Author + information
- Received May 4, 2016
- Revision received May 24, 2016
- Accepted June 2, 2016
- Published online September 12, 2016.
- Yucel Colkesen, MD∗ (, )
- Mustafa Topuz, MD and
- Durmus Yildiray Sahin, MD
- ↵∗Reprint requests and correspondence:
Dr. Yucel Colkesen, Department of Cardiology, Adana Numune Training and Research Hospital Seyhan, 01140 Adana, Turkey.
- mesenteric ischemia
- paroxysmal atrial fibrillation
- percutaneous recanalization
- superior mesenteric artery
We describe a case of thrombotic occlusion of the superior mesenteric artery (SMA) associated with paroxysmal atrial fibrillation (AF). A 74-year-old patient presented with abdominal pain secondary to acute mesenteric ischemia resulting in ischemic gut injury. Electrocardiographic recordings revealed paroxysmal AF, which terminated spontaneously to normal sinus rhythm. Computed tomography demonstrated a luminal filling defect within the SMA (Figure 1A). An exploratory laparotomy was not necessary, because of the absence of peritonism. Selective angiography via the transfemoral approach revealed thrombotic occlusion of the SMA at the ileal and ileocolic bifurcation (Figure 1B). The SMA was engaged with a 7-F Judkins right coronary catheter, and a 0.014-inch floppy coronary guidewire (Choice; Boston Scientific, Natick, Massachusetts) was used to cross the lesion. We performed ad hoc thrombectomy by using a thrombus aspiration catheter (Export AP Aspiration Catheter; Medtronic Vascular, Minneapolis, Minnesota) (Figure 1C). Despite numerous attempts, the flow-limiting lesion remained distally. We decided to perform direct stenting via deployment of a balloon-expandable coronary stent. An additional 0.014-inch floppy coronary guidewire was placed at the ileal branch. A 5 × 30 mm balloon-expandable stent (Liberte Monorail Stent; Boston Scientific) was placed across the occlusion (Figure 1D). For side-branch protection, a 2 × 20 mm monorail balloon (Invader PTCA balloon; Alvimedica, Assen, the Netherlands) was placed at the bifurcation toward the ileal branch and inflated up to 4 atm to eliminate the side-branch loss and thrombus emboli to the ileal branch during provisional stenting (Figure 1E). Completion angiography showed a widely open SMA with normal filling of its branches (Figure 1F). The patient was successfully discharged and remained asymptomatic during follow-up for 3 months.
Paroxysmal AF has not generated as much concern as permanent AF, although no significant differences in thromboembolic event rates between AF types exist (1). In patients without gut necrosis, a patient-based endovascular intervention appears practicable, and early treatment is advised (2).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 4, 2016.
- Revision received May 24, 2016.
- Accepted June 2, 2016.
- 2016 American College of Cardiology Foundation