Sequential Superior Mesenteric and Bilateral Renal Artery Embolism Managed With Staged Surgical and Endovascular Rescue: A Case Report

Acute abdominal and flank pain Clinical Procedure: SMA embolectomy • bowel resection • aspiration thrombectomy Specialty: Gastroenterology and HepatologyObjective: Rare coexistence of disease or pathology Background:Acute mesenteric ischemia due to superior mesenteric artery embolism is associated with high mortality.Embolism to other visceral arteries shortly after treatment is rare.We report a case of bilateral renal artery embolism after emergency surgery for superior mesenteric artery embolism in a patient later diagnosed with pancreatic cancer.Case Report:A 77-year-old woman with previous non-cardioembolic cerebral infarction presented with sudden severe abdominal pain.Contrast-enhanced computed tomography showed complete superior mesenteric artery occlusion with impending bowel necrosis.Emergency laparotomy was chosen over catheter-based therapy.Superior mesenteric artery embolectomy, extensive small-bowel resection, and right hemicolectomy were performed, preserving 140 cm of proximal jejunum.A jejunostomy was created, with the transverse colon stump fixed beside it for later closure.During activated partial thromboplastin time (APTT)-guided heparin therapy for newly detected atrial fibrillation, she developed sudden abdominal and flank pain 32 hours postoperatively.The APTT was within the therapeutic range at symptom onset.Repeat computed tomography revealed bilateral renal artery emboli.Emergency catheter aspiration thrombectomy restored renal perfusion, and renal function recovered.Stoma closure was performed on postoperative day 56, and she was discharged with independent oral intake and ambulation.Pancreatic cancer was diagnosed approximately 3 months after discharge.Conclusions:New abdominal or flank pain after treatment of superior mesenteric artery embolism should prompt immediate reassessment and repeat imaging even if the APTT is therapeutic.Atrial fibrillation was a plausible embolic source, but occult cancer-associated hypercoagulability may also have contributed.Bowel-preserving surgery and early renal thrombectomy may be feasible in selected patients.