Primary percutaneous aspiration and thrombolysis for the treatment of acute embolic superior mesenteric artery occlusion

Objectives:  

To evaluate technical success rate and clinical outcome of patients with acute embolic superior mesenteric artery (SMA) occlusion who were treated with primary percutaneous revascularization.     

直接经皮抽吸并溶栓术治疗急性栓塞性肠系膜上动脉闭塞

目的评估急性栓塞性肠系膜上动脉(SMA)闭塞病人,采用直接经皮穿刺行血运重建的成功率及临床效果。方法通过3个医学中心放射信息系统数据库,收集2001     

肠系膜上动脉分支栓塞的实验研究

目的　观察明胶海绵栓塞肠系膜上动脉 (SMA)分支后肠壁缺血改变程度 ,探讨最佳可栓塞动脉级别、最大可耐受栓塞范围以及栓塞剂颗粒的大小。方法　 2 0只犬随机分为 4组 ,采用 3F微导管以明胶海绵 (GEF)作为栓塞材料超选择栓塞肠系膜上动脉分支。A、B两组分别采用直径 5 0 0～ 1 0 0 0μm ,1mm× 2mm的GEF颗粒在SMA二级分支末梢段水平栓塞。C、D两组分别采用 1mm× 2mm的GEF颗粒在 2、3支毗邻的SMA二级分支末梢段水平栓塞。术后 2d处死动物 ,取栓塞动脉供血相应肠段及系膜 ,测量其长度 ,并行大体观察和病理学检查。结果　栓塞技术成功率 1 0 0 %。A组肠壁呈重度缺血坏死性改变。B组肠壁各层未见缺血性改变。C组肠壁各层呈现轻度缺血性改变。D组肠壁缺血呈移行改变。A、B两组栓塞范围的差异无显著性 (P >0 .0 5 ) ,B组与C组、C组与D组间栓塞范围差异均有显著性。结论　GEF作为栓塞剂 ,其大小应控制在 1mm× 2mm左右 ,栓塞部位最好选择在末级动脉弓前一级分支末梢 ,最大栓塞范围为相互毗邻的 2支末级动脉弓前一级分支     

Superior mesenteric artery balloon occlusion. A nonoperative model of small bowel ischemia in dogs

The purpose of this study was to develop a nonoperative animal model of small bowel ischemia that could be used for subsequent studies of intestinal ischemia. Ten mongrel dogs underwent balloon occlusion of their superior mesenteric artery after percutaneous insertion of a balloon tipped catheter through the femoral artery. Small bowel biopsies taken at various time intervals demonstrated mucosal congestion, hemorrhage, and sloughing consistent with classic small bowel ischemia. These changes consistently began 3 hours after occlusion with transmural necrosis and perforation occurring by 18 hours after occlusion. Fluoroscopy demonstrated little or no flow in the mesenteric circulation during balloon occlusion. This model provides a standard nonoperative approach for the induction of intestinal ischemia in dogs and could be a valuable tool in the study of intestinal ischemia.     

Experimental study on acute ischemic small bowel changes induced by superselective embolization of superior mesenteric artery branches with N-butyl cyanoacrylate

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Successful intraarterial recombinant tissue plasminogen activator therapy for acute embolic occlusion of the superior mesenteric artery

While there have been multiple reports of catheter-directed thrombolysis with streptokinase or urokinase for thromboembolic occlusion of the superior mesenteric artery (SMA), there has been only one previous report describing SMA thrombolysis using tissue plasminogen activator (rt-PA). We present a case of acute embolic occlusion of the SMA initially diagnosed by CT and then successfully treated with selective infusion of rt-PA.     

Percutaneous recanalization and stent placement in chronic proximal superior mesenteric artery occlusion

Atherosclerotic stenosis involving the proximal portion of at least two visceral arteries usually causes symptoms of intestinal ischemia and can lead to massive bowel infarction and death. This report describes a case of chronic proximal occlusion of the superior mesenteric artery (SMA) in a 51-year-old man, successfully treated by local catheter-directed thrombolytic therapy, followed by balloon dilatation and stent placement of the residual atherosclerotic stenosis. At 3 months follow-up, the patient was free of symptoms. This case shows that local thrombolytic therapy, percutaneous transluminal angioplasty and stent placement can be useful in the treatment of chronic atherosclerotic occlusion of the proximal SMA. Received 5 November 1996; Revision received 5 February 1997; Accepted 27 March 1997     

Computed tomographic diagnosis of superior mesenteric artery embolic thrombosis associated with renal and splenic infarction

We describe a case of apparent embolic thrombosis of the superior mesenteric artery that on computed tomography (CT) was noted unexpectedly, making the diagnosis of ischemic bowel disease straightforward. It occurred together with the typical CT findings of renal and splenic infarction. This diagnosis was verified by angiography that provided more information and was confirmed at surgery.     

