- Email: [email protected]
Endovascular treatment of a superior mesenteric artery embolism in a high-risk Jehovah's Witness
From the Midwestern Vascular Surgical Society
Endovascular treatment of a superior mesenteric artery embolism in a high-risk Jehovah’s Witness Christopher W. Seder, MD,a Michael Kramer, BS,b Maciej R. Uzieblo, MD,b and Paul Bove, MD,b Royal Oak, Mich Despite recent advances, emergent treatment of acute mesenteric ischemia carries a mortality of 40%-60%. Endovascular therapy provides a reasonable option for high-risk patients with acute mesenteric ischemia who may not tolerate a laparotomy. We present a case of successful endovascular embolectomy of the superior mesenteric artery, visceral aorta, and right iliac artery in a high-risk octogenarian who refused the transfusion of blood products. As older patients present with more comorbidities, endovascular techniques will play an increasingly large role in the treatment of acute mesenteric ischemia. ( J Vasc Surg 2009;49:1050-2.)
Acute mesenteric ischemia (AMI) is generally caused by an embolic or thrombotic occlusion of the superior mesenteric artery (SMA). Despite recent technological advances, emergent treatment of AMI carries a mortality of 40%60%.1-3 Currently, the gold standard for treatment is exploratory laparotomy and surgical removal of the clot. However, with the evolution of endovascular techniques, patients in whom open embolectomy would be exceedingly dangerous are being considered for catheter-based treatment. We present a case of successful endovascular embolectomy of the superior mesenteric artery, visceral aorta, and right iliac artery in a high-risk octogenarian who refused the transfusion of blood products. CASE REPORT The patient was an 83-year-old Jehovah’s Witness with a past medical history significant for hypertension, diabetes mellitus, chronic atrial flutter, and congestive heart failure who presented to our emergency center with generalized weakness and vague abdominal pain. She had an ejection fraction of 60% and a recent stress test that demonstrated a small, fixed defect in the midanteroseptal wall. Following an extensive work-up, she was found to have second-degree heart block, was placed on intravenous heparin, and was scheduled for pacemaker placement. She was not on oral anticoagulants prior to admission. On hospital day six, prior to pacemaker placement, her abdominal pain worsened and she developed right-sided leg pain. The pain was not associated with hematemesis, melena, or peritonitis. She became febrile and developed a leukocytosis to 24,400/l. Her admission blood urea nitrogen (BUN) and creatinine were 32 mg/dL and 1.1 mg/dL, with an estimated admission glomerular filtration rate (GFR) of 57 ml/min. This rose to 33 mg/dL and 1.8 mg/dL (GFR ⫽ 33 ml/min), respectively. Mesenteric ischemia was suspected, thereFrom the Department of Surgery, Section of Generala and Vascularb Surgery, William Beaumont Hospitals. Competition of interest: none. Presented at the Thirty-second Annual Meeting of the Midwestern Vascular Surgical Society, Madison, Wis, Sep 11-13, 2008. Reprint requests: Paul Bove, MD, 3601 W. 13 Mile Rd, Vascular Services Center, Royal Oak, MI 48073 (e-mail: [email protected]). 0741-5214/$36.00 Copyright © 2009 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2008.11.051
1050
Fig 1. Computed tomography demonstrating the visceral aortic and right renal artery embolism.
fore she was placed on wide-spectrum antibiotics and a vascular surgery consultation was obtained. Dynamic contrast-enhanced computed tomography revealed a mid-aortic thrombus with occlusion of the right renal, superior mesenteric (SMA), and right common iliac artery (Fig 1). Due to her advanced age and comorbid conditions, we felt an endovascular embolectomy without thombolysis would provide her with the best opportunity for recovery, as blood loss from thrombolytic-induced hemorrhage and open SMA venting could be avoided. She was taken to the operating room within eight hours of consultation. We gained access through bilateral femoral artery cut-downs to protect against distal emboli and to provide access for both an aortic embolectomy catheter and a left renal-occlusive catheter. An anterior-posterior aortogram confirmed a non-occlusive thrombus in the visceral aorta that extended into the right common iliac artery. Although the right renal artery and SMA were occluded, the left renal and celiac arteries were patent (Fig 2). A small amount of SMA filling was noted via collateral vessels. An angled Glidewire (Terumo, Ann Arbor, Mich) was advanced through a right-sided sheath, the thrombus was negotiated, and a Kumpe
JOURNAL OF VASCULAR SURGERY Volume 49, Number 4
Fig 2. Initial aortogram demonstrating visceral aortic, superior mesenteric artery, and right renal artery embolus involvement.
