Acute embolic mesenteric infarct

[leviathan]

I had a patient with an embolic SMA occlusion who was in severe pain and looked terrible. She had no peritoneal findings, her lactate was only 2.3 and she was still hemodynamically stable, so gen surg wouldn't take her. I've read that you need to do embolectomy ASAP, so I'm confused. Is this an alternative way to manage acute mesenteric infarcts that I'm not aware of?

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[leviathan]

Generality was all I was interested in, since it was something that happened awhile ago. IR had refused to do anything with this patient and said call gen surg, so I assumed they do embolectomies. Maybe it should have been a call to vascular then, I'll have to look into what happened tomorrow with that case (I'm assuming vascular was called at some point).

 

[balaguru]

Hopefully the surgeon saw the patient, made recs and continued to follow the patient and not continued the game of hot potato. If you could post a de-identified image demonstrating the embolism it would have some interesting educational value.

 

[leviathan]

I just wanted generalized information about mgmt of this problem so nobody felt like they were giving medical advice, as this actually just happened last night, not in the past like I said. I can look into posting the image or if anything the radiologist report. It turns out the resident on call for gen surg was also on for vascular, so that's why there was some confusion there about who was consulted. The patient finally went for surgery this morning, after her WBC had gone up to 33,000 and she developed peritoneal findings.

I think she should have gone yesterday and it's not clear why that didn't happen. I was sitting at home wondering if I should be more aggressive with calling them back and forcing them to reconsider. I had already got the junior resident in-house to call them once and then a second time to clarify why they wouldn't take her - the answer was "not unless she devleops peritonitis, worsening lactate, hematochezia" etc).

For what it's worth, the CT showed good collaterals from her celiac + IMA, so I wonder if that was one of the reasons they held off on a more conservative approach at first for this woman in her 80s.

 

[balaguru]

A radiologist's report wouldn't be very interesting. Most surgeons just use them to make sure they didn't miss anything when they reviewed the images themselves. While it's on your mind you should ask one of the surgeons involved. I personally like it when ER/consulting docs follow up. It doesn't happen often enough.

 

[SouthernSurgeon]

I just wanted generalized information about mgmt of this problem so nobody felt like they were giving medical advice, as this actually just happened last night, not in the past like I said. I can look into posting the image or if anything the radiologist report. It turns out the resident on call for gen surg was also on for vascular, so that's why there was some confusion there about who was consulted. The patient finally went for surgery this morning, after her WBC had gone up to 33,000 and she developed peritoneal findings.

I think she should have gone yesterday and it's not clear why that didn't happen. I was sitting at home wondering if I should be more aggressive with calling them back and forcing them to reconsider. I had already got the junior resident in-house to call them once and then a second time to clarify why they wouldn't take her - the answer was "not unless she devleops peritonitis, worsening lactate, hematochezia" etc).

For what it's worth, the CT showed good collaterals from her celiac + IMA, so I wonder if that was one of the reasons they held off on a more conservative approach at first for this woman in her 80s.

Good flow through the celiac and IMA often doesn't matter for acute mesenteric ischemia; more important in chronic. Especially if you're talking about embolic disease.

Now the fact that you're talking bout someone in their 80s (esp if they may have significant comorbidity burden and atherosclerosis which would contribute to developing collaterals) - that may be someone where you can skirt by without operating just with heparin and resuscitation.

But my other point was that while embolectomy is probably the textbook answer, I think most vascular surgeons would try an endo approach first (*obviously this depends on the imaging). I also think the availability of an endovascular approach somewhat lowers the threshold for intervention - since it is less morbid than an open embolectomy.

What would usually happen for a patient like this at my institution is that we would book them in a hybrid OR suite. General surgery can perform a laparotomy and assess/resect any non-viable bowel, and vascular has options for either an endo approach or if that is not feasible an open embolectomy.

 

[mimelim]

I had a patient with an embolic SMA occlusion who was in severe pain and looked terrible. She had no peritoneal findings, her lactate was only 2.3 and she was still hemodynamically stable, so gen surg wouldn't take her. I've read that you need to do embolectomy ASAP, so I'm confused. Is this an alternative way to manage acute mesenteric infarcts that I'm not aware of?

