A rare complication following ureteroscopic laser lithotripsy: a lethal case report of superior mesenteric artery thrombosis

Introduction

Ureteroscopic laser lithotripsy (URSL) is a minimally invasive surgical procedure for the treatment of ureteral stones. It offers advantages such as minimal trauma, rapid recovery, and a high stone clearance rate, making it one of the preferred treatment options for ureteral stones (1). However, despite continuous advancements in surgical techniques, postoperative complications remain inevitable. Among these, thromboembolic complications, although relatively rare, are often critical and associated with a poor prognosis once they occur (2).

Acute mesenteric arterial thrombosis is a rare yet lethal vascular emergency, with a high mortality rate ranging from 60% to 80%, which necessitates urgent diagnosis and intervention (3). Its etiology is multifactorial, including atrial fibrillation, myocardial infarction, congestive heart failure, hypercoagulable states, among others (4). Acute mesenteric arterial thrombosis is a rare but critical vascular emergency that carries a high mortality rate ranging from 60% to 80%, and requires urgent diagnosis and treatment. Its etiology is diverse, including atrial fibrillation, myocardial infarction, congestive heart failure, hypercoagulable states, among others. In recent years, isolated cases of superior mesenteric artery (SMA) thrombosis following surgical procedures have been documented in the literature (5,6), suggesting that factors such as surgical trauma and postoperative immobility may potentially trigger thrombogenesis. However, there have been no reports to date of SMA thrombosis specifically subsequent to URSL. This case report presents a patient who developed SMA following URSL, which resulted in a fatal outcome. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-253/rc).

Case presentation

A 60-year-old female patient was admitted on October 27, presenting with a 2-day history of right abdominal pain occurring 10 days after undergoing right URSL. On October 17, the patient had undergone right URSL under general anesthesia for a right intramural ureteral stone (Figure 1). The postoperative course was initially uneventful, and she was discharged two days after surgery. Two days prior to admission, she developed right-sided abdominal pain accompanied by nausea and vomiting, without urinary frequency, urgency, dysuria, chest tightness, palpitations, fever, abdominal distension, diarrhea, hematemesis, or melena. She was subsequently admitted through the emergency department. Her medical history included hypertension for over 10 years, managed with metoprolol with adequate control, and a history of stroke more than 10 years ago. Physical examination on admission revealed: body temperature 36.5 ℃, blood pressure 119/69 mmHg, and respiratory rate 18 breaths/min. She was alert but appeared lethargic. Her extremities were warm. No superficial lymphadenopathy was detected, and no jaundice, petechiae, or ecchymoses were observed on the skin or mucosa. Lung auscultation showed clear breath sounds without rales. Heart rate was 66 bpm and regular, with no pathological murmurs heard over any valve area. The abdomen was flat without visible intestinal patterns or peristaltic waves. Abdominal palpation was soft, with mild right costovertebral angle tenderness and tenderness along the right ureteric course. No rebound tenderness was noted. No masses were palpable in the liver or spleen regions. Shifting dullness was negative, and bowel sounds were present at 3 times per minute. Laboratory tests results were as follows: white blood cell count (WBC) 30.97×10⁹/L, neutrophils 91.94%, lymphocytes 5.52%, hemoglobin (Hb) 117 g/L, platelet count (PLT) 411×10⁹/L, procalcitonin (PCT) 0.12 ng/mL, blood glucose 8.27 mmol/L, aspartate aminotransferase (AST) 18.7 IU/L, alanine aminotransferase (ALT) 14.50 IU/L, C-reactive protein (CRP) 59.6 mg/L, and urine WBC 479/high power field (HPF). The electrocardiogram showed a normal sinus rhythm. Computed tomography (CT) imaging revealed that the previous right intramural ureteral stone had been resolved, with a right double-J stent in place. No abnormalities were detected in the left kidney or ureter. Inadequate gastrointestinal filling was noted, limiting clear evaluation. No retroperitoneal lymphadenopathy or free fluid in the abdominal or pelvic cavity was observed (Figure 2).

Figure 1 Preoperative imaging showing a right intramural ureteral stone, measuring approximately 0.7 cm × 0.5 cm. The red arrow indicates the stone.

Figure 2 Emergency CT scan demonstrating that the previously identified right intramural ureteral stone is no longer visible, with a double-J stent in place on the right side. No abnormalities were observed in the left kidney or ureter. Inadequate gastrointestinal filling limited evaluation clarity. No retroperitoneal lymphadenopathy or free fluid was detected in the abdominal or pelvic cavity. CT, computed tomography.

