Acute Superior Mesenteric Artery [SMA] thrombosis is an uncommon, but life-threatening emergency, carrying a high rate of morbidity and mortality. It constitutes about 0.1% of all hospital admissions. Despite, all advancements in its diagnosis and treatment, it still carries an indoor mortality rate of 59-93% [1].

Endovascular thrombolysis, thrombo-aspiration, angioplasty and stenting of mesenteric vasculature are established management strategies, but only when the patient presents in an early stage. Late cases are usually treated with the more invasive option of surgical resection of gangrenous bowel, which itself carries high morbidity and mortality rates.

A 36 years old female presented with sudden onset, vague, non-localised, abdominal pain and distention. Other than type 2diabetes, there was no significant medical or surgical history. Also, there was no previous history of any such abdominal pain.

For initial four days, the patient got admitted at some other hospital, where her serial ultrasound scans were reported as normal. Hence, she was treated on conservative grounds.

The patient was then shifted to our hospital after seven days of onset of symptoms. The Contrast Enhanced Computerized Tomography [CECT] of abdomen confirmed complete short-segment thrombosis of celiac trunk [Fig.1], and partial short-segment thrombosis of SMA [Fig.2].

The Inferior Mesenteric Artery [IMA] and its branches were patent. Her White Blood Cell [WBC] count was 29000cells/cu mm, with infrequent spikes of high-grade fever and progressive abdominal distention.

She was immediately started on continuous intravenous heparin infusion. With now a history of 7 days duration, the possibility of bowel gangrene was high, and the need for open surgery was imminent. Still, due to young age of patient, and an otherwise good general condition, a decision of endovascular management was made.

Figure 4: Satisfactory post-stenting flow achieved in SMA [arrow]

A left brachial artery access was taken with 6F sheath. Abdominal aortogram was performed which reconfirmed the findings of CECT scan.The 5F cobra catheter was placed in proximal SMA. 4400units/Kg body weight of Urokinase was slowly injected as bolus, over 10 minutes. The catheter was secured in place and urokinase was further administered through the catheter at a rate of 4400units/Kg body wt/hr for next 15 hours. Weight-adjusted heparin was also administered via side arm of the sheath. The course during thrombolysis was uneventful. After 15 hours of thrombolysis, patient’s pain subsided near completely and WBC count dropped to 16000 cells/cu mm. Check aortogram was performed, which revealed near-complete recanalisation of celiac trunk, and partial [approx. 30%] recanalisation of SMA [Fig. 3]. Owing to significant residual stenosis, a balloon-mounted, nitinol stent of size 8x36mm [Valeo, BD, NJ, USA] was placed in proximal SMA. Satisfactory post-stenting flow was achieved [Fig. 4]. Heparin infusion was continued through sheath for next 12 hours, and dual antiplatlet therapy was initiated. She was gradually started on oral feeds, with normal bowel movements. As such, she did not require any further surgical intervention, and was discharged uneventfully 10 days after the procedure.

The causes of acute mesenteric ischemia include arterial embolus, which occurs most frequently (40%-50%), arterial thrombosis, venous obstruction and nonobstructive causes. Patients present with severe abdominal pain that is initially out of proportion to any physical findings.

The above case depicts the importance of “bowel-salvage” attitude rather than a “bowel-sacrifice” one. In selected young patients, with a satisfactory general condition, and after a thorough inter-disciplinary communication; a decision for endovascular treatment can be taken even in a delayed presentation of acute mesenteric ischemia.