Case of the Month 2016-03

Submitted by Jordan Gutovich, MD and Thomas J. Learch, MD.

The patient is a 56-year-old female with a past medical history significant for morbid obesity, deep vein thrombosis and pulmonary embolism. She took Coumadin daily but discontinued the medication, as instructed by her physician, 10 days prior to undergoing an elective gastric bypass. Approximately two weeks after her elective surgery, she developed acute diffuse severe abdominal pain and presented to our institution. On initial exam, her abdomen was soft and obese with well-healing surgical sites. She was mildly tender to palpation in the epigastrium, but without guarding or peritoneal signs. However, her labs revealed an elevated white blood cell count. Imaging was performed.

For larger images, please click on March 1 , March 2 , March 3   and March 4 .

Above: Contrast enhanced axial image of the abdomen demonstrating dilated loops of small bowel with associated wall thickening and hyperemia. Mesenteric fat stranding is present.

Above and below: Coronal reformatted images demonstrating the same findings as above.

Below: Coronal reformatted image showing acute thrombosis of the superior mesenteric vein from just below the portal confluence all the way to and including several branch vessels. In addition, the superior mesenteric vein is expanded.

The patient was referred to interventional radiology where she underwent portal venography. Thrombus was identified projecting into the main portal vein at the confluence of the the portal and superior mesenteric veins. Pulse spray AngioJet was performed with TPA along the main superior mesenteric vein. However, superior mesenteric venography after AngioJet showed persistent clot within the mid and proximal portions of the superior mesenteric vein. Thrombectomy was performed with a Trerotola device, as well as venoplasty with an 8 mm balloon. The final superior mesenteric venogram demonstrated successful thrombectomy of the superior mesenteric vein with rapid antegrade flow into the portal vein. A small amount of chronic clot remained along the wall of the mid superior mesenteric vein. However, the patient improved and did not require any resection of small bowel.

For larger images, please click on March 5 March 6 , March 7 and March 8 .

Below: Venography demonstrating well opacification of the portal and splenic veins.

Below: There is a large filling defect in the superior mesenteric vein secondary to thrombus.

Below: Image of balloon venoplasty being performed in the SMV near the confluence with the portal vein.

Venography post venoplasty and heparin infusion via an AngioJet device demonstrating improved opacification of the superior mesenteric vein.

Superior Mesenteric Vein Thrombosis

In comparison to superior mesenteric artery thrombosis and small bowel obstruction, superior mesenteric vein (SMV) thrombosis is a rare cause of mesenteric ischemia. Some inciting causes include a hypercoagulable state, recent surgery, portal hypertension and narrowing of the SMV due to malignancy. Our patient’s history include both a hypercoagulable precondition as well as recent abdominal surgery. Traditionally, surgery has been employed for evaluation of bowel necrosis and bowel resection when necessary. More recently, patients without evidence of bowel infarction are seen by interventional radiology and undergo catheter directed thrombolysis and or thrombectomy of the clot. Such was the case for our patient who was successfully treated by interventional radiology.

References

Furukawa A, Kanasaki S, Kono N et-al. CT diagnosis of acute mesenteric ischemia from various causes. AJR Am J Roentgenol. 2009;192 (2): 408-16.

Warshauer DM, Lee JK, Mauro MA et-al. Superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases. AJR Am J Roentgenol. 2001;177 (4): 837-41.

Goldberg MF, Kim HS. Treatment of acute superior mesenteric vein thrombosis with percutaneous techniques. AJR Am J Roentgenol. 2003;181 (5): 1305-7.

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