Producción CientíficaReport: A 67-year-old man with atrial fibrillation developed acute liver failure due to an embolic
occlusion of the CA and SMA, with a severe coagulation disorder. He was successfully managed with
percutaneous stent placement and an exploratory laparotomy was not needed. He remains symptomfree
1 year after the procedure, and duplex follow-up showed stent patency.
Conclusion: Endovascular techniques in patients with liver failure, no signs of peritonism, early diagnosis
and high operative risk seem feasible and should be used if possible, as first-line option

González Fajardo, José Antonio

Gutíerrez Alonso, Vicente

San Norberto García, Enrique María

European Journal of Vascular and Endovascular Surgery

Spanish

Repositorio Documental de la Universidad de Valladolid

at SciVerse ScienceDirectEuropean Journal of Vascular and Endovascular Surgery xxx (2011) 1e3Contents lists availableEuropean Journal of Vascular and Endovascular Surgeryjournal homepage: www.ejves.comShort ReportPercutaneous Treatment of Liver Failure and Acute Mesenteric IschaemiaE.M. San Norberto a,*, V.M. Gutiérrez a, J.A. González-Fajardo a, J. Chehayeb b, M.A. Ibáñez a, C. Vaquero aaDivision of Vascular Surgery, Valladolid University Hospital, C/ Ramón y Cajal n3, 47005 Valladolid, SpainbDivision of Emergency, Valladolid University Hospital, Valladolid, Spaina r t i c l e i n f oArticle history:Received 6 August 2011Accepted 2 October 2011Available online xxxKeywords:Coeliac arterySuperior mesenteric arteryAcute liver failureMesenteric vascular diseaseAngioplastyStent* Corresponding author. Tel.: þ34 686754618.E-mail address: esannorberto@hotmail.com (E.M.1078-5884/$ e see front matter  2011 European Sodoi:10.1016/j.ejvs.2011.10.001Please cite this article in press as: San NorbeJournal of Vascular and Endovascular Surgea b s t r a c tIntroduction: Synchronous embolism to the superior mesenteric artery (SMA) and coeliac axis (CA) isa rare disease.Report: A 67-year-old man with atrial fibrillation developed acute liver failure due to an embolicocclusion of the CA and SMA, with a severe coagulation disorder. He was successfully managed withpercutaneous stent placement and an exploratory laparotomy was not needed. He remains symptom-free 1 year after the procedure, and duplex follow-up showed stent patency.Conclusion: Endovascular techniques in patients with liver failure, no signs of peritonism, early diagnosisand high operative risk seem feasible and should be used if possible, as first-line option. 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.The survival rate of liver and mesenteric ischaemia has notimproved substantially during the past years, despite the advancesin open surgery and endovascular techniques.1 Endovascular ther-apies include different techniques, such as catheter-directed vaso-dilator, aspiration thrombolytic therapy, endovascular angioplastyor stent placement.ReportA 67-year-old man with a nephrectomy done the previous daypresented with a history of acute liver failure and mid-to-upperabdominal pain. The patient’s medical history was significant foran atrial fibrillation. An urgent computed tomography (CT) angi-ography revealed a coeliac trunk and superior mesenteric artery(SMA) occlusion. On physical examination, he had absent periton-ism signs. Laboratory data revealedmetabolic acidosis, leucocytosis(14,580  103 ml1) and elevated levels of lactate (55 mg dl1),aspartate aminotransferase (AST, 4337 U l1), alanine aminotrans-ferase (ALT, 2190 U l1), lactate dehydrogenase (LDH, 10170 U l1),International normalised ratio (INR) 3.73 and activated partialthromboplastin time (aPTT, 59 s).An anterioposterior and lateral aortogram was performed viathe transfemoral approach (Fig. 1). A Simmons 1 catheter (BardAngiomed, Karlsruhe, Germany) was used to select the expectedSan Norberto).ciety for Vascular Surgery. Publisherto EM, et al., Percutaneous Try (2011), doi:10.1016/j.ejvs.2origin of the SMA. The occlusion could then be crossed witha 0.035-inch hydrophilic wire (Radiofocus M; Terumo, Leuven,Belgium). The technique included placement of an 8  59-mmballoon-expandable stent (Omnilink Elite, Abbott VascularDevices, Ulestraten, the Netherlands) across the occlusion withoutpredilation, introduced over a stiff guide wire (Amplatz Super Stiff;Boston Scientific, Natick, MA, USA) to prevent a prolapse into theaorta. A left brachial approach was added to improve the angle ofentry into the ostia of the coeliac axis (CA) and because of the acuteangle of entry into the CA from the femoral approach. A 5-F cobra-shaped catheter (Bard Angiomed, Karlsruhe, Germany) with a lesstraumatic 0.014-inch wire (Spartacore 14, Abbott Vascular Inter-national, Diegem, Belgium) was employed to cross the occlusivelesion. Once the wire was placed across the occlusion, a catheter(CXI Support Catheter, Cook Medical, Bloomington, IN, USA) wascarefully advanced over the wire across the lesion and a secondstiffer wire (Amplatz Super Stiff; Boston Scientific, Natick, MA, USA)was exchanged through the catheter to facilitate the placement ofa 8  59-mm balloon-expandable stent (Omnilink Elite, AbbottVascular Devices, Ulestraten, the Netherlands). A subsequentarteriogram confirmed an excellent flow to the liver territory.The patient was haemodynamically