Direct-Puncture-Guided Sharp Recanalization Technique in a Case of Long-Segment Superior Mesenteric Vein Occlusion

Abstract

We describe the case of a moderately long chronic superior mesenteric vein (SMV) occlusion following Whipple procedure. Anticoagulation therapy and traditional recanalization techniques through retrograde approach, collateral inferior mesenteric venous vasculature, and recanalization upstream of the SMV occlusion via direct transabdominal puncture failed. Sharp recanalization downstream of the occlusion via retrograde approach, using the stiff end of a glidewire sharpened with a blade, with guidance from the tip of a catheter placed upstream of the occlusion as a target was successful. Our rendezvous technique, combined with use of orthogonal views, allowed for increased precision and decreased risk of catastrophic extravasation.

 

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Keywords

mesenteric venous thrombosis - sharp recanalization - superior mesenteric vein - occlusion

Introduction

Mesenteric venous thrombosis (MVT) disrupts bowel venous return. Causes include insult from surgery or inflammation, mass compression, hypercoagulable states, or congestion from cirrhosis or heart failure. The superior mesenteric vein (SMV) is most affected. Chronic MVT represents 20 to 40% of MVT cases and presents with nonspecific abdominal symptoms or variceal gastrointestinal (GI) hemorrhage. Standard diagnosis is via contrast-enhanced computed tomography (CT).[1] Recanalization of chronically occluded SMV can be challenging. This report describes a recanalization technique for a moderately long SMV occlusion, utilizing direct transabdominal puncture of the SMV upstream of the occlusion as a target for retrograde downstream sharp recanalization.

 

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Case Report

A 72-year-old woman was referred for chronic SMV occlusion following Whipple procedure with SMV sleeve reconstruction for pancreatic head adenocarcinoma. SMV thrombosis occurred repeatedly requiring anticoagulation/antiplatelet therapy and retrograde endovascular recanalization. Eventually chronic occlusion occurred despite anticoagulation and endovascular treatments. The patient later presented with duodenal variceal bleeding. CT demonstrated occlusion of the superior segment of SMV and narrowing of the main portal vein (MPV)–splenic vein (SV) junction. A more aggressive recanalization approach was undertaken.

The procedure started with transhepatic portal vein access. There was no portal hypertension in the downstream intrahepatic portal system, as expected by the absence of liver disease. Pressures across the MPV–SV stenosis revealed a significant gradient of 13 mm Hg upstream of the stenosis ([Fig. 1A]). Traditional SMV recanalization attempts (catheter, microcatheter, and glidewires) and attempts for reaching the patent upstream SMV via inferior mesenteric vein (IMV) collaterals to try an antegrade recanalization failed.

Fig. 1 (A) Venography of the portal venous circulation using a KMP catheter (Cook Medical, Indiana, United States) demonstrating occlusion of the proximal SMV with a small round stump (arrow), and stenosis at the confluence of the portal and splenic veins (arrowhead). Clips in the abdomen are mostly from previous Whipple procedure with SMV grafting for pancreatic cancer. (B) Direct percutaneous puncture of the SMV distal to the occlusion with a 21-gauge Chiba needle, followed by advancement of a 2.6 Fr microcatheter (white arrow) bare-back over a placed guidewire into the SMV, showing complete occlusion just proximal to the confluence of the main SMV branches (black arrow), and flow diversion through prominent collateralization (arrowhead). (C) Use of the support catheter (Navicross, Terumo Medical, Tokyo, Japan; arrow) inserted through the direct SMV puncture as target for distal landing of sharp guidewire tip advanced through the percutaneous hepatic access sheath/catheter (arrowhead). (D) Successful advancement of the sharp guidewire tip and sharp recanalization past the occlusion (arrow), with contrast injection verifying intraluminal position. (E) Placement of a 6 × 40 mm S.M.A.R.T. CONTROL Nitinol stent (Cordis, Florida, United States; arrows demarking inferior and superior ends of the stent) with subsequent balloon angioplasty, showing adequate flow through the stent, disappearance of the multiple collaterals, and no evidence of flow obstruction. SMV, superior mesenteric vein.

An ultrasound-guided direct percutaneous access to the upstream patent SMV was achieved using a 21-gauge needle, allowing bare-back placement of a 0.018 guidewire and a 2.6 Fr Navicross (Terumo, Tokyo, Japan) microcatheter ([Fig. 1B, C]). Antegrade recanalization attempts from the upstream access also failed. Retrograde sharp recanalization using the upstream access as a target was then considered as a last resource.

Through the transhepatic portal venous access catheter, the back end tip of a glidewire (Terumo)—bent for directionality and sharpened with a blade—was used to pierce through the occluded SMV segment using the Navicross catheter placed at the inferior occlusion stump as target. Successful intraluminal crossing without extravasation was confirmed by contrast injection ([Fig. 1D]). Over a wire, the crossed-occluded segment was angioplastied and bare-stented. Venography showed adequate flow through the stent with disappearance of the multiple collaterals ([Fig. 1E]). The MPV stenosis was also angioplastied with reduction in pressure gradient to 5 mm Hg. Portal venous access hemostasis was achieved using an absorbable gelatin sponge pledget injected via the sheath into the peripheral intrahepatic tract. No complications occurred and the patient was discharged after 48 hours.

Three months later, investigation of repeat GI hemorrhage demonstrated re-thrombosis of the mesenteric stent. Correcting this required transjugular intrahepatic portosystemic shunt (TIPS) creation and repeat angioplasty of the SMV stent and stenting of the MPV–SV stenosis ([Fig. 2]). Further re-thrombosis did not occur and GI hemorrhage resolved.

Fig. 2 (A) Axial and (B) sagittal contrast-enhanced CT of the abdomen, showing SMV stent with internal hypodensity representing developing thrombus (arrows). (C) Eventual occlusion of the SMV stent confirmed by venography. (D) Venography demonstrating improved flow following TIPS (white arrow showing inferior border of stent), splenoportal junction stenting with 12 × 50 mm Protege stent (Medtronic, Minnesota, United States; black arrows showing borders) and presence of patent SMV stent (arrowheads showing superior and inferior borders). (E) Follow-up coronal CT of the abdomen showing patent TIPS stent (white arrows), splenoportal junction stent (black arrows), and SMV stent (arrowhead showing superior border). CT, computed tomography; SMV, superior mesenteric vein; TIPS, transjugular intrahepatic portosystemic shunt.

 

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Discussion

Sharp vascular recanalization, including the use of the back end of a wire, mostly described in superior vena cava occlusions, carries risks of extravascular perforations.[2] When the vessel to recanalize is straight, such approaches can be done with relative safety and ease. However, when there are vascular junction points or angles in the vessel, such as with SMV–MPV junction, the sharp recanalization tool needs to be shaped appropriately to maneuver through these angles while reducing the risk of extravascular perforation. In such cases, having a distal target downstream of the angled occlusion is critical to confirm alignment of the shaped sharp recanalization tool and target. Our procedure was unique because it was performed in the mesenteric system with the target placed via a direct puncture of the SMV. Percutaneous SMV access has mainly been reported in the context of nonsharp main portal vein recanalization–TIPS,[3] and is limited by operator experience, patient body size, and habitus or anatomical constraints.[4] Other techniques to recanalization of occluded vessels including use of endovascular radiofrequency (RF) wire or surgical exploration might also have been options. In this case, difficulties that can occur in directing an RF wire across an angled vascular segment and hostile abdomen from previous surgery seem to make an argument disfavoring these approaches.

In the absence of known hepatic disease in our patient, TIPS was initially not thought to be necessary to maintain SMV stent patency, which was ultimately proven to be a mistake. In retrospect, a preemptive TIPS at the initial setting would likely have been useful to improve flow through the SMV stent and maintain primary patency. In addition, although there was a stenosis at the MPV/SV confluence, this was not involving the recanalized/stented SMV and was thought to be noncontributary to the SMV occlusion. In fact, the opinion was that reduced SV to MPV flow may, in fact, redirect flow through the IMV into the SMV system and improve flow through the recanalized/stented SMV and help maintain patency. It is unclear whether stenting the MPV–SV stenosis from the start could have improved primary SMV stent patency.

A rendezvous technique, combining antegrade–retrograde approach, traditionally described in chronic total occlusion in peripheral artery disease,[5] combined with sharp recanalization, can prove to be a promising avenue to explore for similar cases of chronic mesenteric vein occlusions.

 

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Conclusion

Sharp recanalization of SMV occlusions is a feasible technique that should be considered after traditional methods fail. This case showcases the utility of direct transabdominal upstream SMV puncture, allowing placement of a catheter, the tip of which positioned upstream of the occlusion as a target for sharp retrograde recanalization combined with orthogonal fluoroscopic views reduces risks of extravasation and catastrophic hemorrhage.

 

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Conflict of Interest

A.A. received funding to attend the 2023 Penumbra's Physician in Training Course and the 2023 Symposium on Clinical Interventional Oncology events. M.B and L.-M.B. have no conflicts of interest to declare.

Consent

Written consent for publication was obtained from the individual.

• References

• 1 Hmoud B, Singal AK, Kamath PS. Mesenteric venous thrombosis. J Clin Exp Hepatol 2014; 4 (03) 257-2632
• 2 Rashwan B, Shwaiki O, Partovi S, Karuppasamy K, Gill A, Gadani S. Thoracic central venous occlusion from the interventional radiology perspective. Cardiovasc Diagn Ther 2023; 13 (01) 299-310
• 3 Entezari P, Riaz A, Thornburg B, Salem R. Percutaneous ultrasound-guided superior and inferior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt: a case series. Cardiovasc Intervent Radiol 2021; 44 (03) 496-499
• 4 Ghosh A, Seyoum N, Anand S, Akhter N. Percutaneous CT-guided superior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt. Radiol Case Rep 2022; 17 (08) 2603-2606
• 5 Sugihara M, Ueda Y, Yano Y, Miura SI. Successful case of direct puncture of a prosthetic bypass graft in endovascular treatment for long superficial artery chronic total occlusion: a case report. Eur Heart J Case Rep 2020; 4 (06) 1-5

Publication History

Article published online:
29 July 2025