Virtuosic craftsmanship of surgical team of MC Erebouni saved the patient with combined acute thromboembolism of the superior mesenteric and right femoral arteries.
Despite of the significant achievements in the sphere of diagnosis and treatment of acute surgical diseases, in recent decades, there are still rather poor prognoses for the patients with acute thrombosis of mesenteric artery that frequently (in 59-93% cases) are accompanied by in-hospital mortality. In more than 20% of cases of thromboembolism of mesenteric arteries, emboli are multiple, located in various arteries and organs, which even worsens the prognosis of the disease.
If there is a suspicion of thromboembolism of the artery of one or another organ of the abdominal cavity, first of all it is necessary to exclude mesenteric artery embolism. Rapid diagnosis, correct surgical approach and intensive treatment can significantly improve prognosis and reduce mortality.
On 06.03.17, patient A.E., 72, was admitted to the Emergency Medical Care Department in severe condition and was hospitalized to the Intensive Care Unit.
Complaints appeared and developed a day before coming to the hospital (the patient also had atrial fibrillation and post-thrombophlebitic syndrome).
CT angiography revealed a picture of stenosis of the abdominal aorta and its branches, embolism of the right branch of the superior mesenteric artery (Fig. 1), embolism of the right common femoral artery (Fig. 2), and post infarction cystic formations in the spleen.
CT images of the embolism of the right branch of the superior mesenteric artery
CT images of post infarction cystic formations in the spleen.
On 06.03.17, due to strict life-threatening indications, median laparotomy was carried out by the team of general surgeons of the General & Thoracic Surgery Department headed by Dr. Vardanyan A.S., PhD (c.m.s.). During the intraoperative inspection necrosis of the distal 2/3 of the jejunum, the entire ileal and right half of the colon was revealed (Fig. 3).
Intraoperative inspection showed necrosis of the distal 2/3 of the jejunum, entire ileal and right half of the colon.
Viable was only the proximal part of the jejunum for a long of 50-60 cm from the Treitz ligament, and also in the left half of the large intestine, including the sigmoid colon and rectum (Fig. 4).
The viable part of the intestine.
Resection of necrotic intestinal parts with the formation of jejuno-transverse anastomosis side-by-side with 2-row nodal sutures was performed.
After closing the laparotomy wound, the team of vascular surgeons under the Head of Vascular and Laser Surgery Department Dr. A. Badalyan MD, Ph.D, performed endarterectomy of the right common and deep femoral artery, profundoplasty with an alloy prosthesis (chronic occlusion of the superficial femoral artery from its ostium was revealed, the common femoral artery was also obstructed by embolus; significant fibrocalcinosis of blood vessels was also revealed, including deep femoral artery up to 5 cm). (Fig. 5).
Endarterectomy of the right common and deep femoral artery, profundoplasty with alloy prosthesis.
The postoperative period was uneventful, intestinal activity was restored on the 3rd day. Acute ischemia of the right lower limb was completely solved without postischemic complications. After repeated duplex scanning with positive results, the patient was transferred to the general surgery department, and was discharged on the 10th day with recovery.
There are 4 types of acute hypoperfusion of the intestine. The most common cause (40-50% of cases) is arterial embolism. Cardiogenic embolism is the most common cause of acute mesenteric ischemia. By frequency of occurrence, on the second place is an acute mesenteric thromboses (25-30%). Non-occlusive mesenteric ischemia occurs in a low cardiac output combined with diffuse mesenteric vasoconstriction. Thrombosis of mesenteric veins is a relatively rare cause of ischemia (just over 10%) of the abdominal organs. The superior mesenteric artery is most vulnerable to embolism due to the acute angle with the aorta and its large diameter.
Researches revealed only 2 cases when combined embolization of the mesenteric artery and lower extremity with acute ischemia were described (in the literature the case of combined thromboembolism of the superior mesenteric artery and brachial artery was described, when late diagnosis led to amputation of the upper limb).
Highly complex and unique surgical intervention, carried out by a multidisciplinary team of highly qualified surgeons of the Erebouni MC, with the correct definition of tactics and sequence of the multiprofile intervention, not only saved the patient's life, but also prevented limb amputation and his further disability!