Splenic and superior mesenteric artery thrombolytic infusion therapy for acute portal and mesenteric vein thrombosis

Intestinal ischemia is a condition associated with a high degree of morbidity and mortality. Mesenteric venous thrombosis is an uncommon cause of intestinal ischemia accounting for 5%-15% of such cases.' Surgical intervention in cases of intestinal ischemia resulting from portal/superior mesenteric vein thrombosis is fraught with difficulty owing to the extent of bowel resection required and the inability to address the underlying thrombosis. We present a case report of acute intestinal ischemia secondary to portal and superior mesenteric vein (SMV) thrombosis successfully treated with tissue plasminogen activator (tPA) via the superior mesenteric artery (SMA) and splenic artery (a route not previously used for this purpose). Selective catheterization of the superior mesenteric artery (SMA) and institution of tissue plasminogen activator (t-PA) thrombolysis (10 mg bolus then an infusion of 2 mg/hr) was performed. A CT scan 7 hours later showed a stable thrombus, but angiography showed increased visualization of the SMV. The tPA infusion was then increased to 4 mg/hr. Angiography 20 hours later showed some thrombus progression within the portal vein but enhanced SMV visualization. The catheter was repositioned in the splenic artery, and the t-PA infusion was continued at 4 mg/hr. Angiography at 48 hours showed marked regression of portal vein (Fig. 2a) and SMV thrombus. The patient's symptoms had almost completely resolved; the t-PA infusion was stopped and IV heparin anticoagulation initiated. He was later discharged on oral systemic anticoagulation, with CT showing resolution of bowel thickening and a partial portal vein thrombus (Fig. 2b). Hematological workup did not reveal any abnormalities.