(Cook, Bloomington, Ind) catheter was used to select the left renal artery. A #4 French over-the-wire Fogarty balloon was advanced over a V18 wire (Boston Scientific, Natick, Mass) and inflated to protect the left kidney from emboli. An adequate length was advanced into the renal artery to prevent dislodgement during the aortic embolectomy. The left femoral sheath was converted to a #12 French sheath, through which a Reliant balloon (Medtronic, Santa Rosa, Calif) was used to perform a visceral aortic embolectomy via a transverse arteriotomy. A moderate amount of clot was returned; pathologic examination of the specimen revealed fresh and organized clot. The SMA was then cannulated with an RDC catheter (Medtronic), followed with a V18 wire, and a #4 Fogarty was used to perform an SMA embolectomy. The left kidney was re-perfused after a warm-ischemia time of approximately 25 minutes. A lateral SMA angiogram revealed residual ostial narrowing, therefore we converted to a 0.035-inch platform and a 6 ⫻ 18 mm balloon-expandable Palmaz Genesis stent (Cordis, Warren, NJ) was advanced into the SMA and deployed. Follow-up angiogram demonstrated continued ostial narrowing and a 70 mm Hg gradient. Due to stent availability, the SMA was reselected with a 0.018-inch platform and an overlapping 6 ⫻ 20 mm Palmaz Blue stent was deployed with slight extension into the aorta. The Fogarty catheter in the left renal artery was deflated, and repeat angiogram revealed brisk antegrade flow through the recannulated SMA (Fig 3), celiac, and left renal arteries. The right renal artery was deemed unsalvageable due to the absence of blood flow on computed tomography (CT) scan and the presence of ischemic symptoms for approximately six days prior to vascular surgical consultation. Bilateral common femoral embolectomies via the transverse arteriotomies, using #4 and #5 regular Fogarty cathe-
Seder et al 1051
Fig 3. Superior mesenteric artery angiogram demonstrating successful revascularization with embolectomy and stenting. ters, produced a moderate amount of clot. Follow-up angiogram revealed patent bilateral common iliac and hypogastric arteries, both femoral arteries had strong pulses, and both feet demonstrated brisk capillary refill. The procedure took approximately 300 minutes, 270 mL of contrast was injected, and the blood loss was 300 mL. No cell salvage was used. Postoperatively, she developed oliguric renal failure, with her BUN and creatinine rising to a maximum of 62 mg/dL and 3.6 mg/dL (GFR ⫽ 16 ml/min), respectively. However, her urine output improved to greater than 0.5 ml/kg/hr and her BUN and creatinine returned to admission levels without need for dialysis. She never required transfusion of blood products, although her postoperative hemoglobin did drop from a baseline of 9.4 g/dL to as low as 6.2 g/dL. Six weeks after her combined open-endovascular SMA embolectomy, the patient was discharged on warfarin to a subacute rehabilitation center. She never received a pacemaker. Based on 27 months of clinical followup, the patient has had no complications; however, no imaging studies have been performed to confirm the patency of the SMA.
