Kimura, Takayoshi

Kumita, Shinichiro

Miki, Izumi

Mine, Takahiko

Murata, Satoru

Ogawa, Toshihide

Onozawa, Shiro

Sugihara, Fumie

Ueda, Tatsuo

Yasui, Daisuke

Tottori University Research Result Repository

237Yonago Acta medica 2016;59:237–240 Patient ReportCorresponding author: Takayoshi Kimura, MDsrkbc189@yahoo.co.jpReceived 2016 May 16Accepted 2016 June 8Abbreviations: CT, computed tomography; IR, interventional radiol-ogy; PVMVT, portal vein and mesenteric vein thrombosis; SMV, superior mesenteric veinCombination Therapy of Interventional Radiology and Surgery for Infarction of the Small Intestine Caused by Portal Vein and Mesenteric Vein Thrombosis: A Patient ReportTakayoshi Kimura,* Satoru Murata,† Shiro Onozawa,† Takahiko Mine,† Tatsuo Ueda,† Fumie Sugihara,† Daisuke Yasui,† Izumi Miki,† Shinichiro Kumita† and Toshihide Ogawa**Division of Radiology, Department of Pathophysiological and Therapeutic Science, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan and †Department of Radiology, Nippon Medical School, Tokyo 113-8603, JapanABSTRACTWe report the case of a man in his 70s who suffered from intestinal infarction caused by acute portal vein and mesenteric vein thrombosis (PVMVT). Combina-tion therapy with percutaneous transcatheter throm-bectomy and surgical bowel resection was successfully performed, and a satisfactory outcome was achieved. Intestinal infarction caused by PVMVT can be fatal and has a high mortality rate even if surgical resection is performed. The combination therapy of intervention-al radiology and surgery might be a safe and effective method for patients with this life-threatening condition.Key words    interventional radiology; intestinal infarc-tion; portal vein thrombosis; surgical resection Acute portal vein and mesenteric vein thrombosis (PVMVT) is a rare and insidious disease that is associ-ated with significant mortality and morbidity. Its clinical manifestations are often asymptomatic or nonspecific, such as nausea, anorexia, and abdominal distension. Thus, the diagnosis of PVMVT is frequently delayed, which can be fatal owing to complications such as mes-enteric ischemia and infarction with multiorgan failure. In patients with PVMVT-related intestinal infarction, the mortality rate has been reported to be 37–76%.4 Therefore, early accurate diagnosis is very important. The traditional management of this condition has been anticoagulation therapy. Surgery is reserved for patients who have failed anticoagulation therapy or for those who present with signs of mesenteric ischemia and infarction. Due to recent advances in catheter-directed treatment, interventional radiology (IR) such as the percutaneous transhepatic technique has been recognized as an al-ternative, less invasive option with minimal complica-tions.1–8 However, despite previous reports, a reliable therapeutic strategy for PVMVT-related with intestinal infarction is yet to be established. We report here a case of PVMVT-related intestinal infarction that was successfully treated with a combina-tion therapy of IR and surgical resection.PATIENT REPORTA man in his 70s with no significant medical history was hospitalized in the emergency department because of abdominal pain and bloody stool persisting for 4 days. On physical examination, abdominal rebound tender-ness was found. Initial laboratory test results revealed a white blood cell count of 13100/μL and a C-reactive pro-tein level of 2.41 mg/L. Abdominal enhanced computed tomography (CT) revealed extensive necrosis of the terminal ileum and continuous thrombus from the ileal branches via the superior mesenteric vein (SMV) to the main trunk of the portal vein (PV, Fig. 1). The condition was diagnosed as ileal necrosis due to venous thrombo-sis, and the combined treatment of IR and surgery was administered immediately. First IR procedure: Under local anesthesia, using ultrasonographic guidance, percutaneous transhepatic access to the left portal vein was established and a 5-Fr vascular sheath was inserted. Direct portography re-vealed occlusion with extensive thrombosis from the il-eal branches up to the main trunk of the PV. The throm-bosed PV and SMV were passed through by a 0.035-inch guidewire, and catheter-directed thrombolysis was per-formed after injecting a high dose of urokinase (120000 units, Uronase; Mochida, Tokyo, Japan) via a pulse-spray catheter (Fountain; Merit Medical, South Jordan, UT; Figs. 2A and B).  