289

Case Report

I
Percutaneous Transhepatic Recanalization and
Thrombolysis of the Superior Mesenteric Vein
J. Robert Yankes,1 John P. Uglietta,1 John Grant,2 and Simon D. Braun1’3

Thrombolysis has been described in a variety of settings branch of the right portal vein was punctured in a single pass with a
and is well established in the treatment of peripheral arterial, 22-gauge Chiba needle (Medi-Tech, Watertown, MA). A 0.01 8-in.
dialysis shunt, and coronary arterial thrombosis. We report (0.046-cm) mandril guidewire was advanced into the portal vein. A
our experience in applying this technique in a patient who had coaxial 4/6 French Braun dilator (Cook, Bloomington, IN) was used
to dilate the tract with exchange to a 6.5-French Kumpe catheter
thrombosis of the superior mesenteric vein.
(Cook). Vigorous hand injection showed a contour bulge at the orifice
of the superior mesenteric vein. A 0.038-in. (0.097-cm) straight guide-
wire was used to probe the orifice and was advanced through the
Case Report
thrombus. The wire was advanced more peripherally into the superior
A 58-year-old woman presented with a 10-month history of pro- mesentenc vein, and the Kumpe catheter was advanced through the
gressive epigastric and back pain and recent onset of jaundice and thrombus. As the catheter was slowly withdrawn through most of
acholic stools. An abdominal CT was performed at another hospital, the length of the thrombus, urokinase was injected by hand at a
and a mass was identified in the head of the pancreas. Subsequent concentration ofS000 units/mlfor a total of2O,000 units. The catheter
percutaneous biopsy revealed pancreatic carcinoma. She was trans- was left with its tip embedded in the most central portion of the
ferred to Duke University Medical Center and underwent a pancrea- thrombus, and urokinase was infused at a rate of 4000 units/mm for
ticoduodenectomy. During this procedure, the superior mesenteric a total of 4 hr, with periodic hand injections of contrast material to
vein was mobilized and freed of adherent tumor, leading to a rent in adjust the catheter position more peripherally and to follow the
the vein, which was closed with a 6.0 suture. Her postoperative progression of thrombolysis. After demonstration of a narrow but
course was complicated by sepsis, pneumonia, and respiratory dis- patent lumen, a 0.038-in. (0.097-cm) guidewire was once again
tress requiring prolonged intubation. She developed massive ascites advanced into the peripheral superior mesenteric vein, and an 8-mm
and had hypoactive-to-absent bowel sounds. Plain abdominal radio- occlusion balloon was introduced. This was swept repeatedly through
graphs suggested the presence of bowel wall edema. A CT scan the central region of the superior mesenteric vein in order to clear
suggested thrombus in the superior mesenteric vein (Fig. 1A). She residual thrombus. At the location of previous thrombosis, significant
was started on total parenteral nutrition. Three weeks later, because resistance and balloon deformation indicated a structural stenosis.
her condition had not improved, the patient was referred for mesen- An 8-mm-diameter angioplasty balloon was introduced, and the vein
teric angiography, which revealed severe peripheral splanchnic vaso- was dilated with three separate 60-sec inflations. Reinjection of the
constriction, bowel wall thickening, and occlusion of the proximal peripheral superior mesenteric vein through the angioplasty balloon
superior mesenteric vein (Fig. 1B). Selective splenic arteriography lumen showed patency (Fig. i C). The catheter was slowly withdrawn
showed patency of the portal vein. Because of the patient’s poor through the portal vein until hand injection of contrast material mdi-
overall physical condition, she was considered a poor candidate for cated that its tip lay in the liver parenchyma. Two tandemly placed 3-
surgical thrombectomy and was referred for percutaneous recanali- mm Gianturco coils were deposited within the tract, and a single large
zation of the superior mesenteric vein. plug of Gelfoam was placed peripherally near the liver surface. The
Because the splanchnic venous flow was being shunted away from patient was then given heparin.
the occlusion by collateral vessels and because an arterial approach Bowel sounds gradually returned during the week after the pro-
would preclude passing a guidewire through the occluded segment cedure. A follow-up sonogram of the portal and mesenteric veins
to create a channel for the flow of thrombolytic agents, a portal indicated antegrade flow of blood from the superior mesenteric vein
venous approach was chosen. In order to limit the number of needle into the portal vein, and CT performed 16 days later confirmed
passes and thus reduce the risk of hemorrhage, sonographic guid- patency of the superior mesenteric and portal veins. Ascites gradually
ance was used to choose an entry point for transhepatic catheteri- resolved, and the patient was started on nasojejunal tube feedings.
zation of the portal vein. With the patient under local anesthesia, a Two weeks later, clinical deterioration led to exploratory laparotomy,

