Acute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a high mortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the past decade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case of acute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suction thrombectomy device (Penumbra Inc)

Abai, Babak

Creisher, Brandon A.

DiMuzio, Paul J.

Nooromid, Michael

Palvannan, Prashanth

Salvatore, Dawn

Jefferson Digital Commons

Thomas Jefferson University Jefferson Digital Commons Department of Surgery Faculty Papers Department of Surgery 8-2-2023 Penumbra Aspiration Thrombectomy of the Superior Mesenteric Artery for Mesenteric Ischemia Brandon A. Creisher Prashanth Palvannan Dawn Salvatore Paul J. DiMuzio Babak Abai See next page for additional authors Follow this and additional works at: https://jdc.jefferson.edu/surgeryfp  Part of the Surgery Commons Let us know how access to this document benefits you This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Department of Surgery Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: JeffersonDigitalCommons@jefferson.edu. Authors Brandon A. Creisher, Prashanth Palvannan, Dawn Salvatore, Paul J. DiMuzio, Babak Abai, and Michael Nooromid Penumbra aspiration thrombectomy of the superiormesenteric artery for mesenteric ischemiaBrandon A. Creisher, BS, Prashanth Palvannan, MD, MPH, Dawn M. Salvatore, MD, Paul J. DiMuzio, MD,Babak Abai, MD, and Michael J. Nooromid, MD, Philadelphia, PAABSTRACTAcute mesenteric ischemia from thromboembolic occlusion is a life-threatening emergency associated with a highmortality rate. Prompt diagnosis and intervention are vital to preserve viable bowel and prevent mortality. In the pastdecade, a shift has occurred toward minimally invasive alternatives such as endovascular therapies. We present a case ofacute mesenteric ischemia from superior mesenteric artery thrombosis treated promptly with the Penumbra suctionthrombectomy device (Penumbra Inc). (J Vasc Surg Cases Innov Tech 2023;9:101278.)Keywords: Acute mesenteric ischemia; Aspiration thrombectomy; Penumbra system; Superior mesenteric arterythromboembolic occlusionAcute mesenteric ischemia (AMI) from thromboem-bolic occlusion is a potentially fatal vascular emergencywith an overall mortality rate as high as 80%.1 Early diag-nosis and intervention are vital to restore mesentericblood flow and preserve viable bowel. Before the pastdecade, laparotomy was the standard of care to assessand treat bowel ischemia. The diagnostic evaluationhas significantly improved with the development ofmultidetector computed tomography angiography(CTA) and has led to decreased bowel ischemia times.In addition to better diagnostics, the increase in endovas-cular therapies and minimally invasive alternatives hasimproved outcomes, such as a shorter average lengthof resected bowel and lower 30-day mortality comparedwith open surgical treatment.2-4 We present a case ofAMI from superior mesenteric artery (SMA) thrombosistreated by aspiration thrombectomy, followed bydiagnostic laparoscopy. The patient provided writteninformed consent for the report of her case details andimaging studies.CASE REPORTThe patient is a 63-year-old woman with a history of newlyidentified SARS-CoV-2 (severe acute respiratory syndromecoronavirus 2) infection, coronary artery disease requiringquadruple vessel bypass, aortoiliac disease with prior end-to-side aortobifemoral bypass, hypertension, hyperlipidemia,and chronic obstructive pulmonary disease. She presentedto our institution with a 1-day history of abdominal pain,diarrhea, and hematochezia. The laboratory test results onadmission included arterial blood gas, pH 7.46; bicarbonate,23 mmol/L; anion gap, 15 mEq/L; lactate, 1.4 mmol/L; creati-nine, 0.6 mg/dL; white blood cell count, 23.5  109/L hemoglo-bin, 14.6 g/dL; and COVID-19 (coronavirus disease 2019)positivity.Her presentation prompted CTA of the abdomen and pelvis,which revealed a heavily calcified SMA with distal, longsegment, completely occlusive thrombus (Fig 1). Her CTA find-ings were also notable for a stenotic right common femoralartery (CFA), a patent celiac axis, a patent aortobifemoralbypass, and complete occlusion of her native aorta, inferiormesenteric artery, and bilateral common, external, and inter-nal iliac arteries. Although her SMA changes appeared chronicand no evidence of bowel infarction was found, her persistentsymptoms and leukocytosis prompted urgent surgical inter-vention w6 hours after her presentation to the emergencydepartment. Given her comorbidities and