stable and a persistentlynormal abdominal examination was presented. On the first post-interventional day, lactic acid decreased to 20 mg dl1; coagula-tion and liver function returned to normal values on the thirdpostoperative day. An angio CT examination showed normalpatency of the CA and SMA (Fig. 2). The patient was dischargedwithoral anticoagulant therapy and 100 mg of aspirin daily indefinitely.d by Elsevier Ltd. All rights reserved.reatment of Liver Failure and Acute Mesenteric Ischaemia, European011.10.001Figure 1. Digital subtraction angiography. A: Abrupt cutoff of the SMA with the absence of collateral circulation (continuous arrow) and complete occlusion of the CA (doted arrow).B: Image during fluoroscopy shows an Amplatz wire selecting the SMA after selective fibrinolysis. C: Wire across CA occlusion and a stent in the SMA showing normal flow. D: CAstent placement without predilation.Figure 2. A: Preoperative CT scan shows occlusion of CA and SMA. B: 3D reconstruction computed tomography angiogram (CT) 5 days post CA and SMA stenting. Adequate luminalpatency of the coeliac artery and hepatic artery is seen.E.M. San Norberto et al. / European Journal of Vascular and Endovascular Surgery xxx (2011) 1e32Please cite this article in press as: San Norberto EM, et al., Percutaneous Treatment of Liver Failure and Acute Mesenteric Ischaemia, EuropeanJournal of Vascular and Endovascular Surgery (2011), doi:10.1016/j.ejvs.2011.10.001E.M. San Norberto et al. / European Journal of Vascular and Endovascular Surgery xxx (2011) 1e3 3At 1 year, duplex examination of the CA and SMA showed nohaemodynamically significant residual stenosis.DiscussionAcute mesenteric ischaemia is a life-threatening surgicalemergency associated with high morbidity and mortality rates.Atrial fibrillation, SMA occlusion and synchronous embolism arecommon findings. Acosta et al. reported that visceral synchronousembolism occurred in 113 of 273 (41%) arterial segments, of which10 emboli were lodged in the coeliac trunk.2Previously, endovascular treatment was not applied to patientspresenting with acute mesenteric arterial thrombosis because itdoes not allow for bowel viability assessment, requires advancedendovascular surgery skills and procedure time can delay revas-cularisation. The advantages of endoluminal techniques includetimely visualisation of the affected vascular anatomy with near-immediate restoration of flow and replacement of the need foropen surgical reconstruction, avoiding aortic clamping and pros-thetic conduit contamination.The systematic review of Schoots et al.3 suggested that catheter-directed fibrinolysis with urokinase may serve as an adjunctivetreatment modality to surgery. Indication requires no developmentof peritonitis and good collaterals in arteriography. SMA percuta-neous transluminal angioplasty (PTA) can achieve a rapid recanal-isation more quickly than primary thrombolysis. Peripheralembolisation of the thrombus partly dissolved and broken by PTA isthe most likely complication of PTA. Stenting could avoid this riskfor distal embolisation. Successful endovascular treatment wasassociated with improved mortality compared with traditionalPlease cite this article in press as: San Norberto EM, et al., Percutaneous TJournal of Vascular and Endovascular Surgery (2011), doi:10.1016/j.ejvs.2therapy (36% vs. 50%).4 The technique called ‘retrograde superiormesenteric artery stenting’ (ROMS) combines both open surgicaland endovascular methods.According to the literature, this seems to be the first case of anacute liver failure due to a combined thrombo-embolic occlusion ofCA and SMA treated with stenting. In the largest single-centreexperience published,5 liver function alterations were rare, withAST mean value of 25 U l1 (18e35) and ALT of 20 U l1 (11e39). Inour opinion, endovascular treatment in patients with liver failure,no signs of peritonism, early diagnosis and high operative risk,seems feasible and should be used if possible, as first-line option.Conflict of InterestNone.FundingNone.References1 Resch TA, Acosta S, Sonesson B. Endovascular techniques in acute arterialmesenteric ischemia. Semin Vasc Surg 2010;23:29e35.2 Acosta S, Ögren M, Sternby NH, Bergqvist D, Björck M. Clinical implications forthe management of acute thromboembolic occlusion of the superior mesentericartery. Autopsy findings in 213 patients. Ann Surg 2005;241:516e22.3 Schoots IG, Levi MM, Reekers JA, Lameris JS, van Gulik TM. Thrombolytic therapyfor acute superior mesenteric occlusion. J Vasc Interv Radiol 2005;16:317e29.4 Do N, Wisniewski P, Sarmiento J, Vo T, Aka PK, Hsu JH, et al. Retrograde superiormesenteric artery stenting for acute mesenteric arterial thrombosis. Vasc Endo-vascular Surg 2010;44:468e71.5 Arthurs ZM, Titus J, Bannazadeh M, Eagleton MJ, Srivastava S, Sarac TP, et al.A comparison of endovascular revascularization with traditional therapy for thetreatment of acute mesenteric ischemia. J Vasc Surg 2011;53:698e705.reatment of Liver Failure and Acute Mesenteric Ischaemia, European011.10.001

Percutaneous treatment of liver failure and acute mesenteric ischaemia

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Percutaneous treatment of liver failure and acute mesenteric ischaemia

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