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Catheter direct thrombolysis of occluded SMA

Case of the Thumbnail
Case of the Thumbnail

A 45 yr old male patient was diagnosed with peripheral vascular disease in 2017 when he had presented with claudication pain in the left lower limb. He was a chronic smoker. CT angio at that time revealed diffuse atherosclerotic disease with significant narrowing and non opacifation of right internal iliac, bilateral femoral, popliteal and tibial arteries. He was treated with Aspirin, Clopidogrel, Heparin, Cilostazol and Pentoxifylline. He was later given 6 cycles of PGE-1 therapy with which he had partial improvement. Since late 2019, he was poorly compliant to medication with irregular follow up with recurrence of claudication pain.

He presented now with a one week history of left sided abdominal pain, predominantly after food intake associated with black stools. A possibility of mesenteric ischemia was considered and USG abdomen with Doppler revealed thickened jejunal folds with SMA thrombosis. CT angiogram also revealed SMA thrombosis with circumferential thickening of jejunum with associated fat stranding. He was anticoagulated with UFH while monitoring APTT and was later changed to LMWH. He was monitored for any evidence of bowel gangrene. He continued to have pain abdomen following food intake. Doppler after 5days and 10 days of heparin therapy revealed non clearance of thrombus with no blood flow. Then we took the help of our esteemed and very experienced cardiology colleagues.

Patient was taken up for SMA intervention. Occlusion of SMA was confirmed via angiography (1). SMA was crossed with a pilot wire and dilated with 4 mm balloon. Flow not established despite dilatation. In view of persistent thrombosis, reperfusion Catheter was placed in SMA and Streptokinase was infused over 48 hrs at 1ml / hr resulting in good reperfusion (2).

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