DISCUSSION As medicine has evolved, the proportion of patients with multiple comorbidities has risen. Endovascular techniques provide a treatment option for this emerging patient population who may not tolerate the morbidity associated with open repair. Although limited to case reports,4-6 it seems intuitive that the high perioperative mortality associated with open repair in AMI could be lowered with endovascular therapy, especially in high-risk subgroups. In a review of 132 patients who underwent open repair for AMI, previous cardiac illness (P ⫽ .045), plasma urea levels (P ⬍ .001), and small and large bowel involvement were identified as independent risk factors of perioperative mor-
JOURNAL OF VASCULAR SURGERY April 2009
1052 Seder et al
tality.7 Our patient had both cardiac arrhythmias and acute renal insufficiency (although no reports identified renal emboli as a risk factor), making her a high-risk candidate for open surgery. These factors combined with her refusal of blood products prompted us to attempt an endovascular approach to her AMI. Currently, there is no definitive evidence supporting the use of an endovascular approach in acute or chronic mesenteric ischemia. If there is any doubt regarding the viability of the bowel, it must be examined via laparotomy or laparoscopy. In the 48 hours following surgery, our patient’s abdomen became significantly less tender and distended. A patient must be monitored closely and demonstrate signs of ongoing clinical improvement for at least 48 hours prior to determining that the patient has no irreversible bowel injury. This period allows enough time for infarcted bowel to manifest itself as pain, leukocytosis, or hemodynamic instability. As older patients present with more comorbidities, endovascular techniques are likely to play an increasingly large role in the treatment of acute mesenteric ischemia. AUTHOR CONTRIBUTIONS Conception and design: CS, PB Analysis and interpretation: CS, MK, MU, PB Data collection: CS, MK, PB Writing the article: CS, MK, PB Critical revision of the article: CS, MK, MU, PB
Final approval of the article: CS, MK, MU, PB Statistical analysis: N/A Obtained funding: N/A Overall responsibility: CS REFERENCES 1. Park WM, Gloviczki P, Cherry KJ Jr, Hallett JW Jr, Bower TC, Panneton JM, et al. Contemporary management of acute mesenteric ischemia: factors associated with survival. J Vasc Surg 2002;35:445-52. 2. Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer RM Jr. Surgical management of thrombotic acute intestinal ischemia. Ann Surg 2001;233:801-8. 3. Foley MI, Moneta GL, Abou-Zamzam AM Jr, Edwards JM, Taylor LM Jr, Yeager RA, et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg 2000;32:37-47. 4. Wakabayashi H, Shiode T, Kurose M, Moritani H, Fujiki S, Morimoto N, Kusachi S. Emergent treatment of acute embolic superior mesenteric ischemia with combination of thrombolysis and angioplasty: report of two cases. Cardiovasc Intervent Radiol 2004;27:389-93. 5. Yilmaz, Gurkan A, Erdogan O, Sindel T, Ceken K, Luleci E. Endovascular treatment of an acute superior mesenteric artery occlusion following failed surgical embolectomy. J Endovasc Ther 2003;10:386-91. 6. Loomer DC, Johnson SP, Diffin DC, Demaioribus CA. Superior mesenteric artery stent placement in a patient with acute mesenteric ischemia. J Vasc Interv Radiol 1999;10:29-32. 7. Acosta-Merida MA, Marchena-Gomez J, Hemmersbach-Miller M, Roque-Castellano C, Hernandez-Romero JM. Identification of risk factors for perioperative mortality in acute mesenteric ischemia. World J Surg 2006;30:1579-85.
Submitted Sep 20, 2008; accepted Nov 13, 2008.
Endovascular treatment of a superior mesenteric artery embolism in a high-risk Jehovah’s Witness Christopher W. Seder, MD,a Michael Kramer, BS,b Maciej R. Uzieblo, MD,b and Paul Bove, MD,b Royal Oak, Mich Despite recent advances, emergent treatment of acute mesenteric ischemia carries a mortality of 40%-60%. Endovascular therapy provides a reasonable option for high-risk patients with acute mesenteric ischemia who may not tolerate a laparotomy. We present a case of successful endovascular embolectomy of the superior mesenteric artery, visceral aorta, and right iliac artery in a high-risk octogenarian who refused the transfusion of blood products. As older patients present with more comorbidities, endovascular techniques will play an increasingly large role in the treatment of acute mesenteric ischemia. ( J Vasc Surg 2009;49:1050-2.)
Acute mesenteric ischemia (AMI) is generally caused by an embolic or thrombotic occlusion of the superior mesenteric artery (SMA). Despite recent technological advances, emergent treatment of AMI carries a mortality of 40%60%.1-3 Currently, the gold standard for treatment is exploratory laparotomy and surgical removal of the clot. However, with the evolution of endovascular techniques, patients in whom open embolectomy would be exceedingly dangerous are being considered for catheter-based treatment. We present a case of successful endovascular embolectomy of the superior mesenteric artery, visceral aorta, and right iliac artery in a high-risk octogenarian who refused the transfusion of blood products. CASE REPORT The patient was an 83-year-old Jehovah’s Witness with a past medical history significant for hypertension, diabetes mellitus, chronic atrial flutter, and congestive heart failure who presented to our emergency center with generalized weakness and vague abdominal pain. She had an ejection fraction of 60% and a recent stress test that demonstrated a small, fixed defect in the midanteroseptal wall. Following an extensive work-up, she was found to have second-degree heart block, was placed on intravenous heparin, and was scheduled for pacemaker placement. She was not on oral anticoagulants prior to admission. On hospital day six, prior to pacemaker placement, her abdominal pain worsened and she developed right-sided leg pain. The pain was not associated with hematemesis, melena, or peritonitis. She became febrile and developed a leukocytosis to 24,400/l. Her admission blood urea nitrogen (BUN) and creatinine were 32 mg/dL and 1.1 mg/dL, with an estimated admission glomerular filtration rate (GFR) of 57 ml/min. This rose to 33 mg/dL and 1.8 mg/dL (GFR ⫽ 33 ml/min), respectively. Mesenteric ischemia was suspected, thereFrom the Department of Surgery, Section of Generala and Vascularb Surgery, William Beaumont Hospitals. Competition of interest: none. Presented at the Thirty-second Annual Meeting of the Midwestern Vascular Surgical Society, Madison, Wis, Sep 11-13, 2008. Reprint requests: Paul Bove, MD, 3601 W. 13 Mile Rd, Vascular Services Center, Royal Oak, MI 48073 (e-mail: [email protected]). 0741-5214/$36.00 Copyright © 2009 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2008.11.051
1050
Fig 1. Computed tomography demonstrating the visceral aortic and right renal artery embolism.
