We successfully treated a critically ill patient with acute superior mesenteric vein thrombosis by using “minimally invasive interventional therapy as the core of the stepwise treatment model”.
Acute mesenteric ischemia is a rare abdominal vascular emergency, and acute superior mesenteric vein thrombosis is the most rare form of it, accounting for about 5-15%. Its insidious onset and improper treatment can easily cause large intestinal necrosis, requiring large resection of the small intestine, and even leading to multi-organ dysfunction or failure, endangering life. The diagnosis and treatment of this disease is extremely complex, requiring doctors to have excellent gastrointestinal surgery, vascular surgery, endovascular treatment techniques, and to be able to skillfully complete complex operations such as transjugular portal vein puncture (TIPS route) placement, percutaneous transhepatic portal vein puncture placement, and superior mesenteric artery placement, without one. The treatment cycle is long and requires a high level of skill.
The medical team led by Prof. Wu Sex Jiang, Deputy Director of General Surgery of Nanjing General Hospital of Nanjing Military Region and Chief Physician of the Institute of General Surgery of the Chinese PLA, under the guidance of Dr. Li Jieshou, a famous Chinese general surgeon, has explored a new international advanced “minimally invasive interventional therapy as the core of the stepwise treatment model” through long-term exploration and repeated clinical evidence. “It has successfully treated nearly 50 cases of acute superior mesenteric vein thrombosis and achieved excellent clinical efficacy. This model has been published in many international and domestic authoritative journals and has been recognized by domestic and foreign colleagues. The following will introduce a case of acute superior mesenteric vein thrombosis successfully treated by using this diagnosis and treatment model: patient Wang Moumou, female, 36 years old, had sudden onset of peribulbar distension and pain without obvious cause for 4 days, no vomiting, vomiting blood, mild diarrhea, no black stool, blood in stool, physical examination: abdominal softness, pressure pain in right lower abdomen, no rebound pain. He was diagnosed as “acute gastroenteritis” at the local hospital and given symptomatic and supportive treatment such as fasting, acid suppression, rehydration, anti-infection and anti-diarrhea, but no significant improvement was seen. When the patient was transferred to a higher level hospital, the abdominal distension and abdominal pain were further aggravated, and mild to moderate rebound pain in the right lower abdomen, tension in the right lower abdomen, and symptoms of systemic infection such as high fever, chills, and high white blood cells, as well as oliguria and significant increase in creatinine, which showed signs of acute kidney injury. The patient was considered to have acute ischemic enteropathy and possible mesenteric vein thrombosis by enhanced abdominal CT, and was recommended to be transferred to the General Surgery Department of Nanjing General Hospital of Nanjing Military Region for further treatment. After the patient was transferred to our hospital, he was given fasting, acid suppression, fluid replacement and volume expansion, improvement of microcirculation, anti-infection, low molecular heparin anticoagulation and other treatments. “In the afternoon of the same day, DSA portal venography was performed to identify the site of thrombosis and the degree of obstruction, and a thrombolytic catheter was placed via jugular puncture of the portal vein (TIPS route) and superior mesenteric artery. renal replacement) therapy, and total parenteral intravenous nutrition support. After 48 hours of CRRT treatment, creatinine decreased to normal level, abdominal distension and abdominal pain gradually improved, right lower abdominal rebound pain disappeared after 6 days, abdominal tension disappeared, and DSA portal venography and abdominal portal vein vascular enhancement CT were reexamined, suggesting that thrombus was significantly reduced, portal vein and superior mesenteric vein were basically opened, but there was still a little residual thrombus. After 1 week, DSA portal venogram and abdominal portal vein vascular enhancement CT were rechecked again, indicating that the thrombus had dissolved more than 95%, and there was mild to moderate stenosis in the main mesenteric trunk and local contracture and swelling of the intestinal canal in the right lower abdomen. The portal vein thrombolytic catheter was removed and the balloon catheter was stenosed and dilated. After returning to the ward, the patient was treated with intensive nutritional support and gradually transitioned from parenteral nutrition to enteral nutrition, and was discharged successfully.
A, B: On admission, enhanced CT portal venography showed extensive thrombosis in the superior mesenteric vein, intestinal wall edema, and thickened mesentery. C: Direct portal venography through the jugular vein intrahepatic portosystemic shunt route before thrombolysis showed extensive thrombosis in the main trunk and branches of the superior mesenteric vein. D, E: Indirect portal venogram of the superior mesenteric artery before thrombolysis shows dark, defective filling in the superior mesenteric vein and no contrast entry in the intestinal wall. F, G: Enhanced CT portal venography at the same level as A and B after the end of thrombolysis showed that the superior mesenteric vein was patent and no significant wall thrombus remained. H: Direct portal venography via thrombolytic catheter 6 days after the start of thrombolysis showed patency of the portal vein with a small amount of residual thrombus in the superior mesenteric vein. The superior mesenteric artery catheter was removed and the superior mesenteric vein catheter was kept in place for 6 days. I, J: 6 days after the start of thrombolysis, an indirect image of the superior mesenteric artery was performed. The same time phase image as D and E showed patency of the portal vein and the main trunk, branches, and tertiary branches of the superior mesenteric vein.