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Wei N, Mathy RM, Chang DH, Loos M, Merle U, Gauss A, Boxberger M, Mayer P, Klauss M, Kauczor HU, Öcal O, Wielpütz MO. Endovascular management of acute superior mesenteric vein thrombosis: a retrospective study on thrombolysis outcomes. CVIR Endovasc 2025; 8:41. [PMID: 40366487 PMCID: PMC12078909 DOI: 10.1186/s42155-025-00558-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Accepted: 04/28/2025] [Indexed: 05/15/2025] Open
Abstract
BACKGROUND Acute superior mesenteric vein thrombosis (ASMVT) is a rare but life-threatening condition associated with high morbidity and mortality. While anticoagulation remains the standard treatment, endovascular therapies such as thrombolysis, thrombectomy, and angioplasty are increasingly utilized in selected cases. However, evidence on their outcomes remains limited. This study retrospectively reports the clinical outcomes of ASMVT patients treated with endovascular combination therapies. METHODS Between August 2019 and May 2024, 12 patients (males = 9; mean age, 52.33 ± 12.51 years) were diagnosed with ASMVT. The study collected comprehensive data on demographic details, presenting symptoms, etiology, treatment modalities, response to treatment, and follow-up outcomes. Computed Tomography (CT) was available from diagnosis, and an average of 6.3 CT scans with a median follow-up of 3 months (IQR: 2-20 months). RESULTS The average time from symptom onset to angiographic treatment initiation was 8.0 ± 4.71 days, preceded by anticoagulation with heparin from the time of diagnosis. Patients were treated with combination therapy involving endovascular thrombolysis, rheolytic thrombectomy, and balloon angioplasty via transjugular (n = 9, 75%) or percutaneous (n = 3, 25%) approaches. Thrombolysis was performed with an average recombinant tissue plasminogen activator (rt-PA) infusion duration of 2.75 ± 1.14 days and a total dose of 61.25 ± 18.48 mg rt-PA. Superior mesenteric vein (SMV) flow was initially restored almost completely in 58.3% and partially in 41.7% of patients. Complications observed were hepatic artery bleeding (n = 2, 16.7%), hepatic arteriovenous fistula (n = 1, 8.3%), hepatic parenchymal bleeding (n = 1, 8.3%), melena (n = 1, 8.3%), and nostril bleeding (n = 1, 8.3%). Two patients experienced worsening symptoms of post-intervention, leading to bowel resection revealing intestinal necrosis. SMV patency was almost complete in 25%, and partially in 25% of patients at follow-up. CONCLUSION Endovascular combination therapy with long-term thrombolysis and thrombectomy in patients with ASMVT demonstrated promising technical outcomes. In view of complications, individual indication for intervention needs to be confirmed in a multidisciplinary team.
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Affiliation(s)
- Nan Wei
- Translational Lung Research Center (TLRC), German Lung Research Center (DZL), University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
| | - René Michael Mathy
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
| | - De-Hua Chang
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Lucerne, Spitalstrasse, Lucerne, CH-6000, Switzerland
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Fel 420, Heidelberg, 69120, Germany
| | - Uta Merle
- Department of Gastroenterology and Hepatology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Annika Gauss
- Department of Gastroenterology and Hepatology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Monica Boxberger
- Department of Gastroenterology and Hepatology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Philipp Mayer
- Translational Lung Research Center (TLRC), German Lung Research Center (DZL), University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
| | - Miriam Klauss
- Translational Lung Research Center (TLRC), German Lung Research Center (DZL), University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
| | - Hans-Ulrich Kauczor
- Translational Lung Research Center (TLRC), German Lung Research Center (DZL), University of Heidelberg, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany
- Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thoraxklinik at University Hospital of Heidelberg, Röntgenstraße 1, Heidelberg, 69126, Germany
| | - Osman Öcal
- Department of Diagnostic and Interventional Radiology, University Hospital of Heidelberg, Im Neuenheimer Feld 420, Heidelberg, 69120, Germany.
| | - Mark O Wielpütz
- Department of Radiology and Neuroradiology, Greifswald University Hospital, Ferdinand-Sauerbruch-Strasse 1, Greifswald, 17475, Germany
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Ueda T, Saito H, Shirai S, Sugihara F, Fujitsuna R, Matsumoto T, Hayashi H, Kumita SI. Endovascular Treatment for Acute Portal Vein Thrombosis. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2025; 10:e20230027. [PMID: 40384906 PMCID: PMC12078051 DOI: 10.22575/interventionalradiology.2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/27/2023] [Indexed: 05/20/2025]
Abstract
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.
