Acute Portal Vein Thrombosis: Current Trends in Medical and Endovascular Management

Portal vein thrombosis after laparoscopic appendectomy for acute appendicitis: A case report

RATIONALE

Portal vein thrombosis (PVT) has a complex pathophysiologic pathway and may cause life-threatening clinical complications. Malignancies, hepatic cirrhosis, auto-immune disorders, previous splenectomy, and other causes of thrombocytosis (over 1,000,000/mL) are the most common causes of PVT. On the other hand, hematologic disorders and infectious processes in the abdominal cavity may cause PVT uncommonly. We present a case of PVT following acute appendicitis and laparoscopic appendectomy in this report.

PATIENT CONCERNS

A 32-year-old male was admitted to our emergency room due to lower quadrant pain and vomiting. Acute appendicitis was diagnosed and after a routine laparoscopic appendectomy, the patient was discharged. The patient was admitted to the emergency room with nonspecific epigastric pain on postoperative day 30.

DIAGNOSES

Portal vein thrombosis was diagnosed by computed tomography. Hematologic investigations revealed a homozygous mutation of the methylene tetrahydrofolate 1298 gene.

INTERVENTIONS

Immediate low-molecular-weight heparin administration was initiated. The gastrointestinal system council and interventional radiology team opted for a medical approach and converted the low-molecular-weight heparin to apixaban.

OUTCOMES

The computed tomography revealed the complete resolution of the thrombus on postoperative day 100.

LESSONS

Laparoscopic appendectomy can be complicated by portomesenteric axis thrombosis. When unusual findings are encountered during the postoperative follow-up period, rapid and detailed examinations should be performed.

Endovascular Treatment for Acute Portal Vein Thrombosis

Acute portal vein thrombosis is characterized by nonspecific abdominal pain, causing severe morbidity and mortality. Prompt diagnosis is crucial to avoid short-term complications such as intestinal infarction, sepsis, and death. The therapeutic goal is to prevent thrombus extension into the mesenteric veins and intestinal ischemia complications. Systemic anticoagulation is the standard treatment. However, endovascular treatments such as thrombolysis, thrombectomy, balloon angioplasty, stent placement, and transjugular intrahepatic portosystemic shunt placement have been performed in patients who are refractory to anticoagulation therapy or at a high risk of intestinal ischemia. This review discusses the clinical and diagnostic considerations in acute portal vein thrombosis, focusing on current endovascular treatments that are effective and safe. However, prospective data are required to compare endovascular treatment techniques and assess their outcomes.

Direct abdominal vein thrombus imaging (DATI): a contrast-free black-blood MR technique for the diagnosis of abdominal vein thrombosis

OBJECTIVES

To develop and evaluate a direct abdominal vein thrombus imaging (DATI) technique, based on a respiratory navigating SPACE sequence with DANTE black-blood preparation, for diagnosing abdominal vein thrombosis (AVT) without the use of exogenous contrast agents.

METHODS

We prospectively enrolled 10 healthy subjects and 28 suspected AVT patients who underwent DATI scans on 3.0 T MRI. Contrast-enhanced CT venography (CTV) was also conducted on the suspected AVT patients for comparison. All images were analyzed by two blinded radiologists who independently evaluated randomized images and gave image quality and diagnostic confidence scores (1-poor, 4-excellent) for DATI and CTV. The accuracy (ACC), sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of CTV were calculated using CTV as a standard reference. The diagnostic agreement between DATI and CTV as well as the interobserver agreement were conducted using Cohen κ test.

RESULTS

The patient study demonstrated that DATI can provide adequate thrombus signal intensity and the contrast between the thrombus to dark venous lumen for the diagnosis of AVT. It offers good to excellent image quality (reader1/reader2: 3.50 ± 0.64/3.42 ± 0.63, κ = 0.872) and diagnostic confidence (reader1/reader2: 3.71 ± 0.53/3.78 ± 0.42, κ = 0.804) for the diagnosis of AVT. Taking CTV as a reference, DATI has high accuracy (96.6%), SE (91.5%), SP (98.0%), PPV (92.3%), and NPV (97.8%).