Treatment of intestinal angina by percutaneous transluminal angioplasty of a superior mesenteric artery occlusion.

A 47-year-old woman with intestinal angina due to multiple visceral artery occlusions was treated surgically but suffered early thrombosis of an aorta-to-superior mesenteric artery (SMA) bypass graft and the return of her symptoms. Percutaneous transluminal angioplasty (PTA) of the occluded native origin of the SMA was successful. Three months later she is well and gaining weight. Several series of patients treated by PTA of superior mesenteric artery stenoses have been published, but to our knowledge this is the first report of the successful application of the technique to a complete SMA occlusion.     

Impact of MDCT with intravenous contrast on the survival in patients with acute superior mesenteric artery occlusion

Acute thromboembolic occlusion in the superior mesenteric artery (SMA) is a condition with high mortality and morbidity. Multi-detector computerised tomography with intravenous contrast enhancement (MDCTiv) may improve diagnostic accuracy and survival. Patients with acute SMA occlusion were identified between 2004 and 2008 at Malmö University Hospital, Sweden. Medical records were analysed. Each MDCTiv was re-evaluated. A total of 67 patients were identified with SMA occlusion, of which 36 were examined with MDCTiv and ten with plain MDCT without intravenous contrast. In all, 24 (67%) of the 36 patients were correctly diagnosed by MDCTiv at first evaluation. Clinical suspicion of intestinal ischemia followed by a distinct inquiry for intestinal ischemia was associated with trend for a higher rate of correct radiological diagnosis, 18 of 23 (78%), at first evaluation (0.06) but without affecting in-hospital survival (p?=?0.27). At re-evaluation, SMA occlusion was found in all cases with MDCTiv, whereas intestinal findings were present in half. In-hospital mortality rate was 42% for patients who underwent MDCTiv, which was significantly lower compared to 90% for the ten patients examined with plain MDCT (p?=?0.007) and 71% for patients not examined with MDCTiv or plain MDCT (p?=?0.031). Patients that underwent plain MDCT had higher levels of creatinine compared to those examined with MDCTiv (p?=?0.005). Patients who underwent intestinal revascularisation, endovascular or open, had higher survival rate (p?=?0.001). Examination with MDCTiv in patients with acute SMA occlusion was associated with survival benefit. Hence, MDCTiv seems to be the method of choice in the workup phase. Radiologists should routinely describe the mesenteric vessels in patients with acute abdomen even when the diagnosis is not asked for. Patients with high creatinine levels are at risk to be examined without intravenous contrast, and survival in these patients is poor.     

Angioplasty and stenting of the superior mesenteric artery in acute mesenteric ischaemia

Acute mesenteric ischaemia is a challenging diagnostic problem with a very high mortality. Traditionally, laparotomy is required for definitive management. We describe a successful case of angioplasty and stenting of the superior mesenteric artery in a surgically unfit patient. We recommend that stenting be considered only in situations where the diagnosis has been made prior to bowel infarction, and if the patient poses a poor operative risk.     

Embolization of meningohypophyseal and inferolateral branches of the cavernous internal carotid artery.

BACKGROUND AND PURPOSE: Despite the continued improvements in endovascular techniques this decade, few dedicated studies addressing the feasibility of such procedures or their efficacy relative to risk have been conducted. The purpose of this study was to use current endovascular techniques to assess the feasibility, effectiveness, and safety of direct selective catheterization and embolization of the small branches of the cavernous segment of the internal carotid artery. METHODS: We retrospectively reviewed the findings in 10 patients with lesions (five meningiomas and five arteriovenous malformations) primarily or partly supplied by branches of the meningohypophyseal trunk or inferolateral trunk who had undergone endovascular embolization of the feeding arteries during the period from 1991 to 1997. In each case, the artery was selectively catheterized with a microcatheter/microguidewire system and embolized with polyvinyl alcohol particles (n = 5), n-butyl cyanoacrylate tissue adhesive (n = 4), or both (n = 1). RESULTS: In all 10 patients, the feeding artery from the meningohypophyseal trunk (eight patients) or inferolateral trunk (three patients; one patient with both) was successfully catheterized and embolized. In nine patients, embolization resulted in complete obliteration of the vascular territory; in the remaining patient, blood supply was decreased by an estimated 80%. No immediate or delayed complications occurred. CONCLUSION: Advances in microcatheter and microguidewire technology allow more efficient and safer selective catheterization and embolization of branches of the cavernous segment of the internal carotid artery than in the recent past. Meticulous technique and detailed knowledge of the vascular anatomy of the cavernous sinus region are necessary to maximize lesion devascularization and to minimize the risk of stroke, cranial nerve palsies, and blindness.     