Following four days of antibiotic therapy, the patient’s right abdominal pain, nausea, and vomiting markedly intensified, with new onset of abdominal distension and bright red bloody stools. Physical examination demonstrated mild generalized abdominal tenderness without rebound tenderness. Repeat laboratory investigations revealed: WBC (36.48×10⁹/L) with neutrophilia (95.24%) and lymphopenia (1.82%), Hb 118 g/L, PLT 339×10⁹/L, prothrombin time (PT) 13.7 s, activated partial thromboplastin time (APTT) 33.8 s, fibrinogen 6.74 g/L, fibrinogen and fibrin degradation products (FDP) 12.32 mg/L, and D-dimer 3.03 mg/L. Given the clinical suspicion of intestinal vascular occlusion, an abdominal computed tomographic angiography (CTA) was performed. The CTA demonstrated atherosclerotic plaque and intraluminal thrombus within the SMA, resulting in severe stenosis approaching total occlusion; the distal arterial branches appeared slender and demonstrated faint contrast opacification (Figure 3). Based on the patient’s clinical symptoms and laboratory tests, we have diagnosed SMA thrombosis.

Figure 3 CTA revealing mixed atherosclerotic plaque and intraluminal thrombus within the superior mesenteric artery, causing severe stenosis nearing occlusion. Distal arterial branches appear slender with faint opacification. The red arrow indicates the intraluminal thrombus. CTA, computed tomographic angiography.

Consultation with interventional radiology concluded that interventional thrombolysis was contraindicated due to the high risk of hemorrhagic complications secondary to the patient’s severe systemic infection, significant abdominal pain, and potential intestinal necrosis. The general surgery team recommended emergency exploratory laparotomy. After a thorough discussion with the family regarding the prognosis, an emergency laparotomy was performed at 02:00 on November 1. Intraoperative findings confirmed complete ischemia and necrosis of the entire small intestine, which was deemed non-resectable. The abdomen was closed. Postoperatively, the patient’s vital signs remained unstable, requiring endotracheal intubation for ventilatory support. The family declined further aggressive life-support measures, including cardiopulmonary resuscitation, continued intubation, and vasopressor support. The patient died 11 hours post-surgery. The patient’s clinical course timeline (Figure 4) demonstrates the rapid disease progression. 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 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s family member for the 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 4 Timeline of the clinical course: superior mesenteric artery thrombosis following ureteroscopic laser lithotripsy. CT, computed tomography; CTA, computed tomographic angiography; ICU, intensive care unit; SMA, superior mesenteric artery; URSL, ureteroscopic laser lithotripsy.

Discussion

URSL is a well-established surgical intervention for distal ureteral stones, valued for its high stone clearance rates and expedited patient recovery (7). Despite its general safety profile, the present study reports an exceptionally rare and fatal postoperative complication: SMA thrombosis. A comprehensive search of the PubMed database confirmed the absence of previously published cases with similar outcomes. Nevertheless, the potentially fatal implications of this complication warrant serious attention. SMA embolism represents a catastrophic abdominal emergency, with documented mortality rates ranging from 60% to 80% (8).

Anatomically, the pathogenesis can be partly attributed to the acute angulation at which the SMA branches off from the abdominal aorta—a morphological characteristic that predisposes it to trapping circulating emboli. Postoperative factors such as potential dehydration and systemic inflammatory responses further elevate the risk of thrombus formation. The postoperative state itself represents an acquired hypercoagulable condition, involving multifaceted physiological changes including platelet activation, increased clotting factors, and reduced fibrinolytic activity (9). The fundamental pathological process involves embolic occlusion of the SMA trunk or its branches, resulting in acute intestinal ischemia and hypoxia. Without timely intervention, this cascade progresses to bowel necrosis and systemic sepsis (8).

Mesenteric thrombosis typically manifests with an insidious onset. Its early clinical presentation is characterized by a discrepancy between severe abdominal pain and unremarkable physical findings, often leading to a missed diagnosis. While no laboratory test is pathognomonic for early detection, studies have reported potential indicators including leukocytosis, elevated D-dimer and lactate levels (10,11). Definitive diagnosis relies on contrast-enhanced abdominal CT, with CT angiography emerging as the preferred modality for mesenteric vascular evaluation, demonstrating up to 83.33% sensitivity (12). CTA not only directly visualizes the site and extent of vascular occlusion but also detects secondary signs, including bowel wall abnormalities, intra-abdominal fluid, and mesenteric edema (12).

Once mesenteric thrombosis progresses to advanced stages, mortality remains high despite surgical intervention (13,14). Early detection during the initial thrombotic phase is crucial, as timely intervention can reverse intestinal ischemia and improve outcomes in select patients. Key management strategies include: rapid fluid resuscitation, systemic anticoagulation (primarily with heparin), reperfusion therapy, and resection of necrotic bowel segments (14). For most acute SMA occlusions, excision of non-viable intestine represents a critical life-saving procedure (15).

Patients over 75 years or those with risk factors including atrial fibrillation, atherosclerotic diseases (hypertension, hyperlipidemia, diabetes, smoking), prior thrombosis, or hypercoagulable disorders constitute a high-risk population for mesenteric thrombosis (4), and may benefit from prophylactic anticoagulation. Early mobilization and adequate hydration are recommended. This patient had no prolonged immobilization, atrial fibrillation, or coagulopathy. Despite her history of hypertension and stroke, she lacked typical high-risk factors and received no postoperative anticoagulation. On postoperative day 10, she developed acute right abdominal pain, nausea, vomiting, and ureteral tenderness, with laboratory evidence of infection. The absence of constipation, significant distension, or peritonitis, combined with unremarkable emergency CT findings and the pain’s ureteral distribution, led to an initial diagnosis of urinary tract infection treated with antibiotics.

However, the patient demonstrated marked leukocytosis. Her condition deteriorated with worsening pain, bloody stools, generalized abdominal tenderness, and rising inflammatory markers, raising suspicion for vascular compromise. Abdominal CTA confirmed SMA thrombosis. Unfortunately, the extent of intestinal necrosis precluded surgical intervention, resulting in mortality. This case highlights the importance of maintaining a high index of suspicion for postoperative patients with unexplained abdominal pain. Close monitoring, timely screening with D-dimer, and contrast-enhanced abdominal CT should be performed, rather than attributing the symptoms merely to common postoperative discomfort or intestinal cramps.

Conclusions

Although the incidence is low, patients following stone surgery are at risk of mesenteric vascular embolism, a condition associated with high mortality. When encountering abdominal pain where the severity of symptoms is disproportionate to physical signs, clinical suspicion should promptly shift toward possible mesenteric vascular embolism. Timely diagnostic investigations—such as contrast-enhanced abdominal CT—should be performed without delay, and early therapeutic intervention must be initiated.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-253/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-253/prf

Funding: This work was supported by grants from the Project of Yunnan Provincial Clinical Research Center for Chronic Kidney Diseases (No. 202505AJ310005), Yunnan Provincial Science and Technology Plan Project (No. 202501AY070001-070), and Youth Project of Yunnan Provincial Basic Research Program (No. 202301AU070170).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-253/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 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s family member for the 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/.

References

1. Assimos D, Krambeck A, Miller NL, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 2016;196:1153-60. [Crossref] [PubMed]
2. de la Rosette J, Denstedt J, Geavlete P, et al. The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients. J Endourol 2014;28:131-9. [Crossref] [PubMed]
3. Balani P, Bhuiyan AS, Dalal VN, et al. Early Detection and Successful Management of Acute Mesenteric Ischaemia in Symptomatic COVID-19 Patient. Indian J Surg 2022;84:209-11. [Crossref] [PubMed]
4. Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (part I) - Incidence, etiologies, and how to improve early diagnosis. Best Pract Res Clin Gastroenterol 2017;31:15-25. [Crossref] [PubMed]
5. Cho J, Lee D. Postoperative new-onset atrial fibrillation causing acute embolic occlusion of the superior mesenteric artery: A case report. Medicine (Baltimore) 2021;100:e25700. [Crossref] [PubMed]
6. Gaujal L, Simon EG, Kellal I, et al. Superior mesenteric artery thrombosis: a rare and unknown complication after caesarean section. J Obstet Gynaecol 2015;35:413-4. [Crossref] [PubMed]
7. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol 2007;178:2418-34. [Crossref] [PubMed]
8. Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med 2016;374:959-68. [Crossref] [PubMed]
9. Scripcariu DV, Huzum B, Mircea C, et al. Systemic Impact of Platelet Activation in Abdominal Surgery: From Oxidative and Inflammatory Pathways to Postoperative Complications. Int J Mol Sci 2025;26:7150. [Crossref] [PubMed]
10. Acosta S, Nilsson T. Current status on plasma biomarkers for acute mesenteric ischemia. J Thromb Thrombolysis 2012;33:355-61. [Crossref] [PubMed]
11. Chou EL, Wang LJ, McLellan RM, et al. Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia. Ann Vasc Surg 2021;74:53-62. [Crossref] [PubMed]
12. Garzelli L, Nuzzo A, Copin P, et al. Contrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia. AJR Am J Roentgenol 2020;215:29-38. [Crossref] [PubMed]
13. Acosta-Mérida MA, Marchena-Gómez J, Saavedra-Santana P, et al. Surgical Outcomes in Acute Mesenteric Ischemia: Has Anything Changed Over the Years? World J Surg 2020;44:100-7. [Crossref] [PubMed]
14. Sakamoto T, Kubota T, Funakoshi H, et al. Multidisciplinary management of acute mesenteric ischemia: Surgery and endovascular intervention. World J Gastrointest Surg 2021;13:806-13. [Crossref] [PubMed]
15. Sukegawa M, Nishiwada S, Terai T, et al. Acute superior mesenteric artery occlusion associated with COVID-19 pneumonia: a case report. Surg Case Rep 2022;8:6. [Crossref] [PubMed]