In Reply to: Re: Case 497_10 -- Mesenteric Artery Embolus posted by Bob Vogelzang on April 22, 1997 at 07:58:18:
I agree that thrombolysis of SMA clot is a risky situation with potentially disastrous consequences. The key consideration in this case was the likelihood that bowel infarction had occurred. There were a few clinical details that decreased the probability of bowel infarction in this case: 1. The relative short period between the onset of symptoms and treatment (11 hours). 2. There was no evidence of preexisting atherosclerotic disease in the SMA (thrombosed SMA on top of preexisting occlusive disease carries a higher risk for infarction). 3. Normal white count on presentation. 4. No bloody stool on presentation. 5. No evidence of peritonitis on physical examination.
The above clinical information is not a guarantee against bowel infarction but decreases its probability. If there had been clinical information supporting the presence of bowel infarction, chemical thrombolysis would have been a much riskier intervention. In this case we had a patient with recent MI (2 weeks) that was not a good operative candidate. Given the above clinical information the feeling was that the potential benefits outweighed the risks.
As you know, the operative mortality in the context of acute bowel ischemia/infarction is very high. I am convinced that there is a group of patients that can benefit from a thrombolytic approach. If we catch these patients early (less than 12 hours) with no signs of bowel infarction, thrombolysis is worth considering.