肠系膜上动脉-腹主动脉夹角在孤立性肠系膜上动脉夹层中的意义

目的探讨肠系膜上动脉(SMA)-腹主动脉(AA)夹角在孤立性肠系膜上动脉夹层(ISMAD)中的意义。方法回顾性分析2010年1月至2019年8月常州市第二人民医院收治的58例ISMAD患者临床和影像资料。采用1∶4病例对照研究设计,对照组纳入同期232例非ISMAD患者。对比两组患者间SMA-AA夹角。根据SMA-AA夹角分布,分为<50°组(n=18)、50～70°组(n=28)、>70°组(n=12),统计组间比值比(OR)。结果 ISMAD组、对照组患者间年龄、性别、体质量指数(BMI)差异均无统计学意义(均P>0.05)。ISMAD组、对照组SMA-AA夹角分别为(58.6±16.5)°、(48.1±16.9)°,差异有统计学意义(P<0.01)。SMA-AA夹角组间比较,差异均有统计学意义(<50°比50～70°:OR=2.324,P=0.011;<50°比>70°:OR=4.233,P=0.001)。SMA-AA夹角判断ISMAD发生的受试者工作特征曲线下面积(AUC)为0.656(P<0.001),灵敏度为81.03%,特异...     

Magnetic resonance imaging of bowel ischemia induced by ligation of superior mesenteric artery and vein in a cat model

OBJECTIVE: To assess the usefulness of magnetic resonance (MR) imaging for detecting bowel ischemia with strangulation compared with histopathologic findings in an experimental cat model. MATERIALS AND METHODS: Fourteen cats were assigned to the normal control group (n = 3), acute ischemic group (induced by ligation of superior mesenteric vessels for 3 hours, n = 7), and subacute ischemic group (induced by ligation of superior mesenteric vessels for 10 hours, n = 4). Using a 4.7-T MR scanner, contrast-enhanced T1-weighted images were obtained at 0, 10, 20, 30, and 60 minutes after bolus injection of contrast media. T1- and T2-weighted images were obtained from the extracted bowel wall and compared with histopathologic findings. RESULTS: On contrast-enhanced MR images, the target-like bowel wall layers were clearly demonstrated and the submucosal layer showed the most prominent enhancement. At 10 minutes after administration of contrast media, the subacute ischemic group showed significantly lower enhancement of the submucosal layer than the normal or acute ischemic group (P <0.05). On T1-weighted images, there were not significant differences between the normal and ischemic bowel groups (P >0.05). On T2-weighted images, the signal intensity of all layers of acute ischemic bowel wall was significantly higher than that of the normal control or subacute ischemic group (P <0.05). CONCLUSION: Delayed contrast-enhanced MR images and T2-weighted images were helpful for detecting subacute and acute bowel ischemia with strangulation, respectively.     

Doppler sonography of hemodynamic changes of the inferior mesenteric artery in inflammatory bowel disease: preliminary data.

OBJECTIVE: To our knowledge, Doppler data for the inferior mesenteric artery are currently restricted to healthy patients. The present study was conducted to evaluate changes in inferior mesenteric artery flow in patients with inflammatory bowel disease. SUBJECTS AND METHODS: Doppler sonography of the inferior mesenteric artery was prospectively performed in 24 patients with Crohn's disease (active, n = 15; inactive, n = 9), in 22 patients with ulcerative colitis (active, n = 14; inactive, n = 8), and in 40 healthy controls. Disease activity was determined with clinical and laboratory indicators (medical history, physical examination, laboratory data, and endoscopy with histology). Flow velocity, pulsatility index, and estimated flow volume were measured in all patients and compared with the corresponding values for control subjects. Hemodynamic parameters were then correlated with location of disease (small bowel and right and proximal transverse colon versus distal transverse and left colon) and disease activity or inactivity. RESULTS: Among patients with active disease, inferior mesenteric artery flow was significantly greater in those with left colon involvement (group 1, 20 patients) than in patients with involvement of the small bowel or right colon (group 2, nine patients) and in control subjects. Median flow values for group 1 were peak systolic velocity, 1.96+/-0.57 m/sec; mean velocity, 0.63+/-0.25 m/sec; minimum velocity, 0.17+/-0.20 m/sec; pulsatility index, 3.07+/-1.24; and estimated flow volume, 0.40+/-0.17 l/min. Median flow values for group 2 were peak systolic velocity, 1.27+/-0.56 m/sec; mean velocity, 0.29+/-0.14 m/sec; minimum velocity, 0.06+/-0.10 m/sec; pulsatility index, 4.71+/-0.98; and estimated flow volume, 0.14+/-0.11 l/min. Median flow values for control subjects were peak systolic velocity, 1.41+/-0.48 m/sec; mean velocity, 0.43+/-0.19 m/sec; minimum velocity, 0.10+/-0.16 m/sec; pulsatility index, 3.49+/-0.49; and estimated flow volume, 0.13+/-0.06 l/min. Compared with control subjects, patients with acute disease involving the left colon (group 1) presented increases in flow velocity (systolic velocity, p < .001; minimum velocity, p = .01; mean velocity, p < .001) and estimated flow volume (p < .001) and a decreased pulsatility index (p = .01). A significant increase in inferior mesenteric artery flow was also found when group 1 patients were compared with those of group 2 (active disease affecting the small bowel and right colon) and group 3 (13 patients with quiescent disease of the left colon). CONCLUSION: In this preliminary study, active inflammation of the left colon in patients with Crohn's disease or with ulcerative colitis was associated with a substantial increase in inferior mesenteric artery flow that could be seen on Doppler sonography.     