What exactly was the clinical history? I mean you gave the diagnosis, is that radiographic or clinical? TBH, if a surgical resident started talking about lactate and HDS they would be brow beaten in mesenteric ischemia. If you are talking about either, you missed the boat and things are going to be ugly. Please tell me at least a gen surg resident came and saw the patient and evaluated them clinically...

I agree with what @SouthernSurgeon has said.

If you called me from the ER and said, belly pain, CT scan concerning for SMA occlusion...

#1 See the patient immediately, regardless of anything else (labs/films etc)
#2 Review the films myself and if there are any doubts in my mind go to radiology and talk with them about it.
#3 Depending on clinical scenario, there are very few instances that you would sit on this. Belly pain + radiographic findings mandate a good abdominal exam by someone with a decent physical exam/experience, ie. not the overloaded overnight surgical intern. Maybe things are different at other institutions, but where I have been, we are quite aggressive about monitoring and I wouldn't want this patient on a standard medicine floor with normal nursing staffing. That is a recipe for dead bowel.
#4 We would go to the Hybrid in most all of these cases. If the call was somewhat soft, we would start with angiography +/- endo intervention and potentially a diagnostic lap vs. exploratory laparotomy (depending on GS on call).

 

[leviathan]

Clinical history was of an 80ish woman in for pneumonia with new dx of atrial fibrillation. Pneumonia resolved and day before discharge home got diffuse 10/10 abdo pain after breakfast.Belly was soft and non tender with bowel sounds, but patient was diaphoretic and unwell appearing. Immediately called and got a CT angio with an obvious SMA occlusion (radiology was 100% convinced this was the real deal). He thought she was too old for catheter tPA. Or maybe it was new years eve and he wanted to go party instead?

Gen surg was consulted (This was my mistake, not calling vascular), the junior came to see the patient and said they wouldnt take her unless she gets sick peritonitis etc etc. They also suggested reversing my NPO order and advancing diet. They didnt recommend a vascular consult either.

I couldnt believe the above advice so I asked my junior resident to call back and make sure they had 1) reviewed with their senior resident and 2) knew she had an EMBOLIC occlusion and needed EMBOLECTOMY. They again refused to change their stance. I then asked him to call vascular, realizing now I had probably made a mistake (although gen surg hadnt recommended we consult vascular either). It turns the reason for no rec was the senior resident was covering both vascular and gen surg consults, and so my junior spoke to him a third time and continued to receive the same advice that shes not sick enough for either (and vascular was thus already involved from the beginning).

As above didnt plan for surgery until she developed pain + wbc of 30k the next AM. STILL didnt go until that afternoon. They removed 200cm of small intestine. Did a second look with no further intervention. Patient was extubated today and is being transferred to the floor. Has not started feeds yet but pain-free, vitals + labs normalized. She has a long road ahead of her and no idea what her quality of life will be like now but im hoping for the best.

 

[SouthernSurgeon]

I hate to monday morning quarterback, but from everything you've told us that's a pretty terrible outcome.

What we would have done is perform the vascular intervention first. Then when you've optimized the blood flow, figure out how much (if any) bowel is dead. I've had cases where timely intervention to restore flow prevented us from having to resect any bowel.

Part of me wonders if this case was ever staffed with an attending surgeon.

I think in the future, all I can advise is to not be afraid to run things up the ladder further and advocate for your patient if something seems wrong. In other words, this was a case where your attending needed to call their attending directly.

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Edit: The other thing I don't like about this situation the more I think about it. Sometimes the whole hierarchy thing works against you. You said you had your junior call their junior, etc, three times. If you aren't getting an adequate explanation, don't have your junior call again. YOU call. And if you aren't getting an adequate explanation from that person, you call the next most senior person on the chain.

I can't tell you how many times my intern has told me "GI said such and such" - and I thought to myself, that doesn't really make any sense. So I called the GI fellow and got a completely different explanation. Or vice versa - I've read what one of my juniors wrote in a consult note and it was totally wrong.