DATA CONCLUSION

DATI can provide good to excellent image quality, effective venous blood signal suppression, and definitive thrombus detection for the diagnosis of AVT without the use of exogenous contrast agents.

Fatal acute portal vein thrombosis associated with hepatic cysts in a patient with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) often involves polycystic liver disease (PLD). In severe cases, PLD can develop various complications. However, fatal acute portal vein thrombosis (APVT) associated with PLD has not been reported. A 64-year-old male reported mild consciousness disorder. He had been under maintenance hemodialysis for end-stage renal disease due to ADPKD with PLD. Because of recurring hepatic cyst infections, he had sustained high levels of C-reactive protein. Regarding the mild consciousness disorder, a diagnosis of hepatic encephalopathy was made based on an elevation of serum ammonia without any other abnormal liver function tests. Several days after his admission, hepatobiliary enzymes elevated, and acute liver failure progressed. Enhanced abdominal computed tomography suggested the possibility of complete occlusion of the portal vein by a thrombus. Based on an absence of obvious portosystemic collaterals, a diagnosis of APVT was made. The patient died 19 days after admission. Patients with PLD with repeated cystic infections have been seen to develop liver failure, and APVT formation may be one cause of the rapid progression of fatal liver failure. In conclusion, this is the first paper to report on the involvement of APVT in patients with PLD.

Efficacy of endovascular treatment for completely occlusive acute-subacute portal and mesenteric vein thrombosis with severe complications in patients without cirrhosis

PURPOSE

Completely occlusive acute-subacute portal and mesenteric vein thrombosis (PVMVT) with severe complications is fatal. Endovascular treatments (EVTs) of acute-subacute PVMVT are not standardized. Thrombectomy combined with continuous catheter-directed thrombolysis is considered an effective treatment. Here, we aimed to evaluate the outcome of EVTs of completely occlusive acute-subacute PVMVT with severe complications in patients without cirrhosis.

MATERIALS AND METHODS

Nineteen patients (nine men and 10 women; age, 60.1 ± 16.8 years) with completely occlusive acute-subacute PVMVT were retrospectively assessed. Acute-subacute PVMVT was defined as symptom onset within 40 days, with no cavernous transformation observed on contrast-enhanced computed tomography. The patients were treated with EVTs, a combination of thrombectomy (including aspiration thrombectomy, plain old balloon angioplasty, single injection of thrombolytic agents, and stent placement) and continuous catheter-directed thrombolysis. Kaplan-Meier analyses were performed to assess all-cause mortality, acute-subacute PVMVT-related mortality, and portal vein (PV) patency. The degree of recanalization and patency of PV, complications, factors related to acute-subacute PVMVT-related mortality, and factors related to patency of PV were also evaluated.

RESULTS

The all-cause and acute-subacute PVMVT-related mortality rates were 36.8% (7/19) and 31.6% (6/19), respectively. Seven (36.8%) and 11 (57.9%) patients achieved complete and partial recanalization, respectively. Among the 18 patients who achieved recanalization, follow-up images after 608.7 ± 889.5 days confirmed recanalization in 83.3% (15/18) patients, and 53.3% (8/15) of these patients achieved patency of PV. Seven patients (36.8%) developed complications, and two (10.5%) required interventional treatment for complications. Deterioration of liver function significantly worsened the prognosis (P = 0.046), while anticoagulation therapy significantly maintained portal patency (P = 0.03).

CONCLUSION

This endovascular method for acute-subacute PVMVT, which combines thrombectomy and continuous catheter-directed thrombolysis EVT approach was effective for thrombus resolution. However, further studies must define conditions that improve patient prognosis.

