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Fig. 1. Axial CT image shows a filling defect in the SMV, consistent with thrombus. Also noted are dilated loops of small bowel in the left abdomen. |
Fig. 2. Venous phase of a visceral arteriogram shows filling defects in the SMV and nonvisualization of the ileocolic vein. |
Case Reference No. CC-897-04 A 66 year-old female previously diagnosed with primary biliary cirrhosis presented with a five day history of acute onset , unremitting, diffuse abdominal pain. An abdominal CT revealed SMV thrombosis (Fig. 1). Heparin therapy was instituted, after which her abdominal pain improved slightly. The patient had been previously worked-up for liver transplantation, and was subsequently listed. Since SMV thrombosis would preclude successful transplantation, aggressive therapy was proposed. Visceral arteriography was performed, which showed thrombosis of the ileocolic vein, extending into the SMV (Fig. 2). From a transjugular approach, portal venous access was obtained. Portography and selective mesenteric venography was performed to confirm thrombosis (Fig. 3). The AngioJet thrombectomy device (Possis Medical, Minneapolis, MN) was then activated for nine minutes, and repeat venography was performed, demonstrating some recanalization (Fig. 4). Overnight infusion of UK was instituted at 100,000 units/hr. Follow-up study 16 hours later showed minimal improvement. A three level infusion was started at 125,000 units per hour for 14 additional hours. Final venography revealed near-complete thrombolysis, without significant residual thrombus (Fig. 5). The patient's symptoms significantly improved after the first 16 hr infusion, and subsequently resolved entirely. |
Fig. 3. Selective SMV venography performed from a transjugular approach demonstrates occlusion of the ileocolic vein, with venous collaterization. |
Fig. 4. After activation of the AngioJet thrombectomy device for nine minutes, there is partial recanalization. |
Fig. 5. An excellent venographic result after approximately 30 hours of urokinase infusion (total dose: 3.35 million units) directly into the thrombus. |
Questions 1) We were not entirely convinced that the patient's symptoms were related to the SMV thrombosis, particularly in light of the fact that the clot seemed chronic in nature, once we attempted to lyse it. Outside of the fact that eventual transplantation would have been impossible if we didn't act, is there a legitimate case for not proceeding at that point? Could one make a case for simply keeping her on heparin, since her symptoms did improve slightly, and hope that bowel ischemia would not develop? 2) What is the overall experience with mesenteric thrombosis and thrombolysis (and/or mechanical thrombectomy?) 3) Would anyone have preferred a transhepatic versus transjugular portal vein approach? Related cases: |
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