Sometimes in academia the whole telephone game gets really annoying and messages get distorted. Bottom line if you have a patient who isn't getting care in what, from everything you've told us, is a time-critical surgical emergency - you need to push back hard.

**This is all still with the obvious caveat that there may be other aspects of this case that I don't have access to that would change the surgical plan/recs.

 

[leviathan]

All very good points made + agreed. As you said, there may still be parts of the case I'm missing myself that would have changed things. I plan on looking more into it from my end. I just have to find a tactful way of approaching the people involved without saying 'i think you guys screwed up' to find out if there are details about their decision I'm missing.

 

[ACSurgeon]

I hate to monday morning quarterback, but from everything you've told us that's a pretty terrible outcome.

What we would have done is perform the vascular intervention first. Then when you've optimized the blood flow, figure out how much (if any) bowel is dead. I've had cases where timely intervention to restore flow prevented us from having to resect any bowel.

Part of me wonders if this case was ever staffed with an attending surgeon.

I think in the future, all I can advise is to not be afraid to run things up the ladder further and advocate for your patient if something seems wrong. In other words, this was a case where your attending needed to call their attending directly.

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Edit: The other thing I don't like about this situation the more I think about it. Sometimes the whole hierarchy thing works against you. You said you had your junior call their junior, etc, three times. If you aren't getting an adequate explanation, don't have your junior call again. YOU call. And if you aren't getting an adequate explanation from that person, you call the next most senior person on the chain.

I can't tell you how many times my intern has told me "GI said such and such" - and I thought to myself, that doesn't really make any sense. So I called the GI fellow and got a completely different explanation. Or vice versa - I've read what one of my juniors wrote in a consult note and it was totally wrong.

Sometimes in academia the whole telephone game gets really annoying and messages get distorted. Bottom line if you have a patient who isn't getting care in what, from everything you've told us, is a time-critical surgical emergency - you need to push back hard.

**This is all still with the obvious caveat that there may be other aspects of this case that I don't have access to that would change the surgical plan/recs.

Well said. I was essentially going to post the same advice, at the risk of seeming to encourage a low threshold for having the senior or attending called for every little thing (not what I'm advocating).

Unfortunately, this happens too often, where a nurse or non-surgical resident is too hesitant to go up the chain of command out of fear of getting chewed out by the senior resident or attending surgeon. This is something we (surgeons and surgical trainees) have brought on ourselves, and while it saves us from being called over little things non-stop, we end up in situations where a patient needed us and our junior resident does not do the right thing.

Finally, at our program, EVERY consult is staffed with an attending as soon as the senior has assessed the patient. Now some attendings will be content with "I have this consult for mesenteric ischemia which is BS, nothing to do" while other attendings will dig deeper to make sure the assessment and management are appropriate.

 

[Pir8DeacDoc]

Agree with a lot of the above. If you're worried, run it up the chain. If you really think something is wrong, that's your responsibility to your patient. I had a bad situation as ENT chief where I didn't think GS was properly managing one of my patients that they had done a G tube on. I tried to call their chief and got the NTD line. I was still worried so I had my attending call their attending. They still put us off until she got worse and went to ICU where trauma attending running the unit saw her and had a fit and took her to OR. Anyway all you can do is advocate for your pt. I was super pissed but felt like I had done everything I could do for my pt. at the end of the day that's all you can do sometimes.

 

[Gastrapathy]

Medicine attendings at some academic places can be pretty timid WRT stepping up with the surgeons. I feel like I get called by medicine just so I can call surgery on occasion. The odd part is that the surgical attendings are never obstructionist when I call, so I can't decide if I'm being treated differently or the fear is irrational.

Regardless, if the case went down as described, it was an error by a junior surgical resident with a failure of supervision by his seniors. Your team knew the error occurred and, unless there was an attending to attending interaction, that was also poor. Also, it sounds like you didn't get on the phone. Don't be scared to cry wolf. You'll be wrong most of the time but not as often as you fear.

 

[SouthernSurgeon]

Finally, at our program, EVERY consult is staffed with an attending as soon as the senior has assessed the patient. Now some attendings will be content with "I have this consult for mesenteric ischemia which is BS, nothing to do" while other attendings will dig deeper to make sure the assessment and management are appropriate.