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Affiliation(s)
- Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Japan
| | | | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Japan
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Gil-Lopez F, Rios-Olais FA, Mercado LA, Harnois DM. Portal Vein Thrombosis in Patients Without Cirrhosis: Current Practical Approaches and Treatment Strategies. Diagnostics (Basel) 2025; 15:721. [PMID: 40150064 PMCID: PMC11941439 DOI: 10.3390/diagnostics15060721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Revised: 03/01/2025] [Accepted: 03/10/2025] [Indexed: 03/29/2025] Open
Abstract
Portal vein thrombosis in non-cirrhotic individuals, although uncommon, is an increasingly explored condition that affects mainly young people, consequently representing a significant disease burden. Reports primarily including western European populations have recently shed light regarding the pathophysiology, risk factors, natural history, treatment, and prognosis of this entity. Underlying predisposing conditions are documented in ~70% of cases, encompassing local risk factors, inherited and acquired thrombophilia, cancer, and systemic inflammatory conditions. Non-cirrhotic portal vein thrombosis can cause significant portal hypertension in the acute setting, but, more frequently, significant portal hypertension-related complications arise when the condition becomes chronic and portosystemic collaterals develop, increasing the risk for variceal bleeding and ascites. The diagnostic approach to screen for underlying thrombophilia remains a challenge, and recommendations in this regard, although scarce and backed by scarce evidence, have changed notably in the last years, leaning toward a universal screen in patients who develop this condition without a clear provoking factor. Recently, studies have shown that long-term anticoagulation may be appropriate even in the absence of clear provoking factors or underlying thrombophilia. Future studies should address which patients may benefit from this approach, which patients may not need it, and what the most appropriate strategies are to approach patients who do not recover portal vein patency with anticoagulation to further prevent portal hypertension-related complications.
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Affiliation(s)
- Fernando Gil-Lopez
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
| | - Fausto Alfredo Rios-Olais
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City C.P. 14080, Mexico;
| | - Lydia A. Mercado
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
| | - Denise M. Harnois
- Department of Liver Transplant, Mayo Clinic Florida, Jacksonville, FL 32224, USA; (F.G.-L.); (L.A.M.)
- Department of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Wu B, Yang W, Xie Y, Zhou H, Shi H, Liu S, Zhou W. Transjugular intrahepatic portosystemic shunt combined with dual-access thrombolysis for acute severe non-cirrhotic portal-mesenteric vein thrombosis. Dig Liver Dis 2025; 57:436-442. [PMID: 39294045 DOI: 10.1016/j.dld.2024.08.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 08/11/2024] [Accepted: 08/27/2024] [Indexed: 09/20/2024]
Abstract
OBJECTIVE Non-cirrhotic porto-mesenteric vein thrombosis (NC-PMVT) is a rare but severe clinical condition. The study aims to assess the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) coupled with dual-access thrombolysis in patients with acute severe NC-PMVT. METHODS From January 2018 to February 2023, a total of 25 patients with acute severe NC-PMVT who were treated with TIPS in conjunction with mechanical thrombectomy and dual-access thrombolysis. The period of thrombolysis was determined by the improvement of clinical symptoms and vascular recanalization. The technical success, recanalization rate, clinical success, and procedure-related complications were analyzed. RESULTS The technical success rate was 100 %. The median duration for thrombolytic catheter removal was 5 (IQR 3.5 - 7) days. Full and partial recanalization were accomplished in 10 (40 %) and 15 (60 %) patients respectively before discharge. No significant procedure-related complications were reported. The clinical success rate was 88 %, with a mortality rate of 12 %. Over a median follow-up of 8 months, 3/22 (13.64 %) patients had a recurrence of thrombosis; 1/22 (4.54 %) patients underwent partial intestinal resection one and a half months post-discharge; the remaining patients did not experience any portal hypertensive complications. CONCLUSION The combination of TIPS and dual-access thrombolysis appears to be safe and effective for patients with acute severe NC-PMVT.
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Affiliation(s)
- Bifei Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China
| | - Wei Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China
| | - Yuguan Xie
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China
| | - Haifeng Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China
| | - Haibin Shi
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China.
| | - Weizhong Zhou
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Rd, Nanjing, 210029, PR China.
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Lorenz J, Kwak DH, Martin L, Kesselman A, Hofmann LV, Yu Q, Youssef S, Ciolek P, Ahmed O. Endovascular Management of Noncirrhotic Acute Portomesenteric Venous Thrombosis. J Vasc Interv Radiol 2025; 36:17-30. [PMID: 39389231 DOI: 10.1016/j.jvir.2024.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 09/16/2024] [Accepted: 09/28/2024] [Indexed: 10/12/2024] Open
Abstract
Acute portomesenteric venous thrombosis (PVT) is a rare but potentially life-threatening condition in individuals without cirrhosis. Initial management typically involves anticoagulation therapy, but the optimal approach to interventional treatment remains a topic of ongoing research. This article explores both traditional and emerging endovascular techniques, providing an overview of the existing evidence supporting their use. Additionally, it delves into the significance of acute PVT in the context of contemporary pathologies, notably coronavirus disease 2019 infection, vaccine-induced immune thrombotic thrombocytopenia, and liver transplantation.
