Endovascular manual aspiration thrombectomy of acute superior mesenteric artery thromboembolic occlusion: the good, the bad, and the ugly.

The outcome of endovascular treatment in acute superior mesenteric artery (SMA) thromboembolic occlusion is variable at best. We describe three patients who underwent urgent endovascular manual aspiration thrombectomy of the SMA, illustrating the good, the bad, and the ugly. The good: a 63-year-old male patient was admitted to our hospital for acute abdominal pain. Contrast-enhanced multidetector computed tomography (MDCT) showed total occlusion of the SMA with just air distension of the bowel. From the right femoral artery, he underwent emergency angiography that confirmed the diagnosis of total occlusion of the SMA (Fig. 1a). A manual aspiration thrombectomy was performed into the SMA, using a Luer-lock 60-mL syringe, connected to a 7 F catheter (Mach-1, Boston Scientific, Natick, Massachusetts, USA) to generate a vacuum effect (Fig. 1b). The clots were aspirated and removed from the SMA; six passes of the guiding catheter were made. The final control demonstrated patency of the SMA, distal arcades, and vasa rectae (Fig. 1c). Intravenous heparin (1000 IU/hour) was administered for 48 hours. The patient did not need a bowel resection. The bad: a 76-year-old female patient was admitted to our hospital after two days of acute and progressive abdominal pain. MDCT showed total occlusion of the SMA with signs of mesenteric ischemia (pneumatosis intestinalis). From the right femoral artery, she underwent emergency angiography, confirming the diagnosis of total occlusion of the SMA (Fig. 2a). A manual aspiration thrombectomy was performed into the SMA, using a Luer-lock 60-mL syringe, connected to a 7 F catheter (Mach1, Boston Scientific; Fig. 2b). Some clots were removed, but no patency of the SMA was noted; three passes of the guiding catheter were made. During these maneuvers and a SMA postorigin dissection, the distal ileal vascular arcade was accidentally perforated. So, an angioplasty and stenting of the postorigin segment of the SMA, and consequent distal ileal vascular arcade metallic-coil embolization, were performed. The final control demonstrated partial patency of the SMA and continued occlusion of the distal arcades and vasa rectae (Fig. 2c). Due to the vascular perforation, catheter-directed thrombolysis was not performed, and intravenous heparin was given at dose of 1000 IU/hour. The patient underwent urgent abdominal bowel resection surgery and SMA thrombectomy, but she died 72 hours later. The ugly: a 71-year-old male patient was admitted to our hospital with progressive abdominal pain. MDCT showed