Same.

(a) We do not refuse consults. Every consult gets seen - unless it is something that is just not appropriate for our service (i.e. something that should be dealt with by plastics or urology or something like that) in which case we will help dispo it to the correct team.
(b) Every consult gets seen and staffed with the senior resident on call and then immediately with the attending. As the senior resident, the only time I don't see the patient myself before it gets staffed with the attending is if it is a junior resident I trust and a "slam dunk" (e.g. junior says - I got an acute appy in the ED; I might just look at the imaging and labs to verify and then just let them staff it since my abdominal exam isn't going to add anything). If it's a sick patient or a complex case I'm going to see it. Most of our attendings will want to at least see imaging and review the chart at the very least.

 

[mimelim]

Same.

(a) We do not refuse consults. Every consult gets seen - unless it is something that is just not appropriate for our service (i.e. something that should be dealt with by plastics or urology or something like that) in which case we will help dispo it to the correct team.
(b) Every consult gets seen and staffed with the senior resident on call and then immediately with the attending. As the senior resident, the only time I don't see the patient myself before it gets staffed with the attending is if it is a junior resident I trust and a "slam dunk" (e.g. junior says - I got an acute appy in the ED; I might just look at the imaging and labs to verify and then just let them staff it since my abdominal exam isn't going to add anything). If it's a sick patient or a complex case I'm going to see it. Most of our attendings will want to at least see imaging and review the chart at the very least.

+1 to not refusing consults.

If I am on call, my senior/fellow is at home. I generally stack consults that a) I know aren't going to the OR tonight and b) I have literally zero questions about. Then I tell the senior/fellow when they come in the next morning unless I need to call them about something else. My intern year, I called about every consult that came in. The number of calls has been steadily dropping since then. I also have some faculty that I ask me to call them directly about certain things when they are on call and let the seniors sleep. There are also some faculty that point blank say, I'm doing any cases overnight with the Junior, unless it is an aorta that needs complex endo or open (because the seniors need the numbers).

On the other hand... when I am on with others, I always NEED to see the patient/leg/abdomen to feel comfortable if I'm the most senior person around before calling the attending. I've been burned once by trusting and not verifying. And that will NEVER happen again.

 

[vhawk]

Yep. I've never once regretted getting out of bed and going to see the patient. Not a single time. The converse isn't true, sadly.

The same goes with picking up a phone and getting to the bottom of things yourself. The only questions I ever find myself asking during m&m are along the lines of "so when all that happened, and medicine didn't adequately resuscitate...what did their attending say when you called and spoke with him directly? " The answer is always "uh I didn't do that" and it's always the wrong answer. So much better to occasionally be thought of as annoying than to let bad outcomes happen that could have been prevented.

I hope this doesn't sound judgmental or condescending. The reason I say this is because these are mistakes I've made many times.

 

[balaguru]

There were times when something like this happened on my service and depending on the situation I would grab the junior resident for a private discussion or a public rectification. This is perhaps where we get our reputation for malignancy but I prefer to see it as the filtering down of the honest M&M's that we did. Most junior residents become 1 of 2 types when they start carrying the call pager: the first tends to think the person calling the consult in doesn't know what they are talking about and the patient probably has a pulm bleb, gastritis, cellulitis, simple edema, etc and the other tends to think the person calling the consult in doesn't know what they are talking about and the patient probably has a pneumo, acute abdomen, nec fasc, compartment syndrome, etc.

 

[Kahreek]

IR it.
or if your hospital isnt big on spending
Wait very carefully for it.
gen surgs wouldnt know what to do with a mesenteric embolous and no necrotic intestine.
Reading surgical options on medscape right now. Fogarty embolectomy would take a very special kind of surgeon.
SMA thrombosis vs embolism have different treatments. Could you say it was an embolous for sure
Mesenteric bypass, holy hell now i am feeling fancy

 

[leviathan]

Good discussion and agreed again. To clarify, this was discussed with both the junior resident (once) and the senior resident covering both gen surg and vascular (two separate times). When both a junior and a senior are telling you they're not going to touch the patient, I assumed I must be wrong about the management so going over their heads to their staff/attending wasn't something I had the guts to do. What I could have done though was call the senior resident myself. Good lesson but had to learn it the hard way, I guess.

