Thrombolysis for acute occlusion of the superior mesenteric artery

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Thrombolysis for acute occlusion of the superior mesenteric artery Steinarr Björnsson, MD, Martin Björck, MD, PhD, Tomas Block, MD, Timothy Resch, MD, PhD, Stefan Acosta, MD, PhD Journal of Vascular Surgery Volume 54, Issue 6, Pages 1734-1742 (December 2011) DOI: 10.1016/j.jvs.2011.07.054 Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 1 The annual number of patients treated with local thrombolysis for acute superior mesenteric artery occlusion in Sweden between 1997 and 2009. Journal of Vascular Surgery 2011 54, 1734-1742DOI: (10.1016/j.jvs.2011.07.054) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Angiography shows the superior mesenteric artery (SMA) before the start of thrombolysis in a patient with SMA occlusion. B, Angiography after local intra-arterial administration of alteplase (20 mg) through an end-hole catheter just above the embolus shows reduction of the embolic mass. C, Completion angiography shows full restoration of the circulation within the SMA. A check laparotomy afterward showed normal-appearing intestines and recovery was uneventful. Journal of Vascular Surgery 2011 54, 1734-1742DOI: (10.1016/j.jvs.2011.07.054) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 3 Flowchart shows management and survival in relation to effect of thrombolysis of the superior mesenteric artery (SMA). Journal of Vascular Surgery 2011 54, 1734-1742DOI: (10.1016/j.jvs.2011.07.054) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 4 Long-term survival of patients receiving local intra-arterial thrombolysis for acute superior mesenteric artery occlusion in Sweden. Numbers below time axis denote patients at risk at respective time point. Standard error of cumulative proportion of patient survival at end of interval is shown within parentheses. The tick marks indicate censored data. Journal of Vascular Surgery 2011 54, 1734-1742DOI: (10.1016/j.jvs.2011.07.054) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 5 Proposed algorithm for the management of patients with computed tomography (CT) identified acute superior mesenteric artery (SMA) occlusion. #Palliative care should be considered in the event of poor prognosis and extensive intestinal infarction. *Bypass to the SMA with synthetic graft is considered in patients with thrombosis when endovascular options not are available. ¤Mechanical thrombectomy after laparotomy can be performed via the endovascular route after femoral artery access or via open balloon thrombectomy from the exposed SMA. Completion angiography should also be performed after open surgery. Laparotomy is not considered mandatory in the absence of peritonitis, but is performed liberally whenever clinically indicated. Bowel resection is preferably performed after revascularization. Second-look laparotomy is recommended after bowel resections at first laparotomy or when the surgeons at first laparotomy decide to have a second-look. Journal of Vascular Surgery 2011 54, 1734-1742DOI: (10.1016/j.jvs.2011.07.054) Copyright © 2011 Society for Vascular Surgery Terms and Conditions