Presentation and Management of Arterial Thromboembolisms during Active Inflammatory Bowel Disease: Case Series and Literature Review

Ann Vasc Surg. 2020 Aug:67:532-541.e3. doi: 10.1016/j.avsg.2020.02.025. Epub 2020 Mar 24.


Background: Active inflammatory bowel disease (IBD) is associated with considerable risk for thromboembolism; however, arterial thromboembolism is rare and associated with considerable morbidity and mortality. Their management requires careful coordination between multiple providers, and as a consequence, much of the published literature is limited to case reports published across specialties.

Methods: We examined our recent institutional experience with aortoiliac, mesenteric, and peripheral arterial thromboembolisms in patients with either Crohn's disease or ulcerative colitis. To supplement our experience, a comprehensive literature review was performed using MEDLINE and EMBASE databases from 1966 to 2019. Patient demographics, flare/thromboembolism management, and outcomes were abstracted from the selected articles and our case series.

Results: Fifty-two patients with IBD, who developed an arterial thromboembolism, were identified (49 from published literature and 3 from our institution). More than 82% of patients presented during an active IBD flare. Surgical intervention was attempted in 77% of patients, which included open thromboembolectomy, catheter-directed thrombolysis, or bowel resection. Thromboembolism resolution was achieved in 76% of patients with comparable outcomes with either catheter-directed thrombolysis or open thrombectomy (83.3% vs. 68.2%). Nearly one-third of patients underwent small bowel resection or colectomy. In 2 patients, thromboembolism resolution was achieved only after total abdominal colectomy for severe pancolitis. Multiple thromboembolectomies were associated with higher risk for amputation. Overall mortality was 11.5% but was greatest for occlusive aortoiliac and mesenteric thromboembolism (14.3% and 57%, respectively). All survivors of occlusive superior mesenteric artery thromboembolism suffered short gut syndrome requiring small bowel transplant.

Conclusions: Patients with IBD, who develop an arterial thromboembolism, can expect overall poor outcomes. Catheter-directed thrombolysis achieved comparable outcomes with open thromboembolectomy without undue bleeding risk. Total abdominal colectomy for moderate-to-severe pancolitis is an emerging strategy in the management of refractory arterial thromboembolism. Successful surgical management may include open thromboembolectomy, catheter-directed thrombolysis, and bowel resection when indicated.

Publication types

  • Case Reports
  • Systematic Review

MeSH terms

  • Adult
  • Amputation, Surgical
  • Colectomy* / adverse effects
  • Colectomy* / mortality
  • Colitis, Ulcerative / complications
  • Colitis, Ulcerative / diagnosis
  • Colitis, Ulcerative / mortality
  • Colitis, Ulcerative / surgery*
  • Crohn Disease / complications
  • Crohn Disease / diagnosis
  • Crohn Disease / mortality
  • Crohn Disease / surgery*
  • Embolectomy* / adverse effects
  • Embolectomy* / mortality
  • Female
  • Humans
  • Limb Salvage
  • Mesenteric Ischemia / diagnostic imaging
  • Mesenteric Ischemia / etiology
  • Mesenteric Ischemia / mortality
  • Mesenteric Ischemia / therapy*
  • Mesenteric Vascular Occlusion / diagnostic imaging
  • Mesenteric Vascular Occlusion / etiology
  • Mesenteric Vascular Occlusion / mortality
  • Mesenteric Vascular Occlusion / therapy*
  • Middle Aged
  • Risk Factors
  • Thrombectomy* / adverse effects
  • Thrombectomy* / mortality
  • Thromboembolism / diagnostic imaging
  • Thromboembolism / etiology
  • Thromboembolism / mortality
  • Thromboembolism / therapy*
  • Thrombolytic Therapy* / adverse effects
  • Thrombolytic Therapy* / mortality
  • Time Factors
  • Treatment Outcome