 

[balaguru]

Good discussion and agreed again. To clarify, this was discussed with both the junior resident (once) and the senior resident covering both gen surg and vascular (two separate times). When both a junior and a senior are telling you they're not going to touch the patient, I assumed I must be wrong about the management so going over their heads to their staff/attending wasn't something I had the guts to do. What I could have done though was call the senior resident myself. Good lesson but had to learn it the hard way, I guess.

One way to handle it would be to share your concerns with your attending. If you get the sense he/she isn't going to call the vascular attending offer to call him yourself. Bumping it up is the right thing to do.

 

[vhawk]

It doesnt always have to be about "going over their head." When you call them personally, you have another extremely effective option available to you: ask them to explain why. It doesnt have to be condescending, but call them personally, and just say "Hey I dont see this very much, and obviously I'm not a surgery resident, so can you just explain to me the way you guys handle these patients, what you look for, etc." If he is a dick, this may not work, in which case, if you are still concerned, then you've got no choice. But most residents will explain to you in basic terms what their thought process is.

This is useful for a couple reasons. One, if you are intelligent, you should be able to tell if they actually HAVE a thought process. They may not, in which case, bump it up. Two, you should be able to tell if their thought process is guided by a misunderstanding of the patients clinical picture or some piece of information, and you can clarify that for them. Maybe your junior resident sold this poorly, and they were trusting him and making their decision off his bad info. And three, maybe they are right, you are wrong, in which case you might learn something.

 

[SLUser11]

Good discussion and agreed again. To clarify, this was discussed with both the junior resident (once) and the senior resident covering both gen surg and vascular (two separate times). When both a junior and a senior are telling you they're not going to touch the patient, I assumed I must be wrong about the management so going over their heads to their staff/attending wasn't something I had the guts to do. What I could have done though was call the senior resident myself. Good lesson but had to learn it the hard way, I guess.

I've been reading casually, but just to support what others have said, this is a slam dunk for someone that should be evaluated and admitted to either general or vascular surgery. This is a clean kill.

Elderly patient, new-onset A fib without anticoagulation, and severe abdominal pain.....already requires evaluation by both.....now throw in a CT confirming SMA embolism......then a junior surgical resident swings by and says he'll only act if the patient develops peritonitis, and recommends advancing the diet.....then the patient finally develops a clinical situation obvious enough for the team to decipher with peritonitis and severe leukocytosis, they take her and resect 200 cm of small bowel.

Of course, it is obvious this patient is not going to do well, and will likely die soon. If she makes it out of the hospital, there will be plenty more hurdles she will not be able to ascend, and she'll die.

I agree that there were too many middle-men, and direct communication is a priority. I also want to hear the surgery resident's side of the story...but ultimately, the resident's side of the story is not too important to me, as he/she obviously has very bad clinical judgment.

This is a perfect storm of incompetence on many levels. Inadequate clinical abilities, inadequate supervision, inadequate communication, combined with a likely late-night and/or weekend scenario. SO many people involved in this person's care should have been able to intervene sooner, whether it's the senior resident, the surgical attending, the ER doc, the radiologist, the medicine team....it's just hard to fathom such horrible care is happening in training environments.

I would love to hear about the latest and greatest endovascular approaches to EMBOLIC SMA disease. However, in this patient with new-onset Afib and new-onset severe abdominal pain, and CT-confirmed SMA embolism, I would take her immediately to the OR for laparotomy. I wouldn't play hot-potato with the patient because she's on borrowed time. I'd ask the vascular surgeon to come into the OR with me and perform SMA cutdown with embolectomy. I will be quite amused if this approach is considered barbaric, but I'll be happy to do some reading. In the end, you have to think about how well your plan will fail, and this frail 80 year old woman can't tolerate insults well.