Laparotomy: In the laparotomy performed imme-diately after the first IR procedure, infarction of the ter-minal ileum was recognized and approximately 50 cm of the small intestine was resected. Despite the presence of a large venous thrombus, surgical thrombectomy was not performed. At the completion of surgery, intravenous heparin infusion was maintained at the rate of 1000 238T. Kimura et al.A BFig. 1. First dynamic CT. (A) Initial CT shows intraluminal thrombosis in the PV and the mesenteric vein (arrow). (B) Jejunal loop dilata-tion and diffuse wall thickening with ascites are evident (arrow head). CT, computed tomography; PV, portal vein.Fig. 2. Percutaneous transhepatic portography shows thrombus in the portal vein trunk (arrow) extending to the mesenteric vein. Fig. 3. Direct portography at the second and third IR sessions reveal residual thrombus in the PV and SMV. Percutaneous transhepatic thrombectomy, thrombolysis, and angioplasty were performed. IR, interventional radiology; PV, portal vein; SMV, superior mesenteric vein.units per hour.  Second and third IR procedures: Transcatheter thrombectomy for the residual thrombus was performed on day 1 and 2 after the operation as the second and third IR procedure, respectively. Manual aspiration thrombectomy was performed using a 6-Fr guiding catheter (Launcher; Medtronic, Minneapolis, MN). Di-rect thrombolysis was performed using 120000 units of urokinase. Angioplasty was performed using a balloon catheter of 8 mm diameter and 4 cm length (Mustang; Boston Scientific, Natick, MA). At the completion of IR therapy, urokinase administration (5000 units/hour) was continued for an additional 48 hours via the catheter placed in the SMV (Fig. 3). 239IR and surgery for intestine infarction by PVT Follow-up: Four days after the operation, sufficient blood flow and recanalization of the SMV and PV were confirmed by portography (Fig. 4). Follow-up CT per-formed 9 days after the first IR procedure revealed only a small amount of remnant thrombus in the SMV and PV (Fig. 5). No adverse event or complication occurred, and the patient was discharged on day 24 of hospitaliza-tion. He was followed up in the outpatient department with performing anticoagulant therapy using warfarin, and no complication was noted.DISCUSSIONPVMVT is a relatively rare disease with an incidence of approximately 5–15% among mesenteric ischemic events.1, 2 Myeloproliferative disease, intraabdominal in-fections or inflammations, septicemia, cirrhosis, intraab-dominal surgery, trauma, hypercoagulable states (insuf-ficiency of antithrombin III, protein C, protein S, etc.), oral contraceptives use, and liver tumors are the most common causes for PVMVT.3 However, our patient had none of these risk factors and the cause of thrombosis was not identified despite elaborate examinations. The main goals of therapy for acute PVMVT are preventing extension of the thrombus, recanalization of the vessels in the short term, and preventing recurrence in the long term. Anticoagulation is the initial approach in management. Acute PVMVT without bowel ischemia has traditionally been treated using systemic anticoagulation therapy with heparin and warfarin to prevent propagation of the thrombus and recanalize the occluded vessels. How-ever, for patients with intestinal infarction, perforation, and peritonitis, emergency laparotomy with bowel resec-tion may be essential and warranted for survival. Bowel resection and anastomosis are the standard procedures performed with the goal of conserving as much of the bowel as possible. In previous case series of PVMVT-re-lated intestinal infarction, the average length of resected bowel has been 50–60 cm, which is as same as our base. Moreover, these series reported high mortality (37–76%) and high recurrence rates (11–29%).2, 4, 6, 7 Here, we as-sumed that mortality and recurrence rate were associated with the volume of the resected intestine. Moreover, our patient had an extensive thrombosis extending from the ileal branches up to the main trunk of the PV. Hence, sufficient surgical thrombectomy was considered haz-ardous as it comes with a high risk of critical bleeding. Taking these factors into consideration, we employed an endovascular approach simultaneously with a surgical approach to recanalize the thrombosed vein consider-ably and reduce the volume of bowel resection. Endovascular therapy for PVMVT has been recog-nized as a therapeutic alternative that is minimally inva-sive and has a relatively low mortality. In a retrospective study of 20 PVMVT patients with or without intestinal infarction who were treated with thrombolysis via the transhepatic route and/or superior mesenteric artery route, 75% experienced partial or complete clot reso-Fig. 5. Follow-up abdominal CT at day 10 after IR and surgery shows only a small amount of