Received January 4, 1988; accepted after revision February 21 , 1988.

I Department of Radiology, P.O. Box 3808, Duke University Medical Center, Durham, NC 27710. Address reprint requests to J. R. Yankes.
2 Department of Surgery, Duke University Medical Center, Durham, NC 27710.
3 Present address: Department of Radiology, Memorial Mission Hospital, Asheville, NC 28801.
AJR 151:289-290, August 1988 0361-803X/88/1 51 2-0289 © American Roentgen Ray Society
 Fig. 1.-58-year-old woman who had thrombosis of the superior mesenteric vein.
A, CT scan shows thrombus within superior mesenterlc veIn (arrow).
B, Venous phase of superior mesenteric arteriogram shows occlusion of superior mesenteric vein.
C, Postangloplasty Injection of superior mesenteric veIn (arrow) shows patency. Note peripheral splanchnic venous channel (arrowhead).

at which time a short segment of ischemic small bowel was resented. urokinase would minimize any risks associated with potential
The superior mesenteric vein was found to be patent. Progressive embolization of fragments of clot. We employed standard
recovery followed, and the patient was discharged from the hospital techniques of percutaneous transhepatic portography [7] to
in good condition.
gain access to the portal system and adapted the technique
of high-dose urokinase infusion, as previously described for
use in the peripheral arterial system [8]. The use of sono-
Discussion graphic guidance allowed entry into the portal system in a
single pass with a small-gauge Chiba needle; embolization of
Thrombosis of the superior mesenteric vein is a relatively
the access tract at the conclusion of the procedure provided
uncommon cause of intestinal vascular compromise; several hemostasis, thus improving the margin of safety. No data
studies have shown frequencies of 5-23% [i -3]. Thrombosis exist regarding the safety of splanchnic venous angioplasty
may develop in association with portal hypertension, focal or in the postoperative period. It was thought that the thrombotic
generalized abdominal inflammation, or hypercoagulable occlusion was almost certainly the result of the surgically
states; after trauma; or in the perioperative period. It also may induced stenosis and that the likelihood of long-term patency
occur as a primary event [4]. Clinically, it may be acute or would be low if this were not corrected. As the alternative to
subacute. Abdominal pain is usually present and may be of successful percutaneous treatment would have been reex-
either sudden or gradual onset. Physical examination and ploration and venous bypass, the potential benefit of the
laboratory evaluation reveal inconstant and nonspecific find-
procedure was thought to outweigh the risk. Our results
ings such as fever, evidence of volume depletion, ascites, suggest that in the subset of patients with thrombosis of the
leukocytosis, systemic acidosis, and blood in the stools. superior mesenteric vein and nongangrenous bowel, throm-
Plain abdominal radiography may show ileus or ascites.
bolysis via the percutaneous transhepatic approach may be
Bowel wall thickening and mucosal irregularity, when present,
a useful initial approach to treatment.
are suggestive of intestinal ischemia. Specific diagnosis of
mesenteric venous thrombosis requires angiography or dem-
onstration of an intraluminal filling defect on CT. REFERENCES
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review of thirty-two patients. Surgery 1975;78(5):617-618
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