Ann Thorac Surg 2006;82:1127
© 2006 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Severe Hepatic Artery Spasm and Nonocclusive Mesenteric Ischemia After Cardiac Surgery
Kazuhito Imanaka, MD*,
Shunei Kyo, MD,
Keiko Abe, MD
Department of Cardiovascular Surgery, Saitama Medical School, Saitama, Japan
* Address correspondence to Dr Imanaka, Department of Cardiovascular Surgery, Saitama Medical School, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495 Japan (Email: imanaka{at}saitama-med.ac.jp).
Non-occlusive mesenteric ischemia (NOMI) is a life-threatening condition, and renal failure is one of its underlying factors [1]. A 64-year-old woman with a 26-year history of hemodialysis underwent aortic and mitral valve replacement for calcific valvular stenoses. Her early postoperative course was good, but she suddenly fell into a state of shock 6 days after surgery. Severe metabolic acidosis and abdominal pain suggested intestinal necrosis. An emergency angiography revealed a typical finding of NOMI [1], namely, severe diffuse spasm of the superior mesenteric artery (Fig 1). Her portal vein was patent. Papaverine infusion into the superior mesenteric artery failed to relieve the spasm at all. The aortography demonstrated extreme spasm of the hepatic artery (Fig 2;
thick arrows) and a small spastic segment in the splenic artery (thin arrow). The patient's liver was not visualized even in phlebophase. The left gastric artery was unidentifiable. Renal arteries were also absent, possibly because of a very long history of hemodialysis. A subsequent laparotomy revealed gangrene of the entire intestine, except the left side of the colon. The necrotic intestine was resected, but the serum bilirubin level rose steeply and the patient died 4 days later. The cause of the NOMI was histologically unidentified.
We had previously reported another NOMI case that showed intact hepatic circulation and severe spasm in all splanchnic, splenic, and renal arteries [2]. In this case also, many arteries were involved, although the distribution was quite different. Superior mesenteric artery has solely been focused in previous studies regarding NOMI. However, NOMI apparently affects various visceral arteries.
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References
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- Lock G, Scholmerich J. Non-occlusive mesenteric ischemia Hepato-Gastroenterology 1995;42:234-239.[Medline]
- Imanaka K, Kyo S, Ban S. Possible close relationship between non-occlusive mesenteric ischemia and cholesterol crystal embolism after cardiovascular surgery Eur J Cardio-Thorac Surg 2002;22:1032-1034.[Abstract/Free Full Text]
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