 

[Gastrapathy]

The point about admitting the patient to the right service is a very good one. I know it seems petty but ownership affects decision making. There's a study in annals of surgery that showed that the best predictor of mortality in fulminant c diff infection was whether or not the patient was admitted to surgery. This wasn't just about surgeons being better at recussitation, the patients on their service got more surgery.

 

[dpmd]

I've been reading casually, but just to support what others have said, this is a slam dunk for someone that should be evaluated and admitted to either general or vascular surgery. This is a clean kill.

Elderly patient, new-onset A fib without anticoagulation, and severe abdominal pain.....already requires evaluation by both.....now throw in a CT confirming SMA embolism......then a junior surgical resident swings by and says he'll only act if the patient develops peritonitis, and recommends advancing the diet.....then the patient finally develops a clinical situation obvious enough for the team to decipher with peritonitis and severe leukocytosis, they take her and resect 200 cm of small bowel.

Of course, it is obvious this patient is not going to do well, and will likely die soon. If she makes it out of the hospital, there will be plenty more hurdles she will not be able to ascend, and she'll die.

I agree that there were too many middle-men, and direct communication is a priority. I also want to hear the surgery resident's side of the story...but ultimately, the resident's side of the story is not too important to me, as he/she obviously has very bad clinical judgment.

This is a perfect storm of incompetence on many levels. Inadequate clinical abilities, inadequate supervision, inadequate communication, combined with a likely late-night and/or weekend scenario. SO many people involved in this person's care should have been able to intervene sooner, whether it's the senior resident, the surgical attending, the ER doc, the radiologist, the medicine team....it's just hard to fathom such horrible care is happening in training environments.

I would love to hear about the latest and greatest endovascular approaches to EMBOLIC SMA disease. However, in this patient with new-onset Afib and new-onset severe abdominal pain, and CT-confirmed SMA embolism, I would take her immediately to the OR for laparotomy. I wouldn't play hot-potato with the patient because she's on borrowed time. I'd ask the vascular surgeon to come into the OR with me and perform SMA cutdown with embolectomy. I will be quite amused if this approach is considered barbaric, but I'll be happy to do some reading. In the end, you have to think about how well your plan will fail, and this frail 80 year old woman can't tolerate insults well.

Hope it wouldn't be considered barbaric as I had a similar kind of case in the past year and we did just as you suggested.

 

[SouthernSurgeon]

I've been reading casually, but just to support what others have said, this is a slam dunk for someone that should be evaluated and admitted to either general or vascular surgery. This is a clean kill.

Elderly patient, new-onset A fib without anticoagulation, and severe abdominal pain.....already requires evaluation by both.....now throw in a CT confirming SMA embolism......then a junior surgical resident swings by and says he'll only act if the patient develops peritonitis, and recommends advancing the diet.....then the patient finally develops a clinical situation obvious enough for the team to decipher with peritonitis and severe leukocytosis, they take her and resect 200 cm of small bowel.

Of course, it is obvious this patient is not going to do well, and will likely die soon. If she makes it out of the hospital, there will be plenty more hurdles she will not be able to ascend, and she'll die.

I agree that there were too many middle-men, and direct communication is a priority. I also want to hear the surgery resident's side of the story...but ultimately, the resident's side of the story is not too important to me, as he/she obviously has very bad clinical judgment.

This is a perfect storm of incompetence on many levels. Inadequate clinical abilities, inadequate supervision, inadequate communication, combined with a likely late-night and/or weekend scenario. SO many people involved in this person's care should have been able to intervene sooner, whether it's the senior resident, the surgical attending, the ER doc, the radiologist, the medicine team....it's just hard to fathom such horrible care is happening in training environments.

I would love to hear about the latest and greatest endovascular approaches to EMBOLIC SMA disease. However, in this patient with new-onset Afib and new-onset severe abdominal pain, and CT-confirmed SMA embolism, I would take her immediately to the OR for laparotomy. I wouldn't play hot-potato with the patient because she's on borrowed time. I'd ask the vascular surgeon to come into the OR with me and perform SMA cutdown with embolectomy. I will be quite amused if this approach is considered barbaric, but I'll be happy to do some reading. In the end, you have to think about how well your plan will fail, and this frail 80 year old woman can't tolerate insults well.