Portal vein thrombosis in cirrhosis: A literature review

Portal Vein Thrombosis (PVT), a common complication of advanced liver disease, is defined as an obstruction of the portal vein due to thrombus formation that can extend to the superior mesenteric and splenic veins. It was believed that PVT occurred predominantly due to prothrombotic potential. However, recent studies have shown that decreased blood flow related to portal hypertension appears to increase PVT risk as per Virchow's triad. It is well known that there is a higher incidence of PVTs in cirrhosis with a higher MELD and Child Pugh score. The controversy for management of PVTs in cirrhotics lies in the individualized assessment of risks versus benefits of anticoagulation, since these patients have a complex hemostatic profile with both bleeding and procoagulant propensities. In this review, we will systematically compile the etiology, pathophysiology, clinical features, and management of portal vein thrombosis in cirrhosis.

Large Bore Portal Vein Thrombectomy: An Inari FlowTriever Case Series

PURPOSE

Portal vein thrombus (PVT) can worsen portal hypertension and hepatic decompensation in patients with cirrhosis and impact liver transplant outcomes. This retrospective case series describes large bore mechanical thrombectomy of PVT with the Inari FlowTriever device during, or remotely after, transjugular intrahepatic portosystemic shunt (TIPS) placement.

MATERIALS AND METHODS

Ten patients with PVT were treated with large bore thrombectomy. All patients had underlying cirrhosis, complicated by portal hypertension with acute/subacute PVT. Thrombectomy was performed either with TIPS placement, or via a previously placed thrombosed shunt. Median time from TIPS placement to thrombectomy was 3 years.

RESULTS

Thrombectomy was technically successful in all patients with a majority achieving complete resolution of PVT in a single session. During mean follow-up of 13.3 months, all patients achieved complete resolution of PVT without recurrence.

CONCLUSION

Large bore mechanical thrombectomy together with TIPS is a feasible and effective treatment of acute/subacute PVT in cirrhotic patients with portal hypertension, often with complete resolution in a single session.

Small Bowel Perforation Secondary to Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a heterogeneous entity often described as either an acute or chronic occlusion of the portal vein or its tributaries. The clinical presentation is highly variable, and it often mimics other more common causes of abdominal pain. In most patients, imaging studies such as doppler ultrasound, computed tomography, or magnetic resonance imaging are adequate for diagnosis. Occasionally imaging studies may be inadequate, and the diagnosis may not be made until complications such as bowel necrosis and perforation have occurred. We present a case of a morbidly obese 45-year-old female who was initially treated for suspected small bowel enteritis and discharged home on several occasions after nonspecific findings on abdominal imaging were seen and interval improvement in symptoms occurred with intravenous fluids and antibiotics. She then presented with worsening symptoms and was found on abdominal imaging to have a large fluid collection in the peritoneal cavity requiring exploratory laparotomy with peritoneal washout and partial small bowel resection due to perforation. She was diagnosed with PVT with mesenteric extension after samples of the resected mesentery were evaluated in the pathology laboratory. Her treatment included a prolonged course of antibiotics, total parenteral nutrition, and anticoagulation.

Large-Bore Mechanical Thrombectomy for Subacute Portal Vein Thrombosis in Patient With Acute Bleeding

Portal vein thrombosis remains a clinical challenge with limited treatment options. A patient was admitted with decompensated nonalcoholic steatohepatitis and a history of recurrent esophageal and gastric variceal hemorrhages. Contrast-enhanced computed tomography revealed hepatic cirrhosis with concomitant and extensive thrombosis of the portal, splenic, and superior mesenteric veins. The patient was treated with transjugular intrahepatic portosystemic shunt and mechanical thrombectomy with the FlowTriever System (Inari Medical, Irvine, CA). Post-thrombectomy venography and follow-up computed tomography demonstrated patency and brisk flow. This case report shows that mechanical thrombectomy with the FlowTriever System is promising for treating extensive and subacute portal vein thrombosis.

Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis: Two case reports

BACKGROUND

Acute portal vein thrombosis (PVT) with bowel necrosis is a fatal condition with a 50%-75% mortality rate. This report describes the successful endovascular treatment (EVT) of two patients with severe PVT.

CASE SUMMARY

The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d. The second patient was a 48-year-old man who presented with acute abdominal pain. Following contrast-enhanced computed tomography, both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins. Hybrid treatment (simultaneous necrotic bowel resection and EVT) was performed in a hybrid operating room (OR). EVTs, including aspiration thrombectomy, catheter-directed thrombolysis (CDT), and continuous CDT, were performed via the ileocolic vein under laparotomy. The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients, respectively.

CONCLUSION

Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.

Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective

OBJECTIVE

This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided.

BACKGROUND

Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation.

METHODS

Computerized literature search as well as discussion with experts in the field.

CONCLUSIONS

Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.

Percutaneous Transhepatic AngioJet-assisted Mechanical Thrombectomy for the Treatment of Post-Transplant Portal Vein Thrombosis: A Case Report

Portal vein thrombosis (PVT) is an uncommon but serious complication after liver transplantation (LT). Treatments for PVT include thrombolysis, surgical treatment or percutaneous intervention. We here report a case of PVT after LT successfully treated by an AngioJet device using the percutaneous transhepatic approach. A 36-year-old male presented with substantial thrombosis of the portal vein/superior mesenteric vein 2 years after a liver transplant. He was managed with an Angiojet thrombectomy and subsequent stent placement. This approach may be a safe and effective treatment for PVT in post-orthotopic LT patients.

Portal Vein Thrombosis In Cirrhosis: Interventional Treatment Options

PURPOSE OF REVIEW

Portal vein thrombosis (PVT) is a frequent consequence of cirrhosis and its management is variable and controversial. Herein we highlight interventional treatment options and outcomes, together with mention of the physiology, presentation and imaging of PVT.

RECENT FINDINGS

Utilization of transjugular intrahepatic portosystemic shunt (TIPS) for acute and chronic PVT is expanding. In acute PVT, TIPS improves hepatopetal flow which promotes thrombus resorption and prevents rethrombosis. The TIPS also functions as a conduit for thrombectomy devices and allows for embolization of variceal shunts. Chronic PVT is a relative contraindication to liver transplant. Portal vein recanalization (PVR) TIPS restores flow in a previously occluded portal vein, allowing for a conventional end-to-end portal vein anastomosis at transplant. PVR TIPS is technically demanding and often requires percutaneous splenic vein access for portal venous recanalization. Selection of endovascular PVT treatment varies with the age (acute or chronic) and the extent of thrombus, along with presenting symptoms and transplant candidacy.

Noninvasive Management of Complications From Splenic Artery Aneurysm Embolization After Liver Transplant: A Case Report

Splenic artery aneurysms are more common in patients with cirrhosis than in the general population. We report the case of a patient with a history of an orthotopic liver transplant who developed an enlarging splenic artery aneurysm that was treated with splenic artery embolization. He developed extensive portal vein thrombosis and subsequently splenic abscess. Both complications were managed endovascularly, with catheter-directed thrombolysis and percutaneous drains. This case illustrates the possible complications after splenic artery embolization and demonstrates the nonsurgical options for treatment.

Transhepatic Pharmacomechanical Thrombectomy of Symptomatic Acute Noncirrhotic, Nonmalignant Portomesenteric Venous Thrombosis: Midterm Results

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of transhepatic pharmacomechanical thrombectomy of symptomatic acute portomesenteric venous thrombosis. MATERIALS AND METHODS. Transhepatic pharmacomechanical thrombectomy (catheter-directed thrombolysis with mechanical thrombectomy) was performed in the treatment of nine patients with symptomatic acute noncirrhotic, nonmalignant porto-mesenteric venous thrombosis. The medical records, imaging examinations, technique of transhepatic pharmacomechanical thrombectomy, and clinical outcomes were reviewed. RESULTS. The mean follow-up period was 23.1 months (range, 8-34) months. Successful recanalization of the portomesenteric venous thrombosis, restoration of hepatopetal portal flow, clinically significant improvement in the signs and symptoms of acute mesenteric ischemia, and prevention of bowel resection were achieved in all patients. The most frequent minor complication (in three patients) was minor hemorrhage through the transhepatic access track. No procedure-related major complications occurred during hospitalization. No patient had rethrombosis or complications related to portal hypertension due to portomesenteric venous thrombosis. One patient died of massive pulmonary embolism on the 7th day after treatment. Cavernous transformation of the right portal vein occurred in one patient. CONCLUSION. Transhepatic pharmacomechanical thrombectomy is a safe and effective method of treatment of symptomatic acute portomesenteric venous thrombosis and prevention of bowel infarction.

Clinical study of transjugular intrahepatic portosystemic shunt combined with AngioJet thrombectomy for acute portal vein thrombosis in non-cirrhosis

To evaluate the outcomes of the transjugular intrahepatic portosystemic shunt (TIPS) combined with AngioJet thrombectomy in patients with noncirrhotic acute portal vein (PV) thrombosis.Retrospective analysis from January 2014 to March 2017, 23 patients underwent TIPS combined with AngioJet thrombectomy for acute PV thrombosis in noncirrhosis. The rates of technical success, the patency of the PV, liver function changes, and complications were evaluated.Twenty-three patients underwent combined treatment, with a technical success rate of 100%. Twenty-four hours after treatment, PV thrombosis grade was improved significantly (P = .001). Before and after treatment, Albumin (gm/dl), aspartate transaminase (IU/l), alanine transaminase (IU/l), and platelets (109/L) were all significantly improved (P < .05). Minor complications include hematoma, hematuria, and hepatic encephalopathy. After 1 week of treatment, computed tomography scan revealed 8.7% (2/23) cases of hepatic envelope hematoma (thickness less than 2 cm). Hemoglobinuria occurred in 18/23 (78.3%) patients after treatment and returned to normal within 1 to 2 days. Two patients 2/23 (8.7%) had transient grade I encephalopathy after TIPS. The 1-year overall survival rate was 100% (23/23). No major complications during treatment in all patientsAngioJet thrombectomy via TIPS has a favorable short-term effect in clearing thrombus and alleviating symptoms in diffuse acute PVT. The long-term efficacy of this treatment needs to be further studied.

Acute portal vein thrombosis after liver transplant presenting with subtle ultrasound abnormalities: A case report and literature review

BACKGROUND

Portal vein thrombosis (PVT) after liver transplantation (LT) is an uncommon complication with potential for significant morbidity and mortality that transplant providers should be cognizant of. Recognizing subtle changes in post-operative ultrasounds that could herald but do not definitively diagnose PVT is paramount.

CASE SUMMARY

A 30-year-old female with a history of alcohol-related cirrhosis presented with painless jaundice and received a deceased donor orthotopic liver transplant. On the first two days post-operatively, her liver Doppler ultrasounds showed a patent portal vein, increased hepatic arterial diastolic flows, and reduced hepatic arterial resistive indices. She was asymptomatic with improving labs. On post-operative day three, her resistive indices declined further, and computed tomography of the abdomen revealed a large extra-hepatic PVT. The patient then underwent emergent percutaneous venography with tissue plasminogen activator administration, angioplasty, and stent placement. Aspirin was started to prevent stent thrombosis. Follow-up ultrasounds showed a patent portal vein and improved hepatic arterial resistive indices. Her graft function improved to normal by discharge. Although decreased hepatic artery resistive indices and increased diastolic flows on ultrasound are often associated with hepatic arterial stenosis post-LT, PVT can also cause these findings.

CONCLUSION

Reduced hepatic arterial resistive indices on ultrasound can signify PVT post-LT, and thrombolysis, angioplasty, and stent placement are efficacious treatments.

Acute mesenteric vein thrombosis after endoscopic injection sclerotherapy for esophageal varices in a patient with liver cirrhosis

Portal vein thrombosis (PVT) is a common complication of liver cirrhosis. The association between endoscopic injection sclerotherapy (EIS) and PVT is unclear. In this paper, we reported that a male cirrhotic patient developed acute mesenteric vein thrombosis after EIS for secondary prophylaxis of esophageal variceal bleeding. Immediate anticoagulation therapy was effective and safe in this patient.