AJR 2000; 175:855
© American Roentgen Ray Society
Vascular/Interventional Case of the Day |
Case 1
Mesenteric Vein Thrombosis (MVT)
Pablo Gamboa,
Ricardo Barboza and
Dimitrios Spigos
MVT accounts for 5-15% of all mesenteric ischemic events and occurs most
commonly during the sixth and seventh decades of life. It has a mortality rate
of 100% if left untreated and 80% if operative intervention is performed in
the presence of intestinal infarction. MVT has a 30% postoperative recurrence
rate with a 30-40% mortality rate in those patients in whom it reoccurs
[1]. Eighty percent of cases of
MVT are caused by a variety of entities such as coagulation disorders
(protein-C deficiency, protein-S deficiency, antithrombin III deficiency,
dysfibrinogenemia), oral contraception, malignancy, lymphoproliferative
disorders, trauma, intraabdominal and inflammatory infectious processes, and
pregnancy. MVT leads to venous hypertension, outpouring of fluid into the
bowel lumen and mesentery, distention and rupture of venules, hemorrhage, and
edema of the bowel wall. Necrosis of the bowel is found in nearly 40% of
cases. Clinically, patients may present with an acute abdomen or with
insidious progressive pain (Fig.
1A,1B,1C).
In late stages, signs of peritoneal irritation that indicate bowel infarction
and abdominal distention are common. Clinical and laboratory findings are
usually nonspecific. Noninvasive imaging such as CT, MR imaging, or sonography
can enable reliable diagnosis of MVT. Signs of MVT on IV contrast-enhanced CT
scans include a thickened edematous bowel wall, fluid or hemorrhage in the
mesentery, and thrombus within the vein, which may or may not be distended. A
rim of contrast material surrounding the thrombus may represent filling of the
vasa vasorum. If physical examination suggests peritonitis, surgical treatment
is mandatory. All patients should be treated with heparin to prevent
propagation of thrombus. Long-term anticoagulation with warfarin should be
considered as well, and life-long anticoagulation is necessary in patients
with familial coagulopathies
[1]. Few reports on
percutaneous treatment of MVT are available at present. Various interventions
have been performed to restore patency of the superior mesenteric vein. In
cases of acute thrombosis, transcatheter thrombolysis has been successfully
used from a jugular, transhepatic, or transarterial approach. Mechanical
thrombectomy has been used with a transjugular approach as well. A
transjugular intrahepatic portosystemic shunt procedure may be necessary in
other cases to restore good flow and to facilitate additional interventions.
Other authors have used a minilaparotomy operative approach for
revascularization. Selected cases of chronic occlusion have been managed with
percutaneous transhepatic or transjugular revascularization using metallic
stents [2].
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Fig. 1A. —53-year-old man who presented with 5-day history of progressive
acute abdominal pain. CT scan reveals ectatic, lobulated bifurcation of main
portal vein (arrow). Presence of webs within vessel lumen is noted,
which is suggestive of cavernous transformation of portal vein.
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Fig. 1B. —53-year-old man who presented with 5-day history of progressive
acute abdominal pain. CT scan shows patent superior mesenteric artery
(black arrow). Thrombus is noted in lumen of superior mesenteric
vein, surrounded by hyperdense rim (white arrow).
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Fig. 1C. —53-year-old man who presented with 5-day history of progressive
acute abdominal pain. Venous phase of selective superior mesenteric
arteriogram reveals occlusion of superior mesenteric vein with intraluminal
thrombus reaching level of splenoportal confluence (white arrow). No
filling of superior mesenteric vein is seen. Large venous collateral drains
into portal vein (short black arrow). Main portal vein is patent
(long black arrow). Presence of several enlarged, tortuous veins
indicates changes of cavernous transformation of main portal vein at hepatic
hilum (arrowhead). Splenic vein (not shown) was widely patent.
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This particular patient has a hypercoagulable state with protein-C and
protein-S deficiencies, has had several episodes of deep venous thrombosis of
the lower extremities, and has esophageal varices that bled recently and need
endoscopic banding.
Small-bowel obstruction was incorrect because the loops of small bowel seen
in the scans are not dilated.
Mesenteric artery thrombosis with cavernous transformation of the portal
vein was incorrect because the superior mesenteric artery was patent.
References
-
Harward TRS, Coe D, Flinn WR. Mesenteric venous thrombosis. In:
Strandness Jr DE, Van Breda A, eds. Vascular diseases: surgical and
interventional therapy. New York: Churchill Livingstone,
1994: 845-850
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Sehgal M, Haskal Z. Use of transjugular intrahepatic portosystemic
shunt during lytic therapy of extensive portal splenic and mesenteric superior
venous thrombosis. J Vasc Interv Radiol
2000; 11:61
-65[Medline]
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