previous abdominalsurgery, we opted for an endovascular-first approach. Accesswas obtained through the left CFA because both brachialarteries were not adequate for mesenteric intervention at w3to 4 mm, and her right CFA was stenotic and calcified at4.5 mm in size. We chose to cannulate the left CFA becauseminimal plaque was present and the vessel was w8 mm indiameter, with a 1.75-cm distance between the distal anasto-mosis and femoral bifurcation (Fig 2). Once access wasachieved, we successfully traversed the bypass graft andachieved wire access to the SMA with an Aptus Tour Guide(Medtronic) steerable sheath. Initial angiography showed adistal SMA thrombus with no flow to the right colon. Usingthe CAT6 Penumbra suction thrombectomy device(Penumbra Inc), we significantly improved the perfusion, asseen on the pre- and post-thrombectomy images (Fig 3).Finally, we addressed a stenotic left aortobifemoral to CFAanastomosis via angioplasty with a 6  40 mm Advance35LP low-profile PTA balloon (Cook Medical; Fig 2). Next,diagnostic laparoscopy, performed by acute care surgery,ensured no bowel ischemia was present. Postoperatively, thepatient did well and was eventually discharged with clopidog-rel 75 mg once daily (Plavix; Bristol-Myers Squibb e SanofiPharmaceuticals partnership) and apixaban 5 mg twice dailyFrom the Division of Vascular Surgery, Department of Surgery, ThomasJefferson University Hospital.Author conflict of interest: none.Correspondence: Michael J. Nooromid, MD, Division of Vascular Surgery,Department of Surgery, Thomas Jefferson University Hospital, 111 S 11th St,Ste 6210, Philadelphia, PA 19107 (e-mail: Michael.Nooromid@jefferson.edu).The editors and reviewers of this article have no relevant financial relationships todisclose per the Journal policy that requires reviewers to decline review of anymanuscript for which they may have a conflict of interest.2468-4287 2023 The Authors. Published by Elsevier Inc. on behalf of Society for VascularSurgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jvscit.2023.1012781(Eliquis; Bristol-Myers Squibb) on postoperative day 10 afterreceiving SARS-CoV-2 treatment.DISCUSSIONThis case report demonstrates the benefit ofminimally invasive treatment of AMI in a patient withlow physiologic reserve due to multiple comorbidities.AMI commonly presents in the elderly at high risk ofopen surgical complications.1,5 In these patients witha low suspicion of necrotic bowel, we suggest the fullyminimally invasive option of AMI endovascular treat-ment, followed by diagnostic laparoscopy.Open revascularization, followed by explorativelaparotomy, remains the gold standard for the manage-ment of AMI. However, endovascular therapy has beenincreasingly used as a revascularization strategy. Inaddition to our case report, others have reportedtechnical success with the Penumbra suction throm-bectomy system for AMI.6,7 In recent years, anendovascular-first approach has become more popularowing to the improved 30-day mortality and decreasedlength of stay with endovascular strategies.2-4 A largeanalysis from the National Surgery Quality Improve-ment Program showed a 2.5-fold decrease in the riskof death associated with endovascular-first therapy.8The endovascular-first approach is best suited for pa-tients with multiple comorbidities and no signs ofbowel necrosis (leukocytosis [white blood cell count>10,000/mm3], elevated lactate, pneumatosis intestina-lis, bowel dilation or free intraperitoneal fluid oncomputed tomography).9e11 For these patients, thebenefits to avoiding open revascularization and explor-ative laparotomy include reduced morbidity andmortality associated with entering the peritoneumand a shorter length of stay.12 However, these studiesare subject to selection bias, and a randomizedcontrolled trial is needed to determine the superiorityof the interventions.Open bowel resection is required for the manage-ment of bowel infarction. Patients with an acuteabdomen on examination or signs of bowel necrosisand/perforation on imaging are brought emergentlyto the operating room for laparotomy, bowel resection,and revascularization with SMA embolectomy. For thepresent patient, laparotomy and open embolectomywere considered; however, given her body habitus,the reoperative nature of her abdomen, multiplecomorbidities, including COVID-19 positivity withchronic obstructive pulmonary disease and coronaryartery disease, and evidence of distal anastomoticstenosis of the left limb of the aortobifemoral graft,we believed endovascular intervention would bemore