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Affiliation(s)
- Jonathan Lorenz
- Section of Interventional Radiology, Department of Radiology, the University of Chicago Medical Center, Chicago, Illinois
| | - Daniel H Kwak
- Section of Interventional Radiology, Department of Radiology, the University of Chicago Medical Center, Chicago, Illinois.
| | - Lynne Martin
- Division of Interventional Radiology, Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Andrew Kesselman
- Division of Interventional Radiology, Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Lawrence V Hofmann
- Division of Interventional Radiology, Department of Radiology, Stanford University Medical Center, Stanford, California
| | - Qian Yu
- Section of Interventional Radiology, Department of Radiology, the University of Chicago Medical Center, Chicago, Illinois
| | - Salma Youssef
- University College Dublin School of Medicine, Belfield, Dublin, Ireland
| | - Paul Ciolek
- Chicago Medical School of Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Osman Ahmed
- Section of Interventional Radiology, Department of Radiology, the University of Chicago Medical Center, Chicago, Illinois
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6
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Li Z, Zhang S, Wang Q, Xu Y, Li Y, Chen X, Chen P, Chen D, Shi Y, Su B. Untethered & Stiffness-Tunable Ferromagnetic Liquid Robots for Cleaning Thrombus in Complex Blood Vessels. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2409142. [PMID: 39308207 DOI: 10.1002/adma.202409142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 09/13/2024] [Indexed: 11/16/2024]
Abstract
Thrombosis is a significant threat to human health. However, the existing clinical treatment methods have limitations. Magnetic soft matter is used in the biomedical field for years, and ferromagnetic liquids exhibit tunable stiffness and on-demand movement advantages under magnetic fields. In this study, a ferromagnetic liquid robot (FMLR) is developed and applied it to thrombus removal in complex blood vessels. The FMLR consisted of Fe3O4 magnetic nanoparticles and dimethyl silicone oil. The FMLR can pass through a narrow complex maze through shape deformation by tailoring the intensity and direction of the external magnetic field. Finite element simulation analysis is used to validate the mechanism of controllable FMLR movements. Importantly, the storage modulus of FMLR can be tuned from 0.1 to 2018 Pa by varying the external magnetic intensity, ensuring its effectiveness in removing rigid and stubborn thrombi present on the vascular walls. Toward medical robotic applications, FMLR can be used in telerobotic neurointerventional. Experiments demonstrating the capability of FMLR to remove thrombi in the ear veins of rabbits are conducted. This study introduces an efficient approach for thrombus elimination, broadening the utilization of FMLRs within the realm of clinical medicine.
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Affiliation(s)
- Zhuofan Li
- State Key Laboratory of Advanced Electromagnetic Engineering and Technology, School of, Electrical and Electronic Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Shanfei Zhang
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Qi Wang
- State Key Laboratory of Advanced Electromagnetic Engineering and Technology, School of, Electrical and Electronic Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Yizhuo Xu
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Yike Li
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Xiaojun Chen
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Peng Chen
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Dezhi Chen
- State Key Laboratory of Advanced Electromagnetic Engineering and Technology, School of, Electrical and Electronic Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
| | - Yunsong Shi
- School of Stomatology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bin Su
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials, Science and Engineering, Huazhong University of Science and Technology, Wuhan, Hubei, 430074, China
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7
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Elkrief L, Hernandez-Gea V, Senzolo M, Albillos A, Baiges A, Berzigotti A, Bureau C, Murad SD, De Gottardi A, Durand F, Garcia-Pagan JC, Lisman T, Mandorfer M, McLin V, Moga L, Nery F, Northup P, Nuzzo A, Paradis V, Patch D, Payancé A, Plaforet V, Plessier A, Poisson J, Roberts L, Salem R, Sarin S, Shukla A, Toso C, Tripathi D, Valla D, Ronot M, Rautou PE. Portal vein thrombosis: diagnosis, management, and endpoints for future clinical studies. Lancet Gastroenterol Hepatol 2024; 9:859-883. [PMID: 38996577 DOI: 10.1016/s2468-1253(24)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/27/2024] [Accepted: 05/08/2024] [Indexed: 07/14/2024]
Abstract
Portal vein thrombosis (PVT) refers to the development of a non-malignant obstruction of the portal vein, its branches, its radicles, or a combination. This Review first provides a comprehensive overview of all aspects of PVT, namely the specifics of the portal venous system, the risk factors for PVT, the pathophysiology of portal hypertension in PVT, the interest in non-invasive tests, as well as therapeutic approaches including the effect of treating risk factors for PVT or cause of cirrhosis, anticoagulation, portal vein recanalisation by interventional radiology, and prevention and management of variceal bleeding in patients with PVT. Specific issues are also addressed including portal cholangiopathy, mesenteric ischaemia and intestinal necrosis, quality of life, fertility, contraception and pregnancy, and PVT in children. This Review will then present endpoints for future clinical studies in PVT, both in patients with and without cirrhosis, agreed by a large panel of experts through a Delphi consensus process. These endpoints include classification of portal vein thrombus extension, classification of PVT evolution, timing of assessment of PVT, and global endpoints for studies on PVT including clinical outcomes. These endpoints will help homogenise studies on PVT and thus facilitate reporting, comparison between studies, and validation of future studies and trials on PVT.
