A 65-year-old woman was admitted with diffuse abdominal pain, diarrhea, and hematochezia of one day's duration. Her medical history included surgical repair of an anterior mitral valve cleft and an associated ostium primum atrial septal defect, implant of a single-chamber pacemaker programmed in VVIR mode for complete atrioventricular block, and stroke despite appropriate anticoagulant therapy for paroxysmal atrial fibrillation (AF). At admission, the patient had been on chronic anticoagulant therapy with acenocoumarol (target international normalized ratio, 3.0). Mesenteric arterial embolization was highly suspected.

Abdominal computed tomographic angiograms revealed a large thrombus in the first 5 cm of the superior mesenteric artery (SMA) distal to its ostium (Fig. 1). Within 6 hours, this finding was confirmed on a mesenteric angiogram (Fig. 2A). Access was obtained by introducing a 6F angiographic catheter into the right brachial artery and advancing it to the SMA. Next, the 6F angiographic catheter was exchanged for a 6F multipurpose guiding catheter. Under fluoroscopic guidance, the multipurpose catheter was passed through the thrombotic segment several times. A large amount of thrombotic material was manually aspirated from the SMA and its branches by means of suction from a large-bore 50-mL syringe connected externally to the guiding catheter (Fig. 2B). A final postprocedural mesenteric angiogram confirmed thrombus removal (Fig. 2C), which was accompanied by prompt relief of symptoms and normalization of laboratory values.

Fig. 1

Computed tomographic angiograms show nonobstructive thrombus in A) the distal segment (arrow) of the superior mesenteric artery (left lateral view) and B) its branches (arrow) (oblique transverse view).

Fig. 1

Computed tomographic angiograms show nonobstructive thrombus in A) the distal segment (arrow) of the superior mesenteric artery (left lateral view) and B) its branches (arrow) (oblique transverse view).

Fig. 2

A) Angiogram of the superior mesenteric artery (SMA) shows thrombus (arrow), located at a large bifurcation, causing subocclusive stenoses. B) Photograph shows thrombotic material manually aspirated from the SMA, next to a 2.5-mL syringe shown for scale. C) Postthrombectomy angiogram shows the SMA free of thrombus proximally (arrow) but still containing residual microemboli distally.

Fig. 2

A) Angiogram of the superior mesenteric artery (SMA) shows thrombus (arrow), located at a large bifurcation, causing subocclusive stenoses. B) Photograph shows thrombotic material manually aspirated from the SMA, next to a 2.5-mL syringe shown for scale. C) Postthrombectomy angiogram shows the SMA free of thrombus proximally (arrow) but still containing residual microemboli distally.

The thrombotic event was considered embolic, given the patient's history of stroke despite anticoagulant therapy, incomplete occlusion of the SMA just distal to its ostium, and the absence of ostial calcified atherosclerosis. The patient's anticoagulation regimen was switched from acenocoumarol to apixaban 5 mg 2×/d and clopidogrel 75 mg/d. Four days after the thrombectomy and an uncomplicated course of recovery, she was discharged from the hospital. At one-year follow-up, she had experienced no recurrent cardioembolic events.

Comment

Acute mesenteric ischemia is typically caused by SMA emboli and, despite advances in endovascular therapy, is associated with high morbidity and mortality rates.1  Early diagnosis and revascularization are essential to prevent intestinal complications. However, because acute mesenteric ischemia is rare and often associated with nonspecific abdominal pain, diagnosis is difficult. This is particularly relevant in patients with AF, in whom early evaluation by computed tomographic angiography is crucial.2  The development of thrombosis despite appropriate anticoagulation for comorbid AF puts patients at high risk for bleeding during surgery and thus poses additional therapeutic challenges. For patients who are promptly diagnosed and show no signs of advanced bowel ischemia, percutaneous revascularization is a viable option.3  If an aspiration catheter is not available, manual aspiration thrombectomy is feasible.

Section editor: Raymond F. Stainback, MD

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