expeditious and less morbid. Open vs endovascu-lar revascularization should be determined on a case-by-case basis, and consideration should be given tothe patient’s condition, imaging findings, and thesurgeon’s skill set and available tools. If eventualconversion to laparotomy is necessary, the benefit ofendovascular revascularization is not completely lostbecause it has the added advantage of not leavingbehind prosthetic material, such as Prolene suture orgraft material, which can be necessary with openrepair.This case report is an important example of amedically and surgically complex patient whobenefited from an endovascular-first approach to treatAMI. Even with suboptimal lower extremity access anddifficult SMA cannulation through a previous aortobife-moral bypass, we believe this challenging endovascularprocedure was ultimately beneficial to the patientcompared with an open surgical approach.CONCLUSIONSPatients with multiple comorbidities presenting withAMI without signs of necrotic bowel are good candidatesfor minimally invasive management with anendovascular-first approach, followed by diagnostic lapa-roscopy. The Penumbra aspiration thrombectomysystem was an effective option for this patient presentingwith AMI.Fig 1. Sagittal computed tomography angiography (CTA)image showing superior mesenteric artery (SMA) occlu-sion (arrow).2 Creisher et al Journal of Vascular Surgery Cases, Innovations and TechniquesDecember 2023Fig 2. Angiographic images from before (A) and after (B) angioplasty of the left common femoral artery (CFA)access site showing left aortobifemoral stenotic anastomosis with improvement after angioplasty.Fig 3. Angiographic images from before (A) and after (B) thrombectomy of the superior mesenteric artery(SMA) showing improved blood flow and perfusion to the right colon with restored distal branch.Journal of Vascular Surgery Cases, Innovations and Techniques Creisher et al 3Volume 9, Number 4REFERENCES1. Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD.Acute mesenteric ischemia: a clinical review. Arch Intern Med2004;164:1054-62.2. Arthurs ZM, Titus J, Bannazadeh M, et al. A comparison of endovas-cular revascularization with traditional therapy for the treatment ofacute mesenteric ischemia. J Vasc Surg 2011;53:698-704; discussion:704-5.3. Beaulieu RJ, Arnaoutakis KD, Abularrage CJ, Efron DT, Schneider E,Black JH 3rd. Comparison of open and endovascular treatment ofacute mesenteric ischemia. J Vasc Surg 2014;59:159-64. Erratum in: JVasc Surg. 2014 Jul;60(1):273.4. Zhang Z, Wang D, Li G, et al. Endovascular treatment for acutethromboembolic occlusion of the superior mesenteric artery and theoutcome comparison between endovascular and open surgicaltreatments: a retrospective study. Biomed Res Int 2017;2017:1964765.5. Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (part I) e inci-dence, etiologies, and how to improve early diagnosis. Best Pract ResClin Gastroenterol 2017;31:15-25.6. Mak AK, Andraska EA, Reitz KM, Chaer R, Eslami MH, Avgerinos E.A single institutional experience with suction thrombectomy inacute mesenteric ischemia. Ann Vasc Surg Brief Rep Innov 2022;2:100070.7. Genzel P, Van Dijk LC, Veger HTC, et al. Case report: direct revascu-larization in acute mesenteric ischemia by an endovascularapproach. CVIR Endovasc 2019;2:31.8. Branco BC, Montero-Baker MF, Aziz H, Taylor Z, Mills JL. Endovasculartherapy for acute mesenteric ischemia: an NSQIP analysis. Am Surg2015;81:1170-6.9. Canfora A, Ferronetti A, Marte G, et al. Predictive factors of intestinalnecrosis in acute mesenteric ischemia. Open Med 2019;14:883-9.10. Nuzzo A, Maggiori L, Ronot M, et al. Predictive factors of intestinalnecrosis in acute mesenteric ischemia: prospective study from anintestinal stroke center. Am J Gastroenterol 2017;112:597-605.11. Emile SH. Predictive factors for intestinal transmural necrosis in pa-tients with acute mesenteric ischemia. World J Surg 2018;42:2364-72.12. Lim S, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Contem-porary management of acute mesenteric ischemia in the endovas-cular era. Vasc Endovasc Surg 2019;53:42-50.Submitted Mar 12, 2023; accepted Jul 3, 2023.4 Creisher et al Journal of Vascular Surgery Cases, Innovations and TechniquesDecember 2023

Penumbra Aspiration Thrombectomy of the Superior Mesenteric Artery for Mesenteric Ischemia

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Penumbra Aspiration Thrombectomy of the Superior Mesenteric Artery for Mesenteric Ischemia

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