|Year : 2016 | Volume
| Issue : 4 | Page : 136-138
Celiac artery thrombosis and superior mesenteric artery stenosis
Mohit Sharma, Ghanshyam Kumawat
Department of Cardiovascular and Thoracic Surgery, J.L.N. Medical College, Ajmer, Rajasthan, India
|Date of Web Publication||20-Dec-2016|
Department of Cardiovascular and Thoracic Surgery, J.L.N. Medical College, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
Acute thrombosis of the celiac artery trunk or elsewhere in mesenteric blood supply is a rare cause of acute abdominal pain. Celiac artery thrombosis carries high mortality and morbidity rates if the diagnosis and treatment are delayed. It is frequently associated with other cardiovascular events. The most common etiology is atherosclerosis. The main goal of the treatment is to revascularize and start the diminished or stopped mesenteric blood flow and to avoid end-organ ischemia. Thrombolysis with urokinase followed by anticoagulation with heparin in an emergency situation can save the life of the patient before surgical intervention.
Keywords: Celiac trunk thrombosis, ischemic mesenteric pain, superior mesenteric artery thrombosis
|How to cite this article:|
Sharma M, Kumawat G. Celiac artery thrombosis and superior mesenteric artery stenosis. Heart India 2016;4:136-8
| Introduction|| |
Thrombosis of the celiac artery trunk is a rare cause of acute abdominal pain. Conditions that increase the tendency toward thrombosis such as atherosclerosis, collagen tissue disorders, coagulation abnormalities, and malignancies are the leading causes of celiac artery thrombosis. Computed tomography (CT) angiography is the gold standard of the diagnoses. The purpose of treatment is to reestablish blood flow in the mesenteric vessels and to prevent end-organ ischemic damage and infarct. Percutaneous angioplasty and surgical treatment are the preferred methods of treatment for celiac artery thrombosis. It is usually associated with other cardiovascular diseases. Although there is a substantial development in the diagnoses and treatment of celiac artery thrombosis, hospital mortality is still rated at 59–93%. The successful treatment depends on early diagnoses and elective intervention with thrombolysis followed by either surgical or endovascular to reestablish blood flow and surgical resection of necrotic parts and good intensive care unit management.
| Case Report|| |
A 45-year-old, chronic smoker, male was presented to the emergency department with 1 day history of severe, excruciating, and constant pain in the abdomen mainly in the central and right upper quadrant. The pain was severe enough to awake the patient from sleep and increased after having food. There was no history of vomiting, loose stool, hematemesis, melena, fever, trauma, and oliguria. Similar attack of pain was also present for the last 2 years, and the frequency was once in a month. On examination, pulse rate 130 beats/min, blood pressure 110/60 mmHg, respiratory rate 25/min, and the temperature was normal. Pain and tenderness was present in the right hypochondrium and epigastrium. There was no guarding and rigidity; per-rectal examination was also normal. Routine laboratory investigations suggested hemoglobin 13.0 g%, total leukocyte count 17,900, differential leukocyte count (N 80%, L 9%), platelet 2 lacs, fasting blood sugar 108 mg/dl, serum urea 20 mg%, creatinine 0.7 mg%, serum amylase 41 I.U., bilirubin (T 0.9 mg/dl D 0.2 mg/dl), and international normalized ratio (INR) 1.31. X-ray - flat plate abdomen was normal; ultrasound suggested superior mesenteric artery (SMA) thrombosis. For confirmation, CT angiography abdomen was also done [Figure 1] and [Figure 2]. Celiac trunk was completely thrombosed and SMA narrowing >50% was evident in CT angiography [Figure 2]. After thrombolysis with urokinase and anticoagulation with heparin, the patient recovered well. After achieving the target INR, the patient was discharged with oral antiplatelet and anticoagulant drugs. In a follow-up after 1 month, there were no fresh complaints and the patient doing well.
|Figure 1: Computed tomography angiography showing celiac artery thrombosis|
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|Figure 2: Computed tomography angiography showing superior mesenteric artery stenosis|
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| Discussion|| |
Celiac artery thrombosis is a rare entity and carries a high mortality rate. The main pathogenic causes such as atherosclerosis, thrombocytosis, protein S, protein C, antithrombin III deficiency, and Behcet's disease and malignancies increase thrombotic tendency. Patients may present with sudden onset abdominal pain or nonspecific abdominal complaints. Direct abdominal X-ray and ultrasonography are helpful in diagnoses; however, computed tomography angiography is the primary diagnostic method; it is helpful in the exact localization of the obstruction and the condition of collateral circulation. Early diagnoses and treatment of acute mesenteric ischemia are apparently demonstrated in many reports.
As a standard protocol of our cardiovascular unit, thrombolysis by urokinase is given first to the patient, then bypass surgery if needed. We use a standard dose of urokinase which is used in pulmonary thromboembolism, i.e. 4400 I.U./kg for loading and 2200 I.U./kg/h for 24–36 h. Then, we start heparin and injection xanthinol nicotinate in dextran with oral antiplatelet and anticoagulants, i.e. aspirin, acitrom, to achieve the target INR up to 2.5. We use xanthinol nicotinate in every case of peripheral vascular disease (PVD) for symptomatic improvement and already reported its role in PVD cases; however, in mesenteric ischemia, its role is yet to prove.
Johnston et al. performed mesenteric arterial bypass in 34 patients with acute or chronic mesenteric ischemia, and they reported good outcomes in both early and late results. Kim and Kim  reported a case of celiac artery thrombosis, and splenic infarction was surgically treated, and it was related to protein S deficiency.
In case of suspicion of acute mesenteric ischemia, emergency angiographic imaging and immediate revascularization by thrombolysis or surgery are always lifesaving. Endovascular procedures such as balloon angioplasty or surgical bypass are the preferred treatment of choice. Endovascular interventions are nowadays becoming popular because of lower complications. A report comparing the endovascular and surgical treatment of mesenteric ischemic patients demonstrated that early inhospital complication rates were higher in the surgically treated group whereas a 3-year mortality rate was similar. However, after 3 years the symptomatic recurrence rate was significantly higher in the angioplasty group. [5,6] Biebl et al. also reported similar results stating that the surgical group has better long-term results with less need of secondary interventions.
| Conclusion|| |
We conclude that initial thrombolysis with urokinase followed by anticoagulation with heparin is a lifesaving management before surgical intervention for celiac trunk thrombosis patients. Early diagnosis and intervention can save the life of the patient. Most of the patients respond to thrombolytic and anticoagulation therapy, so patient can be managed conservatively first if diagnosed properly.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]