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Affiliation(s)
- Laure Elkrief
- Faculté de médecine de Tours, et service d'hépato-gastroentérologie, Le Centre Hospitalier Régional Universitaire de Tours, Tours, France; Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Agustin Albillos
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departamento de Gastroenterología y Hepatología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christophe Bureau
- Service d'Hépatologie Hôpital Rangueil, Université Paul Sabatier, Toulouse, France
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Andrea De Gottardi
- Gastroenterology and Hepatology Department, Ente Ospedaliero Cantonale Faculty of Biomedical Sciences of Università della Svizzera Italiana, Lugano, Switzerland
| | - François Durand
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Juan-Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Ton Lisman
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valérie McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Lucile Moga
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Filipe Nery
- Immuno-Physiology and Pharmacology Department, School of Medicine and Biomedical Sciences, University of Porto, Portugal
| | - Patrick Northup
- Transplant Institute and Division of Gastroenterology, NYU Langone, New York, NY, USA
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, AP-HP Hôpital Beaujon, Clichy, France; Laboratory for Vascular and Translational Science, INSERM UMR 1148, Paris, France
| | - Valérie Paradis
- Department of Pathology, AP-HP Hôpital Beaujon, Clichy, France
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Audrey Payancé
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | | | - Aurélie Plessier
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Johanne Poisson
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Gériatrie, Hôpital Corentin Celton (AP-HP), Paris, France
| | - Lara Roberts
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Riad Salem
- Northwestern Memorial Hospital, Northwestern University, Chicago, IL, USA
| | - Shiv Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Christian Toso
- Service de Chirurgie Viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Dominique Valla
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Maxime Ronot
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Radiologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Pierre-Emmanuel Rautou
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France.
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8
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Willington AJ, Tripathi D. Current concepts in the management of non-cirrhotic non-malignant portal vein thrombosis. World J Hepatol 2024; 16:751-765. [PMID: 38818283 PMCID: PMC11135268 DOI: 10.4254/wjh.v16.i5.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/20/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024] Open
Abstract
Non-cirrhotic non-malignant portal vein thrombosis (NCPVT) is an uncommon condition characterised by thrombosis of the portal vein, with or without extension into other mesenteric veins, in the absence of cirrhosis or intra-abdominal malignancy. Complications can include intestinal infarction, variceal bleeding and portal biliopathy. In this article, we address current concepts in the management of NCPVT including identification of risk factors, classification and treatment, and review the latest evidence on medical and interventional management options.
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Affiliation(s)
- Adam J Willington
- Department of Hepatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
| | - Dhiraj Tripathi
- Department of Hepatology, University Hospitals Birmingham, Birmingham B15 2TH, United Kingdom.
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Kim JH, Kim S, Nam HC, Kim CW, Yoo JS, Han JW, Jang JW, Choi JY, Yoon SK, Chun HJ, Lee SE, Oh JS, Sung PS. Role of Portosystemic Shunt and Portal Vein Stent in Managing Portal Hypertension Due to Hematological Diseases. Cureus 2024; 16:e54206. [PMID: 38496121 PMCID: PMC10942847 DOI: 10.7759/cureus.54206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Patients with hematological diseases experience complications related to portal hypertension, including life-threatening complications such as variceal bleeding. METHODS We analyzed the prognosis of patients with hematological diseases and portal hypertension treated with transjugular intrahepatic portosystemic shunts (TIPS) or portal vein stents. We retrospectively assessed patients with hematological diseases and portal hypertension who had variceal bleeding. We evaluated the characteristics and prognosis of the enrolled patients. A total of 11 patients with hematological diseases who underwent TIPS, or portal vein stenting, were evaluated. RESULTS The median follow-up period was 420 days. Of the 11 patients, eight showed resolution of portal hypertension and its complications following TIPS, or stent insertion. One patient experienced rebleeding due to incomplete resolution of portal hypertension, and two other patients also experienced rebleeding because they underwent TIPS closure or revision due to repetitive hepatic encephalopathy. CONCLUSION Portosystemic shunt and stent installation are effective treatment options for portal hypertension due to hematological diseases.
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Affiliation(s)
- Ji Hoon Kim
- Gastroenterology and Hepatology, Uijeongbu St. Mary's Hospital, Uijeongbu, KOR
| | - Suho Kim
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Hee-Chul Nam
- Gastroenterology and Hepatology, Uijeongbu St. Mary's Hospital, Uijeongbu, KOR
| | - Chang Wook Kim
- The Catholic University of Korea, Internal Medicine, Uijeongbu, KOR
| | - Jae-Sung Yoo
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Ji Won Han
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jeong Won Jang
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jong Young Choi
- Gastroenterology and Hepatology, Seoul St. mary's Hospital, Seoul, KOR
| | - Seung Kew Yoon
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Ho-Jong Chun
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Sung-Eun Lee
- Hematology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Jung-Suk Oh
- Radiology, Seoul St. Mary's Hospital, Seoul, KOR
| | - Pil Soo Sung
- Gastroenterology and Hepatology, Seoul St. Mary's Hospital, Seoul, KOR
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10
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Stancu B, Chira A, Coman HF, Mihaileanu FV, Ciocan R, Gherman CD, Andercou OA. Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review. Diagnostics (Basel) 2024; 14:304. [PMID: 38337820 PMCID: PMC10855345 DOI: 10.3390/diagnostics14030304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.