fore she was placed on wide-spectrum antibiotics and a vascular surgery consultation was obtained. Dynamic contrast-enhanced computed tomography revealed a mid-aortic thrombus with occlusion of the right renal, superior mesenteric (SMA), and right common iliac artery (Fig 1). Due to her advanced age and comorbid conditions, we felt an endovascular embolectomy without thombolysis would provide her with the best opportunity for recovery, as blood loss from thrombolytic-induced hemorrhage and open SMA venting could be avoided. She was taken to the operating room within eight hours of consultation. We gained access through bilateral femoral artery cut-downs to protect against distal emboli and to provide access for both an aortic embolectomy catheter and a left renal-occlusive catheter. An anterior-posterior aortogram confirmed a non-occlusive thrombus in the visceral aorta that extended into the right common iliac artery. Although the right renal artery and SMA were occluded, the left renal and celiac arteries were patent (Fig 2). A small amount of SMA filling was noted via collateral vessels. An angled Glidewire (Terumo, Ann Arbor, Mich) was advanced through a right-sided sheath, the thrombus was negotiated, and a Kumpe
JOURNAL OF VASCULAR SURGERY Volume 49, Number 4
Fig 2. Initial aortogram demonstrating visceral aortic, superior mesenteric artery, and right renal artery embolus involvement.
(Cook, Bloomington, Ind) catheter was used to select the left renal artery. A #4 French over-the-wire Fogarty balloon was advanced over a V18 wire (Boston Scientific, Natick, Mass) and inflated to protect the left kidney from emboli. An adequate length was advanced into the renal artery to prevent dislodgement during the aortic embolectomy. The left femoral sheath was converted to a #12 French sheath, through which a Reliant balloon (Medtronic, Santa Rosa, Calif) was used to perform a visceral aortic embolectomy via a transverse arteriotomy. A moderate amount of clot was returned; pathologic examination of the specimen revealed fresh and organized clot. The SMA was then cannulated with an RDC catheter (Medtronic), followed with a V18 wire, and a #4 Fogarty was used to perform an SMA embolectomy. The left kidney was re-perfused after a warm-ischemia time of approximately 25 minutes. A lateral SMA angiogram revealed residual ostial narrowing, therefore we converted to a 0.035-inch platform and a 6 ⫻ 18 mm balloon-expandable Palmaz Genesis stent (Cordis, Warren, NJ) was advanced into the SMA and deployed. Follow-up angiogram demonstrated continued ostial narrowing and a 70 mm Hg gradient. Due to stent availability, the SMA was reselected with a 0.018-inch platform and an overlapping 6 ⫻ 20 mm Palmaz Blue stent was deployed with slight extension into the aorta. The Fogarty catheter in the left renal artery was deflated, and repeat angiogram revealed brisk antegrade flow through the recannulated SMA (Fig 3), celiac, and left renal arteries. The right renal artery was deemed unsalvageable due to the absence of blood flow on computed tomography (CT) scan and the presence of ischemic symptoms for approximately six days prior to vascular surgical consultation. Bilateral common femoral embolectomies via the transverse arteriotomies, using #4 and #5 regular Fogarty cathe-
Seder et al 1051
Fig 3. Superior mesenteric artery angiogram demonstrating successful revascularization with embolectomy and stenting. ters, produced a moderate amount of clot. Follow-up angiogram revealed patent bilateral common iliac and hypogastric arteries, both femoral arteries had strong pulses, and both feet demonstrated brisk capillary refill. The procedure took approximately 300 minutes, 270 mL of contrast was injected, and the blood loss was 300 mL. No cell salvage was used. Postoperatively, she developed oliguric renal failure, with her BUN and creatinine rising to a maximum of 62 mg/dL and 3.6 mg/dL (GFR ⫽ 16 ml/min), respectively. However, her urine output improved to greater than 0.5 ml/kg/hr and her BUN and creatinine returned to admission levels without need for dialysis. She never required transfusion of blood products, although her postoperative hemoglobin did drop from a baseline of 9.4 g/dL to as low as 6.2 g/dL. Six weeks after her combined open-endovascular SMA embolectomy, the patient was discharged on warfarin to a subacute rehabilitation center. She never received a pacemaker. Based on 27 months of clinical followup, the patient has had no complications; however, no imaging studies have been performed to confirm the patency of the SMA.
