Successful management of acute superior mesenteric infarction caused by extensive portal-mesenteric venous thrombosis: a case report

Introduction

Intestinal infarction related to portal vein and mesenteric vein thrombosis (PVMVT) is extremely rare, the mortality rate has been reported to be 37–76% (1). PVMVT has numerous risk factors, including both local and systemic factors, such as cirrhosis, portal hypertension, intra-abdominal malignancies, and infections, as well as factors like deficiency of antithrombin III (2). The formation of PVMVT leads to obstruction of blood flow in the portal and mesenteric venous systems, resulting in intestinal wall congestion and edema, impaired arterial perfusion, and intestinal infarction. The clinical presentation of acute PVMVT is diverse and lacks specificity, making it easily misdiagnosed as common acute abdominal conditions such as pancreatitis, which can lead to missing the critical window for optimal treatment (3). Early diagnosis is crucial for reducing mortality rates. Therefore, early accurate diagnosis and prompt venous revascularization are crucial in symptomatic cases. In our study, we report a case of acute superior mesenteric infarction resulting from extensive PVMVT, which was successfully managed through timely diagnosis and targeted intervention at a primary care center in China. This case highlights the critical importance of early recognition and a multidisciplinary treatment approach, which may contribute to improved outcomes for patients worldwide. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-249/rc).

Case presentation

A 50-year-old man with no significant medical history presented at the emergency department with a 2-day history of severe abdominal pain and vomiting. Physical examination revealed abdominal distension, rebound tenderness, and diminished bowel sounds. He reported no bowel movements for two days and reduced flatus. Laboratory investigations demonstrated leukocytosis (white blood cell count: 20.65×10⁹/L), an elevated C-reactive protein level (110.99 mg/L) and the D-dimer level (10 mg/L). Contrast-enhanced abdominal computed tomography revealed PVMVT, diffuse small bowel wall edema and thickening, along with blurring of the abdominal mesenteric fat planes (Figure 1A,1B).

Figure 1 Contrast-enhanced abdominal computed tomography showed portal vein and mesenteric vein thrombosis (arrows) (A) and diffuse small bowel wall edema and thickening, with indistinct abdominal mesenteric fat planes (arrows) (B).

Given concern for acute superior intestinal necrosis, a diagnostic laparoscopy was performed. This revealed approximately 2 meters of extensively ischemic and necrotic small bowel (Figure 2A), an elongated sigmoid colon (dolichosigmoid) measuring approximately 70 cm, and cirrhotic changes. The infarcted bowel segment was resected via laparotomy, combined with mesenteric thrombectomy (TE) and thrombolysis (TL), followed by anastomosis and fixation of the sigmoid colon. Due to the limited exposure, extreme technical difficulty, high risks, and incomplete removal potential associated with open surgical intervention for portal vein thrombosis, percutaneous transhepatic portal vein angiography (PTPVA) was performed 24 hours after the laparotomy. This procedure clearly delineated the precise location, extent, residual thrombus burden, and flow dynamics of the thrombosis. Consequently, a series of endovascular interventions TE, TL, balloon angioplasty (BA), and stent placement were subsequently carried out. Postoperative pathological examination demonstrated diffuse hemorrhagic necrosis throughout the entire intestinal wall, neutrophilic infiltrate, and thrombi within the mesenteric vasculature (Figure 2B,2C). A diagnosis of acute superior intestinal infarction with extensive PVMVT was established. The patient was discharged home on postoperative day 15 with a prescription for long-term rivaroxaban. At the 2-month follow-up visit, he was recovering well and remains on long-term anticoagulation therapy. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 2 Postoperative examination indicated extensive ischemic necrotic small intestine (A). Pathology results revealed necrosis of the glandular ducts and villi in the intestinal mucosa layer, diffuse hemorrhage of the entire intestinal wall and infiltration of neutrophils, and thrombi in the mesenteric blood vessels (hematoxylin and eosin stain, ×4) (B,C).

Discussion

Extensive PVMVT is a rare and insidious condition associated with significant mortality and morbidity, largely attributable to delays in diagnosis and treatment (4). While an infrequent cause of intestinal ischemia or infarction, PVMVT requires heightened clinical suspicion (5). Here, we present a case of acute superior intestinal infarction secondary to extensive PVMVT that was successfully managed through prompt diagnosis and targeted intervention. The cause of mesenteric vein thrombosis (MVT) in this case is unclear. However, a previous case study indicated acute mesenteric ischemia secondary to superior MVT in a patient with liver cirrhosis (6). The presence of cirrhosis and dolichosigmoid in this case may represent potential risk factors for portal vein thrombosis (PVT) and MVT based on previous studies (7,8). Multidisciplinary team (MDT) management is crucial in mesenteric venous thrombosis cases as it integrates the core expertise of diverse specialties (9). This model ensures seamless coordination throughout the entire clinical pathway—from rapid diagnosis and emergency laparotomy to vascular recanalization, postoperative anticoagulation, and follow-up. Through close collaboration among surgeons, interventional radiologists, hematologists, gastroenterologists, and intensive care specialists, it enables not only life-saving interventions like emergency laparotomy but also addresses underlying etiology through procedures such as percutaneous transhepatic portography, thereby delivering a personalized treatment strategy for critically ill patients with complex conditions (10). This case underscores the importance of early recognition and multidisciplinary management, which may improve outcomes for affected patients globally.

Conclusions

Acute PVMVT is a rare and insidious disease that is associated with significant mortality and morbidity. Physicians must maintain familiarity with this rare condition to enhance patient quality of life and prevent intestinal infarction secondary to extensive portal-mesenteric venous thrombosis. In cases of acute intestinal infarction with extensive thrombosis, prompt surgical intervention is indicated and surgical objectives should prioritize maximal bowel preservation with concurrent TE. Effective MDT including anesthesia, emergency medicine, and vascular surgery teams is essential to ensure safe, timely patient care. This case underscores the importance of early recognition and MDT management, which may improve outcomes for affected patients globally.

Acknowledgments

The authors would like to thank Denghui You in Dongguan Nancheng Hospital for valuable comments on the articles. The authors thank the Institutional Review Board on Bioethics and Biosafety of Dongguan Nancheng Hospital for its guidance.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-249/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-249/prf

Funding: This study was supported by the Project of Traditional Chinese Medicine Bureau of Guangdong Province (No. 20251430).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-249/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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