I think either approach would be fine. From what I've seen from our younger vascular attendings they'd prefer an endo approach (mechanical thrombectomy or lytics). Maybe @mimelim knows some literature. The bigger issue is time. Time is bowel.

I've been reading casually, but just to support what others have said, this is a slam dunk for someone that should be evaluated and admitted to either general or vascular surgery.

If I understand the story right - they were already in the hospital being treated for pneumonia, on the medicine service when this happened.

 

[SouthernSurgeon]

The point about admitting the patient to the right service is a very good one. I know it seems petty but ownership affects decision making. There's a study in annals of surgery that showed that the best predictor of mortality in fulminant c diff infection was whether or not the patient was admitted to surgery. This wasn't just about surgeons being better at recussitation, the patients on their service got more surgery.

That's a good point. I think unfortunately the conclusion a lot of surgeons took away from that annals article is that we just have to get the patients away from the dumb medicine doctors and they will do better.

The reality is that you treat consult patients differently, and there is less ownership. You often catch yourself looking for reasons to sign off; they get rounded on less frequently and often less carefully; etc.

 

[Kahreek]

if i was the vascular surgeon, i would be very wary. How well can the tc differentiate between embolic vs trombotic?

 

[SouthernSurgeon]

if i was the vascular surgeon, i would be very wary. How well can the tc differentiate between embolic vs trombotic?

(a) as SLU pointed out its a textbook history.

(b) embolism classically presents slightly distal to the SMA origin (just distal to the takeoff of the middle colic)

(c) Thrombosis would typically occur in the setting of a flow-limiting stenosis in a patient with pre-existing atherosclerotic burden. It is usually at the origin and you would also see significant calcification of the vessels. Also this sort of SMA occlusion is usually sort of an "acute on chronic" mesenteric ischemia - since the patient has probably already developed significant collaterals and ischemia tolerance (which is what I was alluding to earlier before we got the full history).

 

[maverick_pkg]

I would love to hear about the latest and greatest endovascular approaches to EMBOLIC SMA disease. However, in this patient with new-onset Afib and new-onset severe abdominal pain, and CT-confirmed SMA embolism, I would take her immediately to the OR for laparotomy. I wouldn't play hot-potato with the patient because she's on borrowed time. I'd ask the vascular surgeon to come into the OR with me and perform SMA cutdown with embolectomy. I will be quite amused if this approach is considered barbaric, but I'll be happy to do some reading. In the end, you have to think about how well your plan will fail, and this frail 80 year old woman can't tolerate insults well.

I agree with you. Thats what I would do too. Over the last few years, some people have started doing thrombolysis for this. You can do that only if patient is totally asymptomatic and you dont have any concerns about bowel viability which needs a laparotomy. Plus lysis takes time which bowel might not tolerate. Embolectomy is way faster.

 

[dozitgetchahi]

Finally, at our program, EVERY consult is staffed with an attending as soon as the senior has assessed the patient. Now some attendings will be content with "I have this consult for mesenteric ischemia which is BS, nothing to do" while other attendings will dig deeper to make sure the assessment and management are appropriate.

I'd like to comment on this. Is it ever normal practice for surgery consults to *not* be staffed with attendings for long periods? At our institution, there are literally surgical consults that seem to have gone days without being staffed (in some cases, I've wondered if the consult was ever staffed at all).

In some of these situations, I've just gone ahead and called their staff myself. I'd much rather be chewed out by some random attending from a different service then go to sleep at night knowing that I didn't exhaust every avenue to give a sick patient the best care. Plus, every time I've talked to a surgical attending they've been polite and responsive.

 

[dpmd]

I'd like to comment on this. Is it ever normal practice for surgery consults to *not* be staffed with attendings for long periods? At our institution, there are literally surgical consults that seem to have gone days without being staffed (in some cases, I've wondered if the consult was ever staffed at all).

