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  • Title: Intimal hyperplasia and thrombosis of the visceral arteries in a young woman: possible relation with oral contraceptives and smoking.
    Author: Lamy AL, Roy PH, Morissette JJ, Cantin R.
    Journal: Surgery; 1988 Jun; 103(6):706-10. PubMed ID: 3375998.
    Abstract:
    This is a report of a 26-year-old woman who died of a massive intestinal infarction caused by occlusion of the celiac axis and the superior and inferior mesenteric arteries. Autopsy showed intimal hyperplasia and an overlying thrombus that obstructed the lumen of the vessel. As shown by Irey et al., exogenous or endogenous female reproductive steroids can act on the vascular system as a target organ and induce intimal hyperplasia and thrombus formation. The effects of contraceptive estrogens and progestogens are discussed, but the catalytic effect of heavy cigarette smoking appears to be the factor that induces, in predisposed women with hyperplasia, thrombosis of visceral arteries. In this case report we want to emphasize that the association between smoking and oral contraceptives can cause cardiovascular disease in young women. Failure to recognize this fact could result in delayed diagnosis and worsen the prognosis. To further understand the pathophysiology of arterial diseases induced by oral contraceptives (OCs), a case report is presented of a young woman who died of extensive visceral artery thrombosis. The possible role of estrogens and progestogens and of cigarette smoking as the predisposing factors in this patient are discussed. A 26-year-old woman, who complained of progressive abdominal pain and whose past medical and surgical history was negative, was admitted to the general surgery service. She was the mother of 1 child and had had 2 previous spontaneous abortions. She had received ethinyl estradiol 35 mcg with norethindrone 500 mcg and 1000 mcg for 3 months, but because of a problem with breakthrough bleeding the medication was changed to mestranol 50 mcg with norethindrone 1000 mcg. She had been taking Ortho-Novum 1/50 for 2 1/2 years. She had smoked 25-35 cigarettes daily for about 10 years but denied use of alcohol or other drugs. She was not known to be diabetic, hypertensive, or dyslipidemic, and had no history of atherosclerosis in her family. For 7 months prior to her admission, the patient complained of abdominal pain, which progressively increased in intensity and duration, interrupted by periods of well-being. The patient reported 2 recent, isolated episodes of mild proctalgia but no tenesmus or melena. There had been no fever, but the patient had been anorexic for the past 2 weeks and reported losing 10 kg in the past month. She had no complaints apart from those related to the gastrointestinal system. At an emergency laparotomy, gangrenous acalculous cholecystitis and infarction of the terminal ileum were discovered. A cholecystectomy with resection of the terminal ileum and the right colon was performed. An end-to-end primary anastomosis was performed. On exploration of the superior mesenteric artery, a thrombus was discovered at its origin. As a transverse arteriotomy showed a good retrograde flow, a thrombectomy was performed. There appeared to be an unsatisfactory antegrade flow. The superior mesenteric artery then was transposed in an end-to-end fashion on the abdominal aorta. An immediate postoperative arteriogram showed thrombosis of the celiac axis at its origin. Revascularization failed to improve the condition of the intestine. The patient died. The intent of this case report is to emphasize that the association between smoking and oral contraceptives can cause cardiovascular disease in young women, and a failure to recognize this association can result in delayed diagnosis and worsen the prognosis.
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