静脉吻合在门静脉机化血栓患者的应用

目的:探讨门静脉-内脏曲张静脉吻合在门静脉机化血栓患者肝移植中的应用。方法:对门静脉和肠系膜上静脉均完全被机化血栓阻塞的7例患者实施肝移植,其中3例供体门静脉-曲张冠状静脉吻合;2例髂静脉搭桥供体门静脉和脾门旁曲张的静脉吻合;1例采用供体门静脉-胆总管前曲张静脉吻合;1例供体门静脉—曲张的胃网膜右静脉吻合。结果:7例手术全部成功。1例术后7d死于多脏器功能衰竭,但是门静脉血流一直通畅。1例术后6个月发现吻合口狭窄,术后9个月采用经皮肝穿刺门静脉支架置入治愈;其余患者分别随访12～22个月,门静脉血流均通畅,无狭窄或血栓形成,肝、肾功能正常。结论:肝移植中对门静脉和肠系膜上静脉均完全被机化血栓阻塞的患者,行供体门静脉-曲张内脏静脉吻合可取得良好疗效。     

术中取栓联合导管溶栓治疗急性肠系膜上静脉血栓形成

目的探讨经肠系膜上静脉取栓联合导管溶栓治疗急性肠系膜上静脉血栓形成（AMVT）的疗效。 方法回顾性分析2013年9月至2018年10月内蒙古鄂尔多斯市中心医院收治的12例AMVT小肠坏死、肠切除的患者临床资料,术中应用Fogarty经肠系膜上静脉取栓加术后溶栓。 结果患者治愈出院11例（91.7%）,死亡1例（8.3%）。治愈患者术后无肠瘘、短肠综合征、肠系膜静脉血栓复发等并发症出现,无再次手术。 结论术中经肠系膜上静脉取栓联合导管术后溶栓治疗AMVT简单易行,临床效果良好,联合后续抗凝等预防性治疗,可明显提高患者的生存率。     

肠系膜上动脉阻断技术在胰头癌联合门静脉切除中的应用

胰头癌是一种高度恶性的消化系统肿瘤,手术切除是目前唯一有效的治疗方法,能否对其实施根治性的R0切除是决定胰头癌患者远期生存效果的关键。讲者系统性回顾分析了胰头癌手术中影响R0切除效果的诸多因素,包括肿瘤的后腹膜神经侵犯、胰包膜侵犯、血管侵犯、切缘阳性以及淋巴结转移等,尤其对因肿瘤血管侵犯导致R0切除的难度和风险作了详尽阐述,并详细介绍了肠系膜上动脉（superior mesenteric artery,SMA）阻断技术在胰头癌联合门静脉切除中的应用,该技术可以充分保障血管吻合时间,并能有效减少术中出血,为实施R0切除创造有利条件。视频演示了其手术过程。     

Coronary artery bypass surgery following thrombolytic therapy for acute coronary thrombosis

One hundred thirty-six patients underwent thrombolytic therapy for acute evolving myocardial infarction from June, 1981, through December, 1982. Of these patients, 51 underwent coronary bypass procedures from two hours to 90 days (average, 16 days) following thrombolytic therapy. Six (12%) had single-vessel disease, 15 (29%) had double-vessel disease, and 30 (59%) had triple-vessel involvement. Ejection fraction values ranged from 21 to 60%. The average number of grafts performed per patient was 3.4. There were no operative deaths in this series. Postoperative hemorrhagic problems were minimal, and the incidences were no different from those for other coronary bypass patients. In follow-up ranging from 2 to 18 months, there was no recurrence of severe angina or other clinical evidence of saphenous graft occlusion in the thrombolysed vessels. Of the 45 patients eligible to return to work, 40 (89%) have done so. The data from this series suggest that surgical myocardial revascularization after intracoronary thrombolytic infusion for acute myocardial infarction can be performed safely and that complete recovery and a high return-to-work ratio can be anticipated.     

肠系膜上动脉狭窄的血管腔内治疗

目的探讨介入治疗肠系膜上动脉狭窄的安全性及临床疗效。方法对12例肠系膜上动脉狭窄的患者行选择性肠系膜上动脉造影,然后行球囊扩张或支架植入治疗,评价疗效。结果 12例肠系膜上动脉狭窄的患者技术成功率100%,其中单纯球囊扩张2例,球囊扩张+内支架植入术10例。对所有患者随访6~24个月,平均16个月,其中10例无明显症状,2例有腹痛症状,经再次腔内治疗,症状得到明显改善。随访中所有患者均未出现肠坏死、死亡等严重并发症。结论血管腔内介入治疗肠系膜上动脉狭窄是一种安全、有效的方法。     

联合门静脉和肠系膜上静脉切除重建的胰十二指肠切除术

The majority of the pancreatic cancer was diagnosed at advanced stage.The tumor may invade portal vein and/or superior mesenteric vein.Moore et al.firstly reported pancreaticoduodenectomy combined with...     

肝移植术后门静脉狭窄-肠系膜上静脉血栓的影像诊断

Portal vein stricture complicated with superior mesenteric venous thrombosis is rarely seen in clinical practice. On December 26, 2009, a 51-year-old male patient who had a liver transplantation history was admitted to The General Hospital of Chinese People's Armed Police Forces with the chief complaint of intermittent abdominal pain and diarrhea.A plain and enhanced CT scan showed that the portal vein was constrictive and thrombosis had formed in the main trunk of the superior mesenteric vein, and varicose veins were seen in surrounding tissues of the esophagus. Edema was observed at the end of the ileum and cecum. The results of colonoscopy showed inflammatory changes and varicose veins of the colon. The patient received medical treatment. The thrombosis was dissolved 9 days later, and all symptoms disappeared 12 days later.     

动脉溶栓治疗急性肠系膜上静脉血栓1例

正患者男,64岁,10h前无诱因突感上腹腹胀不适,进食后加重,排气正常,排便1次,排便后症状未缓解;既往无特殊病史。查体:腹平软,全腹部压痛,以脐周明显,无反跳痛,肠鸣音亢进。血常规:白细胞14.61×109/L,中性粒细胞13.41×109/L。腹部CT示小肠肠壁增厚、水肿,管腔部分扩张、积液,可见气液平面,中下腹部肠系膜水肿;肠系膜上动脉尚通畅,远端部分管腔变细、扭曲,肠系膜上静脉远端充盈缺损(图1A),符合肠系膜上静脉血栓形成(superior mesenteric venous thrombosis,SMVT)。     

医源性门静脉和肠系膜上静脉损伤的紧急处理

目的 探讨医源性门静脉和肠系膜上静脉损伤的紧急处理和预防.方法 回顾性分析医源性门静脉和肠系膜上静脉损伤的致伤原因及术中治疗经过,并就预防进行了探讨.结果 该组7例,其中门静脉损伤2例,肠系膜上静脉损伤5例.5例采用pringle手法暂时压迫止血后,用5-0血管缝线缝合修补破口,出血控制;2例因操作粗暴,胡乱钳夹,最终死亡.结论 预防上述血管损伤及预先游离周围组织至关重要,一旦损伤,应冷静沉着,暂时压迫止血后,用血管缝线缝合修补破口,止血效果好,是确实有效的方法.禁止胡乱钳夹止血.