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Affiliation(s)
- Bogdan Stancu
- 2nd Department of General Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400006 Cluj-Napoca, Romania; (B.S.); (F.V.M.); (O.A.A.)
| | - Alexandra Chira
- Department of Internal Medicine, 2nd Medical Clinic, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400006 Cluj-Napoca, Romania
| | - Horațiu F. Coman
- Department of Vascular Surgery, County Clinical Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Florin V. Mihaileanu
- 2nd Department of General Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400006 Cluj-Napoca, Romania; (B.S.); (F.V.M.); (O.A.A.)
| | - Razvan Ciocan
- Department of Surgery—Practical Abilities, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400337 Cluj-Napoca, Romania; (R.C.); (C.D.G.)
| | - Claudia D. Gherman
- Department of Surgery—Practical Abilities, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400337 Cluj-Napoca, Romania; (R.C.); (C.D.G.)
| | - Octavian A. Andercou
- 2nd Department of General Surgery, University of Medicine and Pharmacy “Iuliu Hațieganu”, 400006 Cluj-Napoca, Romania; (B.S.); (F.V.M.); (O.A.A.)
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11
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Beleva EA. Splanchnic Vein Thrombosis in Myelofibrosis-An Underappreciated Hallmark of Disease Phenotype. Int J Mol Sci 2023; 24:15717. [PMID: 37958701 PMCID: PMC10649007 DOI: 10.3390/ijms242115717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Splanchnic vein thrombosis (SVT) encompasses thrombosis in the vessels of the splanchnic basin and has a relatively rare occurrence with a reported frequency in the general population of 1-2%. An episode of seemingly unprovoked SVT almost always triggers a diagnostic work-up for a Philadelphia chromosome-negative myeloproliferative neoplasm (MPN), since atypical site thrombosis is a hallmark of MPN-associated thrombophilia. Primary myelofibrosis (PMF) is a rare MPN with an estimated incidence between 0.1 and 1/100,000 per year. Although prothrombotic tendency in PMF is not envisioned as a subject of specific therapeutic management, unlike other MPNs, such as polycythemia vera (PV) and essential thrombocythemia (ET), thrombotic risk and SVT prevalence in PMF may be comparably high. Additionally, unlike PV and ET, SVT development in PMF may depend more on procoagulant mechanisms involving endothelium than on blood cell activation. Emerging results from registry data also suggest that PMF patients with SVT may exhibit lower risk and better prognosis, thus highlighting the need for better thrombotic risk stratification and identifying a subset of patients with potential benefit from antithrombotic prophylaxis. This review highlights specific epidemiological, pathogenetic, and clinical features pertinent to SVT in myelofibrosis.
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Affiliation(s)
- Elina A. Beleva
- Clinic of Hematology, Military Medical Academy, 1606 Sofia, Bulgaria;
- QSAR and Molecular Modelling, Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria
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12
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Dannecker FD, Aschenbach R, Teichgräber U, Reuken P, Stallmach A, Zipprich A. [Successful therapy of non-cirrhotic non-malignant portal vein thrombosis (NCNMPT) by interventional therapy using transjugular lysis catheter]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1382-1384. [PMID: 36736344 DOI: 10.1055/a-1967-2223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
NCNMPT is a rare condition with a prevalence of 0.3%. THERAPY: Patient (69 y) with NCNMPT and small bowel ileus received interventional therapy using transjugular local lysis into the superior mesenteric vein. OUTCOME/DISCUSSION: Successful lysis with complete remission. Improved therapeutic efficacy of interventional versus drug therapy alone.
