It has been a month since we arrived at the Cleveland CLINIC FOUNDATION, and today we encountered a rare case of THROMBOSIS OF SMV (superior mesenteric vein thrombosis), which is a relatively rare CASE, mostly seen in coagulation disorders, or secondary to pancreatitis or after abdominal surgery. Only 5-15% of ischemic lesions in the small intestine are due to SMV THROMBOSIS. The disease is characterized by non-specific abdominal pain as the first symptom, persistent vomiting, diarrhea and bloody watery stools more often than arterial embolism. On physical examination, abdominal distention, abdominal pressure, rebound pain and abdominal muscle tension are seen. Bowel sounds are diminished or absent. Hemorrhagic fluid may be drawn by laparotomy. Fever and increased white blood cell count and red blood cell pressure are often present. Abdominal radiographs may show dilated and inflated affected small bowel with air-fluid planes. Intestinal peristalsis is absent on fluoroscopy. The current non-invasive examination is mainly based on CT plus CTA. The mortality rate within 30 days with conventional surgery and anticoagulation can be 13% to 50%. The 3-year mortality rate for acute SMV THROMBOSIS at follow-up is 36%. After 30 days, the survival rate can reach 88%. Therefore, it is crucial to make it through 30 days. At present, the treatment is mainly based on medical anticoagulation and thrombolysis, while surgery is based on surgical resection of necrotic intestine and embolization, and interventional treatment includes indirect thrombolysis via superior mesenteric artery and percutaneous mechanical retrieval via intrahepatic catheter with thrombolysis. Interventional treatment is mainly the former in China, while in the United States, only some large hospitals such as M CLINIC, JOHNS HOPKINS, CCF, etc. are equipped with mechanical thrombus retrieval and thrombolysis. The patient today is also an idiopathic SMV THROMBOSIS and was transferred to CCF from an outside hospital for 3 days. However, after nearly 2.5 hours of attempts, we found that the angular relationship between the hepatic vein and the right branch of the portal vein was very complicated and difficult to penetrate. So we chose the percutaneous transhepatic route, guided by CO2 contrast, and directly punctured the right lower limb branch of the portal vein through the right lobe of the liver in the mid-axillary line, and then sequentially placed guidewire catheters to establish access, and the contrast confirmed that the main thrombus was located at the intersection of the SMV and the main trunk of the portal vein. Catheters and long sheaths were used for thrombus aspiration. These are all relatively expensive in China and difficult for the average patient to afford. At this time, I really appreciate the feeling of doing interventional PROCEDURE in the United States, an affluent country, one word — cool, what you want to use without considering the patient’s family or the patient’s financial situation, only one purpose on the stage is to successfully complete the PROCEDURE, all for the sake of the patient’s treatment. Unlike in China, I used two puncture needles for a small chest mass biopsy (because the puncture needles were imported and not covered by medical insurance) and was questioned and even threatened by the family. So this comparison shows that it is much more difficult to be a doctor in China than in the United States. More often than not, doctors have to spend some of their energy explaining the cost of various methods to patients and their families, and then provide options based on the cost and the effectiveness of the corresponding method of treating the disease, with the aim of both seeing well and spending less money, which is the basic principle that patients and doctors have in the domestic medical market. This patient seemed to improve a lot after such an intervention, but because of the long operation time of 5 hours, complete elimination of the thrombus was not achieved, so a special thrombolytic catheter for COOK was then implanted to dissolve the thrombus with a small dose of TPA. Because TIPS was done in front, the number of punctures was high, and the dosage was too large, mainly for fear of bleeding complications. Of course, the specific effect remains to be seen.