Direct aspiration using rapid-exchange and low-profile device for acute thrombo-embolic occlusion of the superior mesenteric artery

Short-term experience with aspiration embolectomy using a ACE68 reperfusion catheter to treat embolic superior mesenteric artery occlusion

We report the short-term results with aspiration embolectomy using an ACE68 reperfusion catheter to treat patients with acute embolic superior mesenteric artery (SMA) occlusion. Our study included 4 consecutive male patients ranging in age from 72 to 86 years (mean age 79 years). In all patients, the main trunk of the SMA was occluded. The technical success rate was 100% for all procedures. There were no major procedure-related complications. One patient underwent laparotomy with intestinal resection after successful recanalization. No patient reported clinical symptoms of abdominal ischemia at follow-up. Our short-term experience shows that percutaneous aspiration embolectomy using an ACE68 reperfusion catheter is an effective treatment for acute mesenteric ischemia.

The role of endovascular therapy in acute mesenteric ischemia

Background

Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes.

Methods

An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016.

The following variables were extracted

number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel.

Results

Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively.

Conclusions

Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

Percutaneous aspiration embolectomy of superior mesenteric artery using a 5MAX ACE reperfusion catheter

Acute mesenteric ischaemia is a rare abdominal emergency that commonly results in bowel infarction and has a very high mortality rate. Therefore, prompt recognition and treatment are crucial for a successful outcome. A thrombectomy for embolism in the mid portion of the main trunk of the superior mesenteric artery (SMA) is proposed. A near-complete thrombi removal from the main trunk of the SMA was achieved by using a 5MAX ACE reperfusion catheter, which was designed for treating cerebral embolism. This is the first report describing the treatment of acute mesenteric ischaemia using this catheter. Percutaneous aspiration embolectomy with this catheter is a useful modality for recanalization of embolic occlusion of not only the cerebral artery but also the SMA.

Radiology and mesenteric ischaemia

This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.

Aspiration therapy for acute superior mesenteric artery embolism with an angled guiding sheath and guiding catheter

Seven patients with superior mesenteric artery embolism were treated by aspiration with the use of a 6-F angled guiding sheath and a 6-F guiding catheter through an 8-F short sheath by direct advancement using a telescopic and "biting-off" technique. Aspiration of the trunk took between 30 and 60 minutes (median, 44.0 min), and total procedure time ranged from 34 to 94 minutes (median, 60 min). Five of six trunk lesions and six of nine branch lesions were successfully aspirated. One dissection was observed. Six patients underwent bowel resection. Two patients died and the remaining five survived for a median of 868.2 days without complications.

Percutaneous mechanical thrombectomy of superior mesenteric artery embolism

Background

The present series present three consecutive cases of successful percutaneous mechanical embolectomy in acute superior mesenteric artery ischemia. Superior mesenteric artery embolism is a rare abdominal emergency that commonly leads to bowel infarction and has a very high mortality rate. Prompt recognition and treatment are crucial for successful outcome. Endovascular therapeutic approach in patients with acute SMA embolism in median portion of its stem is proposed.

Case reports.

Three male patients had experienced a sudden abdominal pain and acute superior mesenteric artery embolism in median portion of its stem was revealed on computed tomography angiography. No signs of intestinal infarction were present. The decision for endovascular treatment was made in concordance with the surgeons. In one patient 6 French gauge Rotarex^® device was used while in others 6 French gauge Aspirex^® device were used. All patients experienced sudden relief of pain after the procedure with no signs of intestinal infarction. Minor procedural complication – rupture of a smaller branch of SMA during Aspirex^® treatment was successfully managed by coiling while transient paralytic ileus presented in one patient resolved spontaneously. All three patients remained symptom-free with patent superior mesenteric artery during the follow-up period.

Conclusions

Percutaneous mechanical thrombectomy seems to be a rapid and effective treatment of acute superior mesenteric artery embolism in median portion of its stem in absence of bowel necrosis. Follow-up of our patients showed excellent short- and long-term results.

Treatment outcome in patients with acute superior mesenteric artery embolism

PURPOSE

The goals of this study were to investigate the treatment outcomes of acute mesenteric ischemia caused by superior mesenteric artery (SMA) embolism and identify the posttreatment prognostic factors.

METHODS

The clinical data of 32 episodes of acute SMA embolism in 30 patients, including 2 recurrent cases, between April 2003 and March 2011 were retrospectively reviewed.

RESULTS

Median patient age was 74 years (range, 39-89 years), and 50% were male. Conservative treatment, including bowel rest, nasogastric drainage, intravenous fluid therapy, parenteral nutritional support, and anticoagulation therapy, was undertaken in 5 patients with no clinical evidence of bowel gangrene, including 1 with recurrent ischemia. No deaths occurred among patients treated conservatively. A total of 27 patients were treated with open surgical repair (25 embolectomies and 2 bowel resections alone). Among 25 patients treated with embolectomy, 14 required bowel resection. Most bowel resections (94%, 15/16) were limited, with the remaining length of small bowel greater than 150 cm, which could not cause short bowel syndrome. In-hospital mortality of surgery was 30%. No variables were associated with mortality after surgical intervention, including, age, gender, presence of bowel gangrene, and symptom duration. The overall 1-, 3-, and 5-year survival rates after initial successful treatment were 96%, 73%, and 44%, respectively, regardless of treatment type.

CONCLUSIONS

Prompt diagnosis and treatment before extensive irreversible gangrene is the mainstay in the treatment of SMA embolism. Limited bowel gangrene was not associated with mortality.

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.

METHODS

At three medical centers the radiological information system databases were used to identify all patients in whom primary percutaneous revascularization for the treatment of acute embolic SMA occlusion was attempted between 2001 and 2010. Percutaneous treatment was performed in 15 patients (median age 80 years, range 49-88 years). These patients represent the study population. Eleven patients reported abdominal pain. Five patients exhibited peritoneal signs. Revascularization was defined as complete technical success if (1) patency of the SMA with residual stenosis of not more than 30% in diameter and (2) sufficient perfusion of the entire bowel were obtained.

RESULTS

Complete technical success was achieved in eleven patients. After percutaneous revascularization laparotomy was performed in six patients and in three of them bowel resection was carried out (length of resected segments 20-80 cm). The 30-day mortality was 33% (five of 15 patients). None of the surviving patients exhibited short-bowel syndrome.

CONCLUSIONS

Primary percutaneous aspiration and thrombolysis constitutes a promising alternative to surgical revascularization in selected patients with acute embolic SMA occlusion.