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Affiliation(s)
- Frank David Dannecker
- Klinik für Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Germany
| | - Rene Aschenbach
- Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Jena, Jena, Germany
| | - Ulf Teichgräber
- Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Jena, Jena, Germany
| | - Phillipp Reuken
- Klinik für Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Germany
| | - Andreas Stallmach
- Klinik für Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Germany
| | - Alexander Zipprich
- Klinik für Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Germany
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13
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Wallace F, Simonetto DA. Portal Vein Thrombosis in Adults without Cirrhosis. CURRENT HEPATOLOGY REPORTS 2023; 22:244-251. [DOI: 10.1007/s11901-023-00616-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 01/04/2025]
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14
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Gao F, Wang L, Pan J, Yin Y, Wang J, Xu X, Xu S, Mancuso A, Qi X. Efficacy and safety of thrombolytic therapy for portal venous system thrombosis: A systematic review and meta-analysis. J Intern Med 2023; 293:212-227. [PMID: 36208172 DOI: 10.1111/joim.13575] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS The role of thrombolytic therapy in patients with portal venous system thrombosis (PVST) remains ambiguous. This study aimed to systematically collect available evidence and evaluate the efficacy and safety of thrombolysis for PVST. METHODS Eligible studies were searched via PubMed, EMBASE, and Cochrane Library databases. Among the cohort studies, meta-analyses were performed to assess the outcomes of PVST patients receiving thrombolysis. Pooled proportions were calculated. Among the case reports and case series, logistic regression analyses were performed to identify the risk factors for outcomes of PVST patients receiving thrombolysis. Odds ratios (ORs) were calculated. RESULTS Among the 2134 papers initially identified, 29 cohort studies and 131 case reports or case series were included. Based on the cohort studies, the pooled rates of overall response to thrombolytic therapy, complete recanalization of PVST, bleeding events during thrombolysis, further bowel resection, thrombosis recurrence, and 30-day mortality were 93%, 58%, 18%, 3%, 1%, and 4%, respectively. Based on the case reports and case series, acute pancreatitis (OR = 0.084), history of liver transplantation (OR = 13.346), and interval between onset of symptoms and initiation of thrombolysis ≤14 days (OR = 3.105) were significantly associated with complete recanalization of PVST; acute pancreatitis (OR = 6.556) was significantly associated with further bowel resection; but no factors associated with the overall response to thrombolytic therapy, bleeding events during thrombolysis, thrombosis recurrence, and 30-day mortality were identified or could be calculated. CONCLUSION Early initiation of thrombolysis should be effective for the treatment of PVST. But its benefits for PVST secondary to acute pancreatitis are weakened.
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Affiliation(s)
- Fangbo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Jiahui Pan
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yuhang Yin
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Jing Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | - Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Andrea Mancuso
- Medicina Interna 1, ARNAS Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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15
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El-Hady HA, Mahmoud Abd-Elwahab ES, Mostafa-Hedeab G, Shawky Elfarargy M. Portal vein thrombosis in patients with COVID-19: A systematic review. Asian J Surg 2022:S1015-9584(22)01547-0. [PMID: 36435627 PMCID: PMC9650574 DOI: 10.1016/j.asjsur.2022.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/25/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022] Open
Abstract
Several studies have proven that COVID-19 is linked to a higher incidence of different thrombotic events. Thrombosis of the portal vein can result in portal hypertension and can extend to the mesenteric vein resulting in intestinal ischemia. A search of PubMed, Web of Science, and Scopus for relevant studies revealed an association between PVT and COVID-19. This review is structured according to PRISMA guidelines. Thirty-three studies met the inclusion criteria. Twenty-nine case studies/series and four cohort/cross-sectional studies were included. Age at diagnosis was lower when compared to PVT due to cirrhosis. In cohort/cross-sectional studies, males comprised 54.83% of subjects, whereas in case reports/series, males comprised 62.1%. Obesity, asthma, hypertension, and diabetes were the most common comorbidities identified. The majority of the thrombotic events occurred within two weeks. The treatment aimed to prevent thrombus progression and improve recanalization. According to the evidence, early intervention prevents the poor prognosis of intestinal ischemia and its propagation.
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Affiliation(s)
- Hany Abdelfatah El-Hady
- Department of Surgery, Faculty of Medicine, Jouf University, Saudi Arabia; Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Egypt.
| | | | - Gomaa Mostafa-Hedeab
- Pharmacology Department, Medical College, Jouf University, Sakaka, Saudi Arabia; Pharmacology Department, Faculty of Medicine, Beni-suef University, Egypt
| | - Mohamed Shawky Elfarargy
- Department of Pediatrics, College of Medicine, Jouf University, Saudi Arabia; Department of Pediatrics, Faculty of Medicine, Tanta University, Egypt
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16
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Salei A, El Khudari H, McCafferty BJ, Varma RK. Portal Interventions in the Setting of Venous Thrombosis or Occlusion. Radiographics 2022; 42:1690-1704. [PMID: 36190859 DOI: 10.1148/rg.220020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.
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Affiliation(s)
- Aliaksei Salei
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Husameddin El Khudari
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Benjamin J McCafferty
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Rakesh K Varma
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
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17
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Gao FB, Wang L, Zhang WX, Shao XD, Guo XZ, Qi XS. Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis. World J Gastrointest Surg 2022; 14:1082-1085. [PMID: 36185556 PMCID: PMC9521475 DOI: 10.4240/wjgs.v14.i9.1082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/01/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
Acute portal venous system thrombosis (PVST) can cause acute mesenteric ischemia and even intestinal infarction, which are potentially fatal, and requires recanalization in a timely fashion. Herein, we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation. Initially, anticoagulation with enoxaparin sodium for 4 d was ineffective, and then systemic thrombolysis for 7 d was added. After that, his abdominal pain completely disappeared, and portal vein system vessels became gradually patent. Long-term anticoagulation therapy was maintained. In conclusion, 7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.
