TY - JOUR
AU - MD, M. T. Harris,
AB - To the Editor A 27-year-old woman underwent an uncomplicated laparoscopic-assisted ileocolic resection for Crohn's disease refractory to medical therapy. The patient had a 1-year history of terminal ileitis unresponsive to treatment with mesalamine, antibiotics, corticosteroids, azathioprine, and multiple infusions of infliximab. Her recovery from surgery was uneventful, and she was prepared for discharge on hospital day 6, when sudden, severe, diffuse abdominal pain developed. Physical examination revealed tachycardia and a firm, distended, diffusely tender abdomen without signs of peritonitis. An emergent CT scan of abdomen and pelvis with intravenous, oral and rectal contrast revealed extensive thrombosis of the portal vein (PV) and superior mesenteric veins (SMV), ischemic changes and massive edema of the entire small bowel and ascending colon, and a heterogeneous liver with perfusion abnormalities predominantly in the left lobe (Fig. 1). The patient was evaluated by a multidisciplinary team of interventional radiologists; gastroenterologists; and general, vascular, and transplant surgeons. She was transferred to the interventional radiology suite, where a transjugular intrahepatic approach to the PV was established, using a Cook Ring Transjugular Intrahepatic Access Set. A venous contrast injection confirmed extensive thrombus in the SMV, main PV, and PV branches (Fig. 2). Aspiration thrombectomy was performed using the Possis AngioJet device in multiple branches of the SMV and PV. Tissue plasminogen activator (TPA) was infused using the AngioJet device (15 mg in 1 L normal saline). Repeat venography demonstrated almost complete resolution of thrombus within the SMV and main PV with residual thrombus in branches of the PV. Heparin was infused overnight through the Cook introducer sheet located in the main PV (partial thromboplastin time maintained for 60–90 sec). On day 7 (24 h post-thrombectomy), the patient's clinical condition improved. At venography, slight improvement was noted in the PV branches. Further TPA was infused into the main PV (2 mg/h for 5 h) and overnight intraportal heparin administered. Venography on day 8 demonstrated good flow within the SMV and main PV and adequate flow in the portal branches (Fig. 3). Figure 1 View largeDownload slide Coronal CT scan of abdomen demonstrating extensive superior mesenteric vein (SMV) and portal vein (PV) thrombosis. An abnormal hepatic perfusion appearance is also present. There is widespread bowel wall thickening (black arrow). Figure 1 View largeDownload slide Coronal CT scan of abdomen demonstrating extensive superior mesenteric vein (SMV) and portal vein (PV) thrombosis. An abnormal hepatic perfusion appearance is also present. There is widespread bowel wall thickening (black arrow). Figure 2 View largeDownload slide Venography demonstrating occlusion of the superior mesenteric vein (SMV), portal vein (PV) and intrahepatic PV (IPV) before interventional therapy. The inferior mesenteric vein (IMV) is patent. Figure 2 View largeDownload slide Venography demonstrating occlusion of the superior mesenteric vein (SMV), portal vein (PV) and intrahepatic PV (IPV) before interventional therapy. The inferior mesenteric vein (IMV) is patent. Figure 3 View largeDownload slide Venography performed 48 h after percutaneous transjugular thrombectomy with AngioJet and TPA infusion. A patent superior mesenteric vein (SMV), inferior mesenteric vein (IMV), portal vein (PV), and intrahepatic portal vein (IPV) are seen. Residual thrombus is seen in a PV branch (black arrow). Figure 3 View largeDownload slide Venography performed 48 h after percutaneous transjugular thrombectomy with AngioJet and TPA infusion. A patent superior mesenteric vein (SMV), inferior mesenteric vein (IMV), portal vein (PV), and intrahepatic portal vein (IPV) are seen. Residual thrombus is seen in a PV branch (black arrow). On day 11, a new onset of severe abdominal pain, distention, tachycardia, and fever developed in this patient. An emergent CT scan showed no signs of recurrent venous thrombosis. The patient underwent laparoscopy, in which a long segment of gangrenous neo-terminal ileum and casts of clot within the adjacent mesentery were found. Four feet (120 cm) of small bowel was resected and an ileocolic anastomosis was performed. During the procedure, Doppler examination of the vascular system revealed patency of the mesenteric arterial and portal venous systems. However, CT scan after surgery demonstrated