SHM Converge Scientific Abstract ePoster Gallery-Between a Rock and a Clot Place: Acute Mesenteric Ischemia After Anti-Platelet Agent Held for Ercp

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This case describes a 58-year-old man with extensive thrombotic history, including chronic mesenteric ischemia with a superior mesenteric artery (SMA) stent, heterozygous factor V Leiden, and atrial fibrillation on apixaban. He presented with right upper quadrant pain and was found on MRCP to have a dilated common bile duct with a distal CBD stone, prompting ERCP.<br /><br />Because ERCP is a high-bleeding-risk procedure, ticagrelor was held for 5 days while aspirin was continued, and apixaban was stopped with heparin bridging. On the day of ERCP, he developed sudden epigastric pain before the procedure and later became profoundly hypotensive after the ERCP, with a rigid, diffusely tender abdomen. Labs showed marked leukocytosis, severe metabolic acidosis, and a lactate of 26. CTA demonstrated thrombosis of the aorto-hepatic bypass and SMA stent. Emergent exploratory laparotomy revealed diffuse bowel ischemia, and he ultimately required ICU care and transitioned to comfort measures.<br /><br />The discussion emphasizes the difficult balance between bleeding risk from endoscopic procedures and thrombosis risk in patients with high-risk vascular disease. This patient had multiple prothrombotic factors, including factor V Leiden, atrial fibrillation, smoking history, and especially a history of recurrent SMA stent stenosis and thrombosis. The case highlights that mesenteric artery stents have poor long-term patency and are prone to recurrent occlusion.<br /><br />Key takeaway: in patients with mesenteric stents and high thrombotic risk, holding antiplatelet therapy can precipitate catastrophic acute mesenteric ischemia. New abdominal pain in such patients should trigger urgent evaluation with CTA of the abdomen and pelvis, and bridging strategies such as IV cangrelor may be worth considering in select high-risk cases.

Asset Subtitle

Daniel Song

Meta Tag

Author List Ann Marie Kumfer, Daniel Song

Category Clinical Vignettes

Concept Endoscopic Retrograde Cholangiopancreatography

Concept Antiplatelet Therapy

Concept Coronary Stent Thrombosis

Concept Mesenteric Ischemia

Concept Thromboembolic Risk

Distinguished Non-Finalist

Presenter Organization Univeristy of North Carolina

Presenting Author Daniel Song

Track Adult

Keywords

mesenteric ischemia

SMA stent thrombosis

ERCP bleeding risk

factor V Leiden

apixaban bridging

ticagrelor interruption

acute bowel ischemia

aorto-hepatic bypass thrombosis

CTA abdomen pelvis

antiplatelet management

Endoscopic Retrograde Cholangiopancreatography

Antiplatelet Therapy

Coronary Stent Thrombosis

Mesenteric Ischemia

Thromboembolic Risk