Local thrombolytic therapy in acute mesenteric ischemia
© Yanar et al.; licensee BioMed Central Ltd. 2013
Received: 25 December 2012
Accepted: 29 January 2013
Published: 9 February 2013
The aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).
From January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.
LTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.
Early intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.
Acute mesenteric ischemia (AMI) is a lethal disease with high mortality rates ranging from 24 to 94%. This is attributed to delayed diagnosis, ineffective treatment regimens and moribund patients [1–3]. Recent advances include use of computerized tomography angiography (CTA) for prompt diagnosis, sophisticated methods such as local thrombolytic therapy (LTT) for treatment and laparoscopy for both. Multidetector CTA is a fast and accurate method with a sensitivity and specificity of 94 and 96%, respectively [4, 5]. This diagnostic accuracy has been combined with promising treatment alternatives, mainly LTT, and better prognosis has been achieved [6, 7]. Recently, laparoscopy has proved itself as an evaluation method of acute abdomen. Thus, laparoscopic exploration became available for diagnosis of necrotic bowel segments, and treatment strategies are tailored thereafter . Second look laparoscopy in order to assess bowel viability after bowel resection or thrombolysis has been employed frequently, which further improves outcomes in acute mesenteric ischemia .
This paper aims to evaluate the experience of a referral center in acute mesenteric ischemia and results of the algorithm applied.
Materials and methods
From January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed and records and data charts of all these patients were evaluated retrospectively.
The method of mesenteric angiography included lateral aortography and catheterization of SMA. The guidewire was threaded into the orifice of the artery. If the SMA could be catheterized, LTT was initiated with recombinant plasminogen activator (rt-PA, Actilyse®, Boehringer Ingelheim GmbH) of 5 mg bolus, followed by 1 mg/h maintenance. After 24 h of treatment another angiography was performed and the catheter was withdrawn.
Patients were discharged with anticoagulating therapy in cases of AMI due to emboli and antiplatelet therapy and statins in cases of atherosclerosis and at follow-up they were evaluated with CTA at 3rd, 6th and 1 year.
LTT was performed in 13 (17.1%) patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). There were 11 (84.6%) males and 2 (15.4%) females. All patients presented with acute abdominal pain. There were no patients with a known diagnosis of chronic mesenteric ischemia (CMI). However, history revealed post-prandial pain suggestive of CMI in 3 patients (23%). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h of onset of symptoms, whilst 9 (69.3%) patients presented after 24 h of the onset of symptoms. Diabetes mellitus was present in 8 (61.5%), hypertension in 6 (46.1%), hyperlipidemia in 2 (15.3%) patients, ischemic heart disease in 7 (53.8%), smoking in 7 (53.8%), and arythmia in 6 (46.1%) patients. Physical examination revealed positive peritoneal signs in 8 (61.5%) patients, while there were not any physical findings in 5 (39.5%) patients.
Patients without peritoneal signs on physical examination and with AMI findings on CTA underwent percutaneous SMA catheterization and LTT. One patient had multiorgan failure during the treatment and died. There were not any signs of intracranial or internal bleeding during the hospitalization of the patient. All other four patients improved and discharged without any further intervention and followed-up by CT- angiography on 3rd, 6th and 1 year follow-up. The admission time was less than 24 h in four of these patients.
Acute mesenteric ischemia is a potentially lethal disease. Early recognition and accurate intervention remains the cornerstone of treatment. Patients may present with severe abdominal pain despite mild physical signs. Therefore, clinical suspicion is mandatory for the diagnosis, though these findings may be absent in 25% of cases . In this series, all patients presented with abdominal pain. However, symptoms ranged from mild to severe such as acute abdomen.
Duplex ultrasonography accurately identifies high-grade stenoses of the celiac artery and superior mesenteric artery (SMA), and is the diagnostic modality of choice for chronic mesenteric ischemia. However, it is not suitable for diagnosing acute arterial mesenteric ischemia. It is operator-dependent and overall diagnostic accuracy may change, especially at off-hours. Moreover, solely the proximal segment of SMA can be evaluated by duplex because SMA emboli tend to lodge more distally. This creates the potential for a false-negative result . Furthermore, although there are case reports concerning contrast-enhanced ultrasonography in AMI, acute cases usually present with overt abdominal gas and inflammatory changes, which may intervene with imaging by duplex . Therefore, recent advances in optimizing CTA had promising results in diagnosing AMI. Helical, multidetector and multislice CTA is a fast and accurate investigation for the diagnosis of acute mesenteric ischemia . It delineates vascular anatomy, evaluates bowel necrosis and allows early diagnosis. In most cases CTA can be used as a sole diagnostic procedure with 96% sensitivity and 94% specificity [4, 5]. In our patients, we preferred to use CT as a first diagnostic step.
Laparoscopic surgery, with high diagnostic accuracy can be safely and effectively applied to the patients with acute abdominal emergencies. It is a valuable tool to prevent unnecessary laparotomies when routine investigations fail to identify the cause. It provides a highly important advantage for detecting the degree of bowel ischemia in AMI following diagnosis with CTA . Although its use in AMI is questioned in a recent review, our experience proved otherwise . After laparoscopy has been successfully introduced and adapted for daily use over the years, its accuracy has been better by improving through technology . Therefore, we utilize laparoscopic exploration in a routine basis in recent years and have shifted our treatment algorithm for AMI in favor of initial laparoscopic exploration. However, if the exploration can not provide enough information regarding the viability of the entire bowel, laparotomy is indicated.
Thrombolytic therapy is an effective and quick treatment modality for AMI and may obviate surgery and has the potential to resolve the clot completely [15, 16]. If resolution occurs partially, it already serves as an adjunctive to surgery by sparing an amount of near-ischemic bowel segments [6, 7].
In conclusion, acute arterial mesenteric ischemia remains one of the most lethal conditions in patients presenting with an acute abdomen. A high index of suspicion is mandatory for diagnosis. CT-angiography combined with early laparoscopic exploration and thrombolytic treatment may have beneficial effects regarding mortality.
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