New concepts in the management of emboli of the superior mesenteric artery

The experience with 47 patients with intestinal ischemia resulting from superior mesenteric artery emboli who were treated at Montefiore Hospital and Medical Center over a 12 year period was reviewed. The over-all mortality was 66 per cent, but patients with infarction of 50 per cent or more of the small intestine did more poorly; 17 of 19 such patients died. Twenty patients were managed according to an aggressive approach which incorporates earlier and more liberal use of angiography and preoperative and postoperative intra-arterial infusions of papaverine into the superior mesenteric artery. Twenty-five patients were managed according to more traditional methods. Two patients died before treatment could be initiated. As the primary treatment, intra-arterially given papaverine was successful in four patients, two who were not operated upon and two with normal intestines at the time of delayed laparotomy. A survival rate of 55 per cent was obtained in the patients managed according to protocol, whereas only 20 per cent of those treated by traditional methods survived. In ten of the 11 survivors in the protocol treated group enough intestine to provide normal gastrointestinal function was preserved. The best survival was achieved in patients who were managed by the protocol and were diagnosed within 24 hours of the onset of pain. Our data indicates that a management plan incorporating the earlier and more liberal use of angiography and of preoperative and postoperative papaverine infusions into the superior mesenteric artery can lower the mortality associated with this catastrophe to less than 50 per cent.