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1/96. Mesenteric and portal vein thrombosis in a young patient with protein s deficiency treated with urokinase via the superior mesenteric artery.

    A 32-year-old man, who was previously healthy, had acute abdominal pain without peritonitis. Diffuse mesenteric and portal vein thrombosis were shown by means of a computed tomography scan. A protein s deficiency was found by means of an extensive workup for hypercoagulable state. Successful treatment was achieved with urokinase infusion via the superior mesenteric artery without an operation. This represents an attractive alternative approach to treating patients with this disease. The previous standard of operative intervention(1) can now be reserved for complications, such as bowel infarction with peritonitis, or for those patients with absolute contraindications to thrombolytic therapy.
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2/96. Simultaneous surgical intervention to coronary artery disease, peripheral arterial disease and superior mesenteric artery stenosis.

    A patient, suffering from angina pectoris, claudicatio intermittens and postprandial abdominal pain underwent coronary and peripheral arteriographic examination; coronary arterial disease and aortoiliac occlusive disease was diagnosed. color Doppler ultrasonography revealed superior mesenteric artery stenosis. CABG with MIDCAB (minimal invasive direct coronary artery bypass) technique was performed together with aortabifemoral graft interposition and graft bypass to superior mesenteric artery and considerable success was obtained.
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3/96. Superior mesenteric artery stenting for mesenteric ischaemia in Sneddon's syndrome.

    Mesenteric ischaemia is a rare but serious cause of abdominal pain. We present the case of a man with Sneddon's syndrome, who had symptomatic mesenteric ischaemia secondary to a superior mesenteric artery stenosis in conjunction with a hepatic artery stenosis. As far as the authors are aware, this has not previously been described in Sneddon's syndrome, which is a vascular systemic disease characterized by an association between cerebrovascular accidents and a livedo reticularis skin rash. He was treated with balloon angioplasty and stent insertion, with good symptomatic improvement. This has implications for other stenoses in this condition should they become symptomatic.
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4/96. Stenting of a superior mesenteric artery lesion via the right arm approach.

    Chronic mesenteric ischemia is rare and commonly presents with abdominal pain and weight loss. Treatment options are limited to surgical or endovascular revascularization. In this report we describe in detail successful stent-supported angioplasty of a high-grade superior mesenteric artery stenosis utilizing a right brachial artery approach. A brief review of the literature is provided.
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5/96. Superior mesenteric venous thrombosis in malrotation with chronic volvulus.

    Malrotation can be difficult to diagnose after the newborn period because of intermittent symptoms and vague clinical findings, but malrotation with midgut volvulus is usually quite striking in its presentation. early diagnosis and surgical treatment are essential to prevent acute ischemic infarction of the bowel, although chronic complications are rare. The authors present an unusual case of mesenteric venous thrombosis secondary to chronic midgut volvulus. A 13-year-old girl presented with an 11-year history of recurrent bouts of abdominal pain evaluated at 3 other institutions without a diagnosis. At the referring hospital, an episode of bilious emesis associated with abdominal pain prompted a computerized tomography scan of the abdomen. This showed a calcified thrombus within the superior mesenteric vein (SMV). At laparotomy, malrotation with chronic 270 degree volvulus was found with evidence of mesenteric venous hypertension. Segmental occlusion was documented on magnetic resonance angiography. SMV thrombosis is an unusual complication of malrotation with chronic midgut volvulus.
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6/96. Spontaneous superior mesenteric vein thrombosis (SMVT) in primary protein s deficiency. A case report and review of the literature.

    Superior mesenteric vein thrombosis (SMVT) is an uncommon but important clinical entity that can induce ischemia or infarction of the small and large bowel. It is rare and accounts for 5-15% of mesenteric vascular occlusions. Bowel infarction due to SMVT can present as an acute abdominal disease, requiring urgent laparotomy with resection of the intestinal segment affected. However, the clinical diagnosis of this event remains difficult and invariably requires specific imaging investigations in order to be able to treat the condition as soon as possible. SMVT without bowel infarction can present as persistent, non-specific abdominal pain and nausea with minimal clinical signs, affecting young individuals without any known predisposing disorder, where laparotomy is not an urgent indication. We report a case of a young adult man with SMVT due to a hypercoagulable state (protein s deficiency), in whom an early diagnosis and appropriate anticoagulant treatment prevented any further extension of the thrombotic process and limited the hemorrhagic infarction of the ileum, which simply required a segmental resection.
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7/96. Superior mesenteric and renal artery embolism during PTA and re-stenting of infrarenal abdominal aorta. Report of a case and review of the literature.

