Thrombolysis via an Operatively Placed Mesenteric Catheter for Portal and Superior Mesenteric Vein Thrombosis: Report of a Case (original) (raw)

bowel resection and thrombolytic infusion via a jejunal vein. Case Report A 52-year-old woman who had been taking warfarin for 4 years because of previous portal vein thrombosis presented with acute abdominal pain. Evaluation of hypercoagulablity revealed decreased protein C activity to 20% (70%-140%) and decreased protein S activity to 56% (70%-123%). The patient stated that she had stopped taking warfarin 6 months earlier. Physical examination revealed a distended abdomen with diminished bowel sounds and rebound tenderness. Laboratory analysis detected an elevated WBC count, and normal prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT) levels, and blood chemistry. Computed tomography (CT) showed thrombosis of the SMV with a thickened small bowel wall (Fig. 1). Heparin treatment was initiated with a bolus dose of 5000 U followed by a continuous infusion of 1000 U/h. Surgical exploration identified free peritoneal fluid, a thickened small bowel, and edematous mesentery with hard and thrombosed jejunal veins. We resected a 20-cm jejunal segment, which was infarcted, and performed end-to-end anastomosis. A peripheral jejunal vein was isolated and cut down. A central venous catheter with side holes was inserted and positioned at the confluence of the SMV and splenic vein under fluoroscopic guidance. Angiography through the catheter showed a tortuous and dilated splenic vein, but no image of the SMV and PV (Fig. 2). The other end of the catheter was brought through the abdominal wall, and a temporary abdominal closure was done in preparation for the planned second-look operation. Mesenteric thrombolysis was carried out with a bolus infusion of 1 500 000 U streptokinase just after the Abstract Mesenteric venous thrombosis (MVT) is a catastrophic form of mesenteric vascular occlusion. In the absence of peritoneal signs, anticoagulation therapy should be started immediately. For selected patients, thrombolysis through the superior mesenteric artery (SMA), jugular vein, or portal vein via a transhepatic route might be successful; however, exploratory laparotomy is mandatory when peritoneal signs develop. We report a case of acute MVT associated with protein C and S deficiency, treated successfully by limited bowel resection and simultaneous thrombolytic infusion, given via an operatively placed mesenteric vein catheter.

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