DISCUSSION As medicine has evolved, the proportion of patients with multiple comorbidities has risen. Endovascular techniques provide a treatment option for this emerging patient population who may not tolerate the morbidity associated with open repair. Although limited to case reports,4-6 it seems intuitive that the high perioperative mortality associated with open repair in AMI could be lowered with endovascular therapy, especially in high-risk subgroups. In a review of 132 patients who underwent open repair for AMI, previous cardiac illness (P ⫽ .045), plasma urea levels (P ⬍ .001), and small and large bowel involvement were identified as independent risk factors of perioperative mor-
JOURNAL OF VASCULAR SURGERY April 2009
1052 Seder et al
tality.7 Our patient had both cardiac arrhythmias and acute renal insufficiency (although no reports identified renal emboli as a risk factor), making her a high-risk candidate for open surgery. These factors combined with her refusal of blood products prompted us to attempt an endovascular approach to her AMI. Currently, there is no definitive evidence supporting the use of an endovascular approach in acute or chronic mesenteric ischemia. If there is any doubt regarding the viability of the bowel, it must be examined via laparotomy or laparoscopy. In the 48 hours following surgery, our patient’s abdomen became significantly less tender and distended. A patient must be monitored closely and demonstrate signs of ongoing clinical improvement for at least 48 hours prior to determining that the patient has no irreversible bowel injury. This period allows enough time for infarcted bowel to manifest itself as pain, leukocytosis, or hemodynamic instability. As older patients present with more comorbidities, endovascular techniques are likely to play an increasingly large role in the treatment of acute mesenteric ischemia. AUTHOR CONTRIBUTIONS Conception and design: CS, PB Analysis and interpretation: CS, MK, MU, PB Data collection: CS, MK, PB Writing the article: CS, MK, PB Critical revision of the article: CS, MK, MU, PB
Final approval of the article: CS, MK, MU, PB Statistical analysis: N/A Obtained funding: N/A Overall responsibility: CS REFERENCES 1. Park WM, Gloviczki P, Cherry KJ Jr, Hallett JW Jr, Bower TC, Panneton JM, et al. Contemporary management of acute mesenteric ischemia: factors associated with survival. J Vasc Surg 2002;35:445-52. 2. Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer RM Jr. Surgical management of thrombotic acute intestinal ischemia. Ann Surg 2001;233:801-8. 3. Foley MI, Moneta GL, Abou-Zamzam AM Jr, Edwards JM, Taylor LM Jr, Yeager RA, et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg 2000;32:37-47. 4. Wakabayashi H, Shiode T, Kurose M, Moritani H, Fujiki S, Morimoto N, Kusachi S. Emergent treatment of acute embolic superior mesenteric ischemia with combination of thrombolysis and angioplasty: report of two cases. Cardiovasc Intervent Radiol 2004;27:389-93. 5. Yilmaz, Gurkan A, Erdogan O, Sindel T, Ceken K, Luleci E. Endovascular treatment of an acute superior mesenteric artery occlusion following failed surgical embolectomy. J Endovasc Ther 2003;10:386-91. 6. Loomer DC, Johnson SP, Diffin DC, Demaioribus CA. Superior mesenteric artery stent placement in a patient with acute mesenteric ischemia. J Vasc Interv Radiol 1999;10:29-32. 7. Acosta-Merida MA, Marchena-Gomez J, Hemmersbach-Miller M, Roque-Castellano C, Hernandez-Romero JM. Identification of risk factors for perioperative mortality in acute mesenteric ischemia. World J Surg 2006;30:1579-85.
Submitted Sep 20, 2008; accepted Nov 13, 2008.