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Affiliation(s)
- Fang-Bo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Wen-Xiu Zhang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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18
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Wang R, Guo X, Tang Y, Qi X. Portal vein thrombosis as the first presentation of paroxysmal nocturnal hemoglobinuria. Drug Discov Ther 2022; 16:200-203. [PMID: 35989282 DOI: 10.5582/ddt.2022.01033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired clonal hematopoietic stem cell disorder, characterized by hemolytic anemia, bone marrow failure and thrombosis. Portal vein thrombosis (PVT) is relatively rare in patients with PNH. In this paper, we reported PVT as the first clinical presentation of PNH in a female patient. PVT related symptoms resolved after anticoagulation therapy.
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Affiliation(s)
- Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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19
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Thimme R. EASL Innovation Award Recipient 2022: Prof. Martin Rössle. J Hepatol 2022; 77:287-289. [PMID: 35750547 DOI: 10.1016/j.jhep.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Robert Thimme
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, University Hospital Freiburg, Freiburg, Germany.
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20
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Roy S, Giles T, Majid A. Portal vein stenting in the management of duodenal varices due to malignant obstruction: A case report and literature review. Int J Surg Case Rep 2022; 95:107246. [PMID: 35661928 PMCID: PMC9163501 DOI: 10.1016/j.ijscr.2022.107246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Ectopic varices of the small bowel are a rare complication of portal hypertension. There are various aetiologies that can cause portal vein hypertension such as portal vein obstruction. Each of these pathologies has their own management strategies. Currently, there is a paucity of literature demonstrating the best management for patients with malignant portal vein obstruction leading to these varices. CASE PRESENTATION This report presents a case of a 66-year-old female who presented with recurrent per-rectal bleeding. Computed tomography angiography diagnosed duodenal varices in the context of malignant obstruction of the portal vein. Due to being a poor operative candidate, she underwent trans-hepatic portal vein stenting leading to resolution of her symptoms. CLINICAL DISCUSSION To date, the management of portal vein obstruction due to various aetiologies has only been reported in case reports with no significant large-scale studies providing recommendations on the most appropriate treatment. This case demonstrates the role of palliative stenting for patients with portal hypertension due to malignant portal vein obstruction. CONCLUSION Duodenal varices are a rare complication of portal vein obstruction. This article contributes to the literature by demonstrating that patients with complications associated with portal vein obstruction can benefit from stenting. For those with malignant obstruction, palliative stenting serves as an important therapeutic option.
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Affiliation(s)
- Susmit Roy
- Department of General Surgery, Calvary Mater Hospital, Waratah, NSW 2298, Australia; Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Department of General Surgery, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia.
| | - Thomas Giles
- Department of General Surgery, John Hunter Hospital, New Lambton Heights, NSW 2305, Australia
| | - Adeeb Majid
- Department of General Surgery, Calvary Mater Hospital, Waratah, NSW 2298, Australia; Discipline of Surgery, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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21
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Bettinger D, Thimme R, Schultheiß M. Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection. Curr Opin Gastroenterol 2022; 38:221-229. [PMID: 35471813 DOI: 10.1097/mog.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review summarizes indications and contraindications for implantation of transjugular intrahepatic portosystemic shunt (TIPS). Further, patient selection strategies are discussed. RECENT FINDINGS TIPS implantation is a highly effective treatment for portal hypertension. Main indications are ascites and variceal bleeding in patients with liver cirrhosis. There is growing evidence that early TIPS implantation after variceal bleeding is associated with an improved survival (preemptive TIPS).Preliminary data also suggest that an analogous concept of early TIPS implantation may be beneficial for patients with ascites. Further, well-selected patients with acute or chronic nonmalignant portal vein thrombosis can be effectively treated with TIPS implantation. In contrast, there is generally no recommendation for TIPS implantation in patients with hepatic veno-occlusive disease, noncirrhotic portal hypertension or prior before surgery to avoid complications of portal hypertension. Apart from evidence-based patient selection, the newly developed FIPS score can be an objective component in decision-making. SUMMARY Consideration of well-established indications and contraindications for TIPS implantation as well as concise patient selection criteria are essential for an optimal outcome after TIPS implantation.
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Affiliation(s)
- Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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22
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP REPORTS : INNOVATION IN HEPATOLOGY 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access. Abdom Radiol (NY) 2022; 47:1177-1186. [PMID: 35020007 PMCID: PMC8863683 DOI: 10.1007/s00261-022-03411-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
Purpose To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis. Methods We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared. Results Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding. Conclusion Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored.
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Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video). Hepatobiliary Pancreat Dis Int 2022; 21:25-32. [PMID: 34426078 DOI: 10.1016/j.hbpd.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children. METHODS From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein. RESULTS Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB. CONCLUSIONS Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.