肝癌合并腹腔动脉与肠系膜上动脉侧支循环通路假性闭塞(附12例报告)

目的：探讨肝癌合并腹腔动脉与肠系膜上动脉侧支循环通路假性闭塞的血管造影表现及其在介入治疗中的价值。方法：回顾性分析12例该类患者的肠系膜上动脉造影，腹腔动脉造影及介入治疗资料。结果：12例假性闭塞中，位于肝总动脉与腹腔动脉分叉处6例，肝总动脉分出胃十二指肠动脉支处5例，1例右肝动脉直接起源于腹腔动脉，并在其分叉处发生假性闭塞。在这12处假性闭塞中，于腹腔动脉造影时呈闭塞状态，而肠系膜上动脉造影却完全通畅，似静脉瓣样。并且导丝、导管能顺利通过该闭塞处。10例患者完成了肝动脉化疗栓塞术。结论：这一少见现象可能与其血液动力学改变和解剖学变异有关，了解此征象对于指导介入治疗有一定价值。     

上腔静脉及其主要属支静脉狭窄或闭塞介入治疗的研究

目的 探讨上腔静脉及其主要属支静脉狭窄或闭塞的介入治疗方法和疗效.方法 搜集2000年10月至2010年10月期间因上腔静脉及其主要属支狭窄或闭塞接受介入治疗的患者60例,男38例、女22例,年龄15～72岁,平均(58±4)岁.17例患者给予单纯球囊扩张,43例给予球囊扩张加支架置入术.治疗前后测量梗阻流入侧血管内压力,结果的比较用配对t检验.结果 60例患者血管成形后,梗阻流入侧测得静脉压力在狭窄开通前为(24.8±2.3)mm Hg(1 mm Hg=0.133 kPa),开通后为(7.1±1.5)mm Hg,差异有统计学意义(t=3.232,P＜0.01);临床症状完全缓解27例,部分缓解28例,无效5例;无严重并发症发生.随访6个月,出现再狭窄10例,经再次介入后再通6例,4例转外科手术.结论 对上腔静脉及其属支静脉狭窄或闭塞行介入治疗可以迅速解除梗阻,恢复血流通畅,降低梗阻远端静脉的压力,缓解临床症状.

Abstract：

Objective To assess the different methods and their outcomes of interventional therapy for stenosis or occlusion in superior vena cava and its branches. Methods Sixty patients with stenosis or occlusion of SVC and its branches were retrospectively analyzed after interventional therapy. Among them, 38 were males and 22 were females, with age range from 15 to 72 years old(mean age 58). Seventeen patients were treated by thrombolysis, and the rest 43 patients accepted percutaneous angioplasty and stenting. Before and after that, the pressures within the vein were measured at the inflow side. The paired-t test was used for statistical analysis. Results After treatment, the pressure at the inflow side dropped from (24.8±2.3)mm Hg to (7.1±1.5)mm Hg(1 mm Hg=0.133 kPa), with a significant difference(t=3.232,P＜0.01). The clinical outcomes included complete relief in 27 patients, partial relief in 28 patients and non-relief in 5 patients. No major complications occurred. During 6 months follow up, restenosis occurred in 10 patients, among whom 6 received repeat intervention with good results. The other 4 patients turned to surgery .Conclusion Interventional therapy for stenosis or occlusion in SVC and its branches could recanalize the vessels, restore the blood flow and relief the clinical symptoms.