recurrent thrombus in the SMV and PV branches. The patient was taken to the interventional radiology suite and underwent repeat thrombectomy. Improved flow was noted in the post-thrombectomy venogram. Overnight intraportal heparin was administered and venography on day 12 revealed no new thrombus formation and improved flow through the intrahepatic branches of the left and right PVs. On day 20, hematochezia developed while she was still receiving systemic anticoagulation. At colonoscopy, superficial ulceration and bleeding were noted at the anastomotic site; this was treated endoscopically with injection therapy, cauterization, Endoclip placement, and topical thrombin therapy. After an additional episode of bleeding on day 28, she underwent selective mesenteric arterial angiography with coil embolization of a tertiary branch of the ileocolic artery in the region of the anastomosis. She had no further episodes of bleeding and was discharged home on day 30. She was maintained on low molecular weight heparin, followed by oral administration of warfarin. Hematologic evaluation showed that the patient was heterozygous for the prothrombin G20210A gene mutation. Upon further questioning, the patient recalled that her sister had been told of a “clotting problem” after undergoing evaluation for infertility. Review of the sister's medical records revealed that she also was heterozygous for the prothrombin G20210A gene mutation, and that she had been treated successfully with heparin during a subsequent pregnancy. Eight months after her initial surgery, the patient remains well and continues to take warfarin adjusted to achieve an INR of 2.0–3.0. Discussion This report describes the clinical course of a young woman with IBD in whom postoperative SMV and PV thrombosis developed that was successfully treated with a thrombectomy device. Subsequent evaluation revealed that she was heterozygous for the G20210A prothrombin gene mutation. Inflammatory bowel disease (IBD) is associated with an increased risk of vascular complications, most importantly arterial and venous thromboembolism (VTE).1 First reported in 1936,2 many subsequent studies have confirmed the association between arterial and venous thromboembolism and IBD. Talbot et al3 reported an incidence of thromboembolic complications of 1.3% among 7199 patients with IBD over an 11-year period. A 3-fold increased risk of deep vein thrombosis or pulmonary embolism has been reported in population based studies of patients with IBD.4,5 This risk is further raised in IBD patients undergoing surgery: Fichera et al6 reported a 4.8% incidence of SMV thrombosis among 83 patients undergoing colectomy for IBD. Thromboembolic complications of IBD are by no means benign: the mortality rate has been reported to be as high as 22%–25%.3,5 Studies have examined whether the risk of VTE could be due to an association of thrombophilic conditions with IBD. In the study by Fichera et al,6 all 4 patients in whom symptomatic postoperative SMV thromboses had developed underwent hematologic evaluations, and one was heterozygous for the prothrombin G20210A mutation. Guedon et al7 found that among IBD patients, the presence of factor V Leiden mutation was associated with an increased risk of thromboembolic events; however, there was no increase in prevalence of this mutation in IBD patients with thrombotic events compared with patients without IBD who had thrombotic events. It appears that Factor V Leiden mutation is not associated with IBD but, when present, it increases the risk of thromboembolism. No association with prothrombin G20210A mutation and IBD patients (with or without thrombotic events) was found in this study. Papa et al8 found no difference in prevalence of factor V Leiden or G20210A prothrombin gene mutations in IBD patients compared with controls, regardless of history of prior thrombotic events. The AngioJet (Possis Medical, Minneapolis, MN) is a percutaneous endovascular mechanical thrombectomy device. It fragments thrombus using a high-pressure (˜10,000 pounds per square inch) water jet infusion and enables immediate clot evacuation directly through the catheter, utilizing the Bernoulli effect.9 Sze et al10 reported a patient with protein S deficiency and portal, splenic, and SMV thrombosis unresponsive to heparin, thrombolysis and jejunal resection. The patient had persistent mesenteric ischemia and subsequently underwent successful thrombectomy with the AngioJet device. Our case is the first report of a patient with IBD successfully