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Meine TC, Becker LS, Dewald CLA, Maschke SK, Maasoumy B, Jaeckel E, Wedemeyer H, Wacker FK, Meyer BC, Hinrichs JB. Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness. Cardiovasc Intervent Radiol 2022; 45:696-702. [PMID: 35018502 PMCID: PMC9018628 DOI: 10.1007/s00270-021-03054-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
Purpose To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. Materials and Methods In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated. Results Transsplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. Conclusions Transsplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-03054-2.
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Affiliation(s)
- T C Meine
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - L S Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - C L A Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - S K Maschke
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - B Maasoumy
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - E Jaeckel
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - H Wedemeyer
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - F K Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - B C Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - J B Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Sturm L, Bettinger D, Klinger C, Krauss T, Engel H, Huber JP, Schmidt A, Caca K, Thimme R, Schultheiss M. Validation of color Doppler ultrasound and computed tomography in the radiologic assessment of non-malignant acute splanchnic vein thrombosis. PLoS One 2021; 16:e0261499. [PMID: 34929009 PMCID: PMC8687587 DOI: 10.1371/journal.pone.0261499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/05/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION International guidelines propose color Doppler ultrasound (CDUS) and contrast-enhanced computed tomography (CT) as primary imaging techniques in the diagnosis of acute splanchnic vein thrombosis. However, their reliability in this context is poorly investigated. Therefore, the aim of our study was to validate CDUS and CT in the radiologic assessment of acute splanchnic vein thrombosis, using direct transjugular spleno-portography as gold standard. MATERIALS AND METHODS 49 patients with non-malignant acute splanchnic vein thrombosis were included in a retrospective, multicenter analysis. The thrombosis' extent in five regions of the splanchnic venous system (right and left intrahepatic portal vein, main trunk of the portal vein, splenic vein, superior mesenteric vein) and the degree of thrombosis (patent, partial thrombosis, complete thrombosis) were assessed by portography, CDUS and CT in a blinded manner. Reliability of CDUS and CT with regard to portography as gold standard was analyzed by calculating Cohen's kappa. RESULTS Results of CDUS and CT were consistent with portography in 76.6% and 78.4% of examinations, respectively. Cohen's kappa demonstrated that CDUS and CT delivered almost equally reliable results with regard to the portographic gold standard (k = 0.634 [p < 0.001] vs. k = 0.644 [p < 0.001]). In case of findings non-consistent with portography there was no clear trend to over- or underestimation of the degree of thrombosis in both CDUS (60.0% vs. 40.0%) and CT (59.5% vs. 40.5%). CONCLUSIONS CDUS and CT are equally reliable tools in the radiologic assessment of non-malignant acute splanchnic vein thrombosis.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Klinger
- Department of Medicine, RKH Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Tobias Krauss
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hannes Engel
- Department of Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Patrick Huber
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Medicine, RKH Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ju C, Li X, Gadani S, Kapoor B, Partovi S. Portal Vein Thrombosis: Diagnosis and Endovascular Management. ROFO-FORTSCHR RONTG 2021; 194:169-180. [PMID: 34649289 DOI: 10.1055/a-1642-0990] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking. METHODS The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted. RESULTS Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization. CONCLUSION Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus. KEY POINTS · This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience.. CITATION FORMAT · Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1642-0990.
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Affiliation(s)
- Connie Ju
- Radiology, University of California Los Angeles Health System, Los Angeles, United States
| | - Xin Li
- Radiology, University of Pennsylvania Health System, Philadelphia, United States
| | - Sameer Gadani
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
| | - Baljendra Kapoor
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
| | - Sasan Partovi
- Interventional Radiology, Cleveland Clinic Foundation, Cleveland, United States
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Benmassaoud A, Rodger M. Challenging anticoagulation cases: Acute extensive portal vein thrombosis in a patient without cirrhosis - Evidence-based management of a rare clinical entity. Thromb Res 2021; 206:133-136. [PMID: 34464871 DOI: 10.1016/j.thromres.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/12/2021] [Accepted: 08/13/2021] [Indexed: 11/19/2022]
Abstract
Acute non-cirrhotic and non-malignant portal vein thrombosis (aPVT) is a rare and heterogenous condition. Current guidelines recommend early initiation of therapeutic anticoagulation to prevent extension of thrombosis, and favor recanalization. Although not formally defined, a poor outcome in the acute setting would include thrombosis extension with progression to intestinal infarction. Patients are also at risk of negative long-term outcomes related to complications of portal hypertension, such as variceal bleeding, ascites, and portal cholangiopathy. Identifying patients at risk of these events despite early initiation of anticoagulation remains challenging. Trials comparing treatment strategies in those failing standard therapy with meaningful radiological and clinical endpoints, whether in the short or long term, are desperately needed. The objective of this review will be to discuss a real-life clinical case and propose a treatment approach for aPVT based on the available evidence. We will mainly focus on management strategies including anticoagulation, prognostic factors, and options beyond anticoagulation, such as thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunts. This review will not cover tumor portal vein thrombosis or thrombosis associated with cirrhosis.
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Affiliation(s)
- Amine Benmassaoud
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Canada.
| | - Marc Rodger
- Department of Medicine, McGill University, Canada; Research