    The authors report a case of acute superior mesenteric and right renal artery embolism that occurred during an interventional radiological procedure on the abdominal aorta of a young diabetic woman. The onset of a severe abdominal pain during the procedure evoked the clinical suspicion of intestinal ischemia related to the dislodgement of atheroembolic material into the mesenteric artery; the event was correctly diagnosed, but the surgical therapy was delayed by many hours because of the fact that the patient was in a peripheral hospital of the region and had to be transferred to our institution. Fortunately in spite of the considerable delay, the operation was fully successful, probably because of the favourable location of the embolus, which allowed collateral splanchnic circulation to maintain a good metabolic balance.
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8/96. Percutaneous stenting of an latrogenic superior mesenteric artery dissection complicating suprarenal aortic aneurysm repair.

    PURPOSE: To report endovascular repair of an iatrogenic superior mesenteric artery (SMA) dissection caused by a balloon occlusion catheter. CASE REPORT: A 68-year-old man with a suprarenal aortic aneurysm underwent conventional prosthetic replacement, during which visceral artery back bleeding was controlled with balloon occlusion catheters. Six hours postoperatively, the patient experienced an episode of bloody diarrhea with abdominal pain and tenderness and mild metabolic acidosis. colonoscopy revealed colitis (grade I) without necrosis of the right and left colon. An emergent abdominal computed tomographic scan showed signs of mesenteric ischemia with bowel dilatation and SMA wall hematoma; angiography identified a dissection 1 cm distal to the SMA origin. An Easy Wallstent was deployed percutaneously, successfully reestablishing SMA patency. The postoperative course was uneventful, and the patient remains asymptomatic with a patent SMA stent and aortic graft at 1 year. CONCLUSIONS: latrogenic SMA dissection should be suspected after suprarenal aortic aneurysm repair if signs of mesenteric ischemia arise. Prompt and thorough imaging studies are necessary to confirm the diagnosis and assess the potential for an endoluminal treatment.
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9/96. Ischaemic jejunal stenosis complicating portal and mesenteric vein thrombosis: a report of two cases.

    A major complication of portal and mesenteric vein thrombosis is acute bowel ischaemia resulting in infarction and requiring immediate resection of the involved segment. Sufficient collaterals can prevent acute haemorrhagic infarction, but bowel stenosis due to chronic ischaemia may develop. We report two cases of ischaemic jejunal stenosis occurring 4 weeks after successful treatment of portal and mesenteric vein thrombosis. Diagnosis of high-grade segmental stenosis of the jejunum was established by contrast medium radiography of the gastrointestinal tract. After laparotomy and resection of the stenosed jejunal segment, both patients recovered well from the operation and were released from hospital. Follow-up examinations revealed an unremarkable state of health. Ischaemic bowel stenosis should be considered in patients with recurring abdominal pain after mesenteric and portal vein thrombosis. A close follow-up of every patient after treatment for mesenteric and portal vein thrombosis should be carried out to ensure early diagnosis of this complication.
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10/96. Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation.

    Mesenteric vein thrombosis is generally difficult to diagnose and can be fatal. A case of extensive thrombosis of the mesenteric and portal veins was diagnosed early and successfully treated in a 26-year-old man with down syndrome who was admitted to hospital because of abdominal pain, severe nausea and high fever. ultrasonography revealed moderate ascites, and there was minimal flow in the portal vein (PV) on the Doppler examination. Computed tomography (CT) showed remarkable thickening of the walls of the small intestine and extensive thrombosis of the mesenteric, portal and splenic veins. Because neither intestinal infarction nor peritonitis was seen, combined thrombolysis and anticoagulation therapy without surgical treatment was chosen. Urokinase was administered intravenously and later through a catheter in the superior mesenteric artery. heparin and antibiotics were given concomitantly. The patient's symptoms and clinical data improved gradually. After 10 days, CT revealed that collateral veins had developed and the thrombi in the distal portions of the mesenteric veins had dissolved, although the main trunk of the PV had not recanalized. The only risk factor of thrombosis that was detected was decreased protein S activity.
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