Thrombolysis with intra-arterial urokinase for acute superior mesenteric artery occlusion: Outcome analysis

Abstract Background The aim of this study was to evaluate the outcome of intra-arterial urokinase thrombolysis for acute superior mesenteric artery (SMA) occlusion. Methods Ten patients with acute SMA occlusion who underwent intra-arterial urokinase therapy between 2008 and 2019 were retrospectively evaluated. Results Among the 10 patients, 7 were men and 3 were women (median age, 75.5 years). The median time from onset of abdominal pain to emergency department admission was 11 hours (interquartile range [IQR], 4.9 hours). None of the patients presented with shock in the triage screening or acute peritonitis on physical examination, and 4 (40%) had bloody stools. On angiography, 6 patients presented with complete SMA occlusion and the other 4 patients had incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.5 hours (IQR, 8.0 hours). During the course of the urokinase therapy, all the patients showed various degrees of recanalization (near-total, n = 2; partial, n = 8) on follow-up angiography. The median urokinase therapy duration was 39.0 hours (IQR, 48.0 hours). After urokinase therapy, bowel perfusion was restored with bowel preservation in 4 patients; however, in the other 6 patients, bowel perfusion was not restored. Comparison between the 4 patients with restored bowel perfusion and 6 patients with unrestored bowel perfusion revealed that the degree of SMA occlusion was statistically significant (complete vs. incomplete, p = 0.012). Of the 6 patients with complete SMA occlusion, 5 underwent bowel resection, of whom 2 died, and the remaining patient died of shock due to delayed surgery. Of the 4 patients with incomplete SMA occlusions, no bowel resection was performed except a partial omentectomy. Of the 3 deaths, one was attributed to delayed surgery, and the other two developed short bowel syndrome with sepsis and multiple-organ failure, with a 30% in-hospital mortality rate. The median hospital stay was 20.0 days (IQR, 32.0 days). Conclusion In our experience, thrombolysis with intra-arterial urokinase may serve as an adjunctive treatment modality to preserve the bowel and obviate surgery for incomplete SMA occlusion. However, it was not suitable for complete SMA occlusion, which requires surgery.