remnant thrombus in the PV and SMV (arrow). CT, computed tomography; IR, interventional ra-diology; PV, portal vein; SMV, superior mesenteric vein. Fig. 4. Portography performed 4 days after IR procedure and sur-gery shows recanalization and antegrade hepatopetal flow in the SMV and PV. IR, interventional radiology; PV, portal vein; SMV, superior mesenteric vein.240T. Kimura et al.lution and 85% experienced resolution of symptoms.8 The ratio of a bleeding complication is not so high as 0.06–15% in the previous reports.9–12 In the present case, we performed percutaneous transhepatic thrombolysis, thrombectomy, and angioplasty, which permits access to the PV and SMV system and thus allows for infusion of thrombolytic agents directly into the occluded vein with a limited amount of lytic agents and for longer dura-tions.2, 3 Using this method, recanalization from the ileal branch up to the PV was achieved safely, and adequate blood circulation was maintained without any adverse events. Moreover, the length of the resected intestine was limited to 50 cm, and thrombosis or bowel ischemia did not recur. To the best of our knowledge, till date, no report has indicated the efficacy of combination therapy of IR and surgical resection for PVMVT-related intestinal infarc-tion. Percutaneous transhepatic thrombolysis, thrombec-tomy, and angioplasty with surgical resection are valid strategies for recanalization, and they may be effective in reducing the mortality rate of patients with PVM-VT-related intestinal infarction.  In conclusion, acute PVMVT-related intestinal in-farction is a rare disease with high mortality; hence, ear-ly diagnosis and treatment are essential. We successfully saved this life-threatening case with the combination therapy of IR and surgical resection. The authors declare no conflict of interestREFERENCES  1 Kim HS, Patra A, Khan J, Arepally A, Streiff MB. Transhe-patic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J Vas Interv Radiol. 2005;16:1685-91. PMID: 16371536.   2 Zhou W, Choi L, Lin PH, Dardik A, Eraso A, Lumsden AB. Percutaneous transhepatic Thrombectomy and pharmacolog-ic thrombolysis of mesenteric venous thrombosis. Vascular. 2007;15:41-5. PMID: 17382054.  3 Ozkan U, Oguzkurt L, Tercan F, Tokmak N. Percutaneous transhepatic thrombolysis in the treatment of acute portal ve-nous thrombosis. Diagn Interv Radiol. 2006;12:105-7. PMID: 16752359.  4 Jun KW, Kim MH, Park KM, Chun HJ, Hong KC, Jeon YS, Cho SG, Kim JY. Mechanical thrombectomy-assisted throm-bolysis for acute symptomatic portal and superior mesenteric venous thrombosis. Ann Surg Treat Res. 2014;86:334-41. PMID: 24949327.  5 Adani GL, Baccarani U, Risaliti A, Sponza M, Gasparini D, Bresadola F, de Anna D, Bresadola V. Percutaneous tran-shepatic portography for the treatment of early portal vein thrombosis after surgery. Cardiovasc Intervent Radiol. 2007;30:1222-6. PMID: 17573552.  6 Ludwig DJ, Hauptmann E, Rosoff L Jr, Neuzil D. Mesenteric and portal vein thrombosis in a young patient with protein S deficiency treated with urokinase via the superior mesenteric artery. J Vasc Surg. 1999;30:551-4. PMID: 10477649.  7 Jun KW, Kim MH, Park KM, Chun HJ, Hong KC, Jeon YS, Cho SG, Kim JY. Mechanical thrombectomy-assisted throm-bolysis for acute symptomatic portal and superior mesenteric venous thrombosis. Ann Surg Treat Res. 2014;86:334-41. PMID: 24949327.  8 Hollingshead M, Burke CT, Mauro MA, Weeks SM, Dixon RG, Jaques PF. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol. 2005;16:651-61. PMID: 15872320.  9 Ouriel K, Gray B, Clair DG, Olin J. Complications associated with the use of urokinase and recombinant tissue plasminogen activator for catheter-directed peripheral arterial and venous thrombolysis. J Vasc Interv Radiol 2000;11:295-8. PMID: 10735422.10 Schäfer C, Zundler J, Bode JC. Thrombolytic therapy in pa-tients with portal vein thrombosis: case report and review of the literature. Eur J Gastroenterol Hepatol 2000;12:1141-5. PMID: 11057461.11 Parikh S, Shah R, Kapoor P. Portal vein thrombosis. Am J Med. 2010;123:111-9. PMID: 20103016.12 Singal AK, Kamath PS, Tefferi A. Mesenteric venous throm-bosis. Mayo Clin Proc. 2013;88:285-94. PMID: 23489453.

Combination Therapy of Interventional Radiology and Surgery for Infarction of the Small Intestine Caused by Portal Vein and Mesenteric Vein Thrombosis: A Patient Report

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Combination Therapy of Interventional Radiology and Surgery for Infarction of the Small Intestine Caused by Portal Vein and Mesenteric Vein Thrombosis: A Patient Report

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