treated with the AngioJet device for acute SMV thrombosis. Furthermore, it is the first report of this device being used through a transjugular venous approach to obtain access to the portal circulation (as is commonly done during a TIPS procedure). Early diagnosis with CT scan is crucial to diagnose the condition early. Data from two series report 100% sensitivity in detecting SMV thrombosis among a total of 19 patients.6,11 Therapy for acute SMV thrombosis has included systemic anticoagulation,3 surgical intervention and thrombolysis.9,12,–14 The application of thrombectomy with the AngioJet device utilizing the tranjugular approach may be an important addition to the list of therapeutic options available for refractory cases. In retrospect, the patient's family history of a clotting disorder should have prompted a thorough preoperative evaluation for thrombophilia. The knowledge of an underlying prothrombotic abnormality would have mandated long-term prophylactic anticoagulation, which could have prevented this potentially catastrophic event. Although it is standard practice to ask patients preoperatively about a family history of bleeding disorders, we would recommend that all patients with IBD also be questioned specifically about family history of clotting disorders before surgery. References 1 Koutroubakis IE. Therapy insight: vascular complications in patients with inflammatory bowel disease. Nat Clin Pract Gastroenterol Hepatol.  2005; 2(6): 266– 272. CrossRef Search ADS PubMed  2 Bargen JA, Barker NW. Extensive arterial and venous thrombosis complicating chronic ulcerative colitis. Arch Intern Med.  1936; 58: 17– 31. CrossRef Search ADS   3 Talbot RW, Heppell J, Dozois RR, et al.   Vascular complications of inflammatory bowel disease. Mayo Clin Proc.  1986; 61(2): 140– 145. CrossRef Search ADS PubMed  4 Bernstein CN, Blanchard JF, Houston DS, et al.   The incidence of deep venous thrombosis and pulmonary embolism among patients with inflammatory bowel disease: A population-based cohort study. Thromb Haemost.  2001; 85(3): 430– 434. PubMed  5 Solem CA, Loftus EV, Tremaine WJ, et al.   Venous thromboembolism in inflammatory bowel disease. Am J Gastroenterol.  2004; 99(1): 97– 101. CrossRef Search ADS PubMed  6 Fichera A, Cicchiello LA, Mendelson DS, et al.   Superior mesenteric vein thrombosis after colectomy for inflammatory bowel disease: A not uncommon cause of postoperative acute abdominal pain. Dis Colon Rectum.  2003; 46(5): 643– 648. CrossRef Search ADS PubMed  7 Guedon C, Le Cam-Duchez V, Lalaude O, et al.   Prothrombotic inherited abnormalities other than factor V Leiden mutation do not play a role in venous thrombosis in inflammatory bowel disease. Am J Gastroenterol.  2001; 96(5): 1448– 1454. CrossRef Search ADS PubMed  8 Papa A, De Stefano V, Gasbarrini A, et al.   Prevalence of factor V Leiden and the G20210A prothrombin-gene mutation in inflammatory bowel disease. Blood Coagul Fibrinolysis.  2000; 11(5): 499– 503. CrossRef Search ADS PubMed  9 Rivitz SM, Geller SC, Hahn C, et al.   Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion. J Vasc Interv Radiol.  1995; 6(2): 219; 224–228. 10 Sze DY, O'Sullivan GJ, Johnson DL, et al.   Mesenteric and portal venous thrombosis treated by transjugular mechanical thrombolysis. AJR Am J Roentgenol.  2000; 175(3): 732– 734. CrossRef Search ADS PubMed  11 Morasch MD, Ebaugh JL, Chiou AC, et al.   Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg.  2001; 34(4): 680– 684. CrossRef Search ADS PubMed  12 Henao EA, Bohannon WT, Silva MB Jr. Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator. J Vasc Surg.  2003; 38(6): 1411– 1415. CrossRef Search ADS PubMed  13 Poplausky MR, Kaufman JA, Geller SC, et al.   Mesenteric venous thrombosis treated with urokinase via the superior mesenteric artery. Gastroenterology.  1996; 110(5): 1633– 1635. CrossRef Search ADS PubMed  14 Tateishi A, Mitsui H, Oki T, et al.   Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation. J Gastroenterol Hepatol.  2001; 16(12): 1429– 1433. CrossRef Search ADS PubMed  © 2006 Crohn's & Colitis Foundation of America, Inc.
TI - Use of an Intravascular Thrombectomy Device to Treat Life-threatening Venous Thrombosis in a Patient With Crohn's Disease and G20210A Prothrombin Gene Mutation
JF - Inflammatory Bowel Diseases
DO - 10.1002/ibd.20037
DA - 2007-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/use-of-an-intravascular-thrombectomy-device-to-treat-life-threatening-aC06pv0EHy
SP - 505
EP - 508
VL - 13
IS - 4
DP - DeepDyve
ER -