In some of these situations, I've just gone ahead and called their staff myself. I'd much rather be chewed out by some random attending from a different service then go to sleep at night knowing that I didn't exhaust every avenue to give a sick patient the best care. Plus, every time I've talked to a surgical attending they've been polite and responsive.

Can't see a scenario where a patient still in house doesn't get seen by staff the next day, if only so that the note can legally get cosigned and billed. So yeah, reasonable they wouldn't hear about something from the time they go home one day to the time they come back the next (assuming the case was considered to be straightforward by the senior and didn't require immediate intervention-infrequently the senior and the senior/staff of the consulting team wouldn't agree on whether this was the case in which case the staff would get called but wouldn't always come in depending on the story given over the phone and how much the other staff pressed, probably also based on how much they trusted the senior). All subspecialty stuff was related to the staff by phone immediately though since it was seen by an intern and not discussed with the senior. It was then up to staff if they wanted to come in or just give directions over the phone.

 

[dpmd]

That sounds about right to me.

Like I said above - all our consults get staffed pretty immediately. If it is someone where the initial recommendation is going to be to get a scan or something like that I would usually wait until the reasonable workup was done before I call the attending, or if I have like 3 consults brewing at once I'd batch them and talk about them all.

The longest I think someone would theoretically wait would be if it was a like 6 or 7pm consult and the staff was already gone home, then the patient might not get seen physically by the attending until the next morning assuming there was nothing to do overnight.

Our staff would be home earlier (or at least not around) especially on the weekends so i would back that time up.

 

[vhawk]

Certain of my staff prefers not to be called at night unless either patient needs OR, I dont know if patient needs OR, or there is some specific question I'm unsure on. So generally if its after 10 or so I just hold them until morning report or some more humane hour. This is basically the bowel obstructions, non-op comp diverticulitis patients, superficial abscesses, and the very boring traumas.

 

[badasshairday]

Old thread but the appropriate treatment for someone with viable bowel (low or normal lactate and no bowel ischemic imaging changes) would be endovascular treatment. If ischemic changes then open embolectomy and resect dead bowel. We had a case just like this and did several passes with Angiojet (pharmomechanical thrombolysis/thrombectomy) followed by PTA/stenting. Outcome was good other than the rare post angiojet extreme hypertension which resolved was controlled with antihypertensive drip later that night .

 

[filter07]

Pharmacomechanical thrombolysis is better. It can treat all the small side branches in the SMA rather than just plucking out a big thrombus and leaving all the small clots behind. It is also much quicker to revascularize than opening up the patient, moving all the bowel out of the way, opening up the SMA, and passing fogarty. They may still need to explore the bowel but my preference is for endo regardless of acute vs chronic. I would not drip overnight, just pass the Angiojet with tPA.

I would do the same for iliofemoral DVT as well, again for the small branches.

 

[Jolie South]

I would love to hear about the latest and greatest endovascular approaches to EMBOLIC SMA disease. However, in this patient with new-onset Afib and new-onset severe abdominal pain, and CT-confirmed SMA embolism, I would take her immediately to the OR for laparotomy. I wouldn't play hot-potato with the patient because she's on borrowed time. I'd ask the vascular surgeon to come into the OR with me and perform SMA cutdown with embolectomy. I will be quite amused if this approach is considered barbaric, but I'll be happy to do some reading. In the end, you have to think about how well your plan will fail, and this frail 80 year old woman can't tolerate insults well.

In my institution without real vascular on call, this is how we do it. CT, who covers our vascular call, will do anything to BS and buy time because if it isn't a CABG, they don't want to do it. I have taken mesenteric ischemia to OR with my gen surgery attendings, resected what needed to be resected and called vascular intra-op. IR where I am won't touch these either unfortunately. Sucks to be between a rock and a hard place.

 

[badasshairday]

It is also much quicker to revascularize than opening up the patient, moving all the bowel out of the way, opening up the SMA, and passing fogarty. They may still need to explore the bowel but my preference is for endo regardless of acute vs chronic. I would not drip overnight, just pass the Angiojet with tPA.

That is true. Even if ischemic changes maybe do rapid endovascular treatment then bowel resection. Seems that the old textboom answer is open embolectomy and bowel resection however.