Successful management of acute portal vein thrombosis by low molecular weight heparin and oral anticoagulation

Portal Vein Thrombosis: A Rare Finding in a Noncirrhotic Patient

Portal vein thrombosis (PVT) is a rare cause of abdominal pain, typically associated with cirrhosis or thrombophilia. A 18-year-old female presented with abdominal pain for 10 weeks. The diagnosis was confirmed with contrast-enhanced computed tomography (CECT) abdomen after an ultrasound showed dilated and obstructed portal vein. This unexpected finding prompted investigation for intrinsic hepatic disease and potential hypercoagulable disorders. Laboratory analysis revealed an elevated serum homocysteine level, an identified risk factor for venous thrombosis. Current literature describes the following factors as indications for anticoagulation: acute thrombus, lack of cavernous transformation, absence of esophageal varices and mesenteric venous thrombosis. PVT is an uncommon cause of abdominal pain, and in the absence of hepatic disease should raise the index of suspicion for an underlying thrombophilia.

How to cite this article: Sahoo AK, Rauta S, Mohapatra SC. Portal Vein Thrombosis: A Rare Finding in a Noncirrhotic Patient. Euroasian J Hepato-Gastroenterol 2014;4(1):55-57.

Vascular complications after orthotopic liver transplantation in Estonia

The aim of this study was to analyse vascular complications (VC) accompanying the introduction in Estonia of orthotopic liver transplantation (OLT) for treatment of end-stage liver disease. We present the incidence and treatment of VC occurring among our first 23 OLT in 22 patients. The 11 female and 11 male patients were aged 12 to 67 years. Their diagnoses were cholestatic disease (n = 8); hepatitis C virus (HCV) cirrhosis (n = 6); tumor (n = 3); Budd-Chiari syndrome (n = 2); autoimmune hepatitis (n = 1); cystic fibrosis (n = 1); or fulminant hepatic failure (n = 1). Only end-to-end vascular reconstructions were used in OLT. The patients' 1-year post-OLT survival rate was 86%. VC were confirmed using computed tomography (CT) or magnetic resonance imaging (MRI). In cases of VC, we started a 1-week course of subcutaneous anticoagulant therapy with low-molecular weight heparin (LMWH) immediately followed by permanent oral treatment. The incidence of VC was 14% (n = 3). There was no hepatic artery thrombosis. One patient developed hepatic venous thrombosis at 3 weeks after retransplantation. She was treated successfully with immediate LMWH followed by a permanent oral anticoagulation. Two patients experienced portal vein complications: 1 with pre-OLT portal vein thrombosis developed right intrahepatic portal vein thrombosis at 5 weeks after OLT requiring portal thrombectomy. He was treated successfully with immediate LMWH followed by permanent oral anticoagulation. The other subject displayed left intrahepatic portal vein thrombosis at 1 week after OLT. Despite immediate LMWH treatment followed by a permanent oral anticoagulation, he required left lobe necrectomy and Roux-Y choledochojejunostomy for recovery. The survival and recovery of all studied patients with VC allow us to recommend immediate subcutaneous anticoagulant therapy for post-OLT portal or hepatic venous thrombosis.

Management of acute non-cirrhotic and non-malignant portal vein thrombosis: a systematic review

BACKGROUND

No definitive evidence exists regarding the treatment of acute portal vein thrombosis (PVT). Treatment modalities described include conservative management, anticoagulation, thrombolysis, and thrombectomy. This review examines the impact of such treatment, its outcomes, and the complications resulting from the resultant portal hypertension.

METHODS

A Medline literature search was undertaken using the keywords portal vein thrombosis, anticoagulation, thrombolysis, and thrombectomy. The primary end point was portal vein recanalization. Secondary outcome measures were morbidity and the development of portal hypertension and its sequelae, including variceal bleeding. Data from articles relating to PVT in the context of cirrhosis, malignancy, or liver transplant were excluded.

RESULTS

Early systemic anticoagulation results in complete portal vein recanalization in 38.3% of cases and partial recanalization in 14.0% of cases. Spontaneous recanalization without treatment can only be expected in up to 16.7% of patients. Frequently this is only when associated with self-limiting underlying pathology and/or minimal thrombus extension. Thrombolysis can be associated with major complications in up to 60% of patients.

CONCLUSIONS

The natural history of acute PVT is poorly described. Spontaneous resolution of acute portal vein thrombosis is uncommon. Early anticoagulation results in a satisfactory rate of recanalization with minimal procedure-associated morbidity. Thrombolysis should be used with caution and only considered if the disease is progressive and signs of mesenteric ischemia are present. Further well-designed trials with precise outcome reporting are needed to improve our understanding of the disease.

Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis

AIM: To summarize our methods and experience with interventional treatment for symptomatic acute-subacute portal vein and superior mesenteric vein thrombosis (PV-SMV) thrombosis.

METHODS: Forty-six patients (30 males, 16 females, aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were accurately diagnosed with Doppler ultrasound scans, computed tomography and magnetic resonance imaging. They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutaneous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization).

RESULTS: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased significantly. Symptoms in these 45 patients were improved dramatically without severe operational complications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment. In 3 patients with interventional treatment, thrombi re-formed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful.

CONCLUSION: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acute-subacute PV-SMV thrombosis.

Extrahepatic portal vein thrombosis in children: etiology and long-term follow-up

OBJECTIVE

Mortality of extrahepatic portal vein thrombosis depends on underlying causes other than gastrointestinal bleeding. The aim of this study was to evaluate the etiology, treatment, and prognosis of patients with extrahepatic portal vein thrombosis.

METHODS

The records of 12 patients (age range: 1-9 years) diagnosed with extrahepatic portal vein thrombosis with a minimum follow-up of 2 years were analyzed retrospectively. Their diagnostic evaluations, treatment modalities, complications and long-term follow-ups were noted.

RESULTS

Mean follow-up period was 7.4 +/- 3.9 years (2-14 years). Hemorrhage from esophageal varices was the prevalent symptom in 6 patients (50%). Six patients had signs of hypersplenism, 5 were found to have thrombophilia: 2 protein C, 1 protein S, 1 combined protein S, C, and antithrombin III deficiency, and 1 homozygous factor V Leiden mutation. Two patients had congenital cardiovascular abnormalities, and 1 patient developed portal thrombosis after splenectomy operation. None of the patients who started propranolol prophylaxis before first bleeding episode bled during their follow-up periods. Endoscopic sclerotherapy succeed in 66.6% variceal hemorrhages. Shunt surgery was performed in 1 patient. The patients neither faced a life-threatening variceal bleeding nor died during follow-up period.

CONCLUSION

Prognosis of extrahepatic portal vein thrombosis is good in childhood. Thrombophilic states are the most frequent precipitating causes. Propranolol for prophylaxis of variceal bleeding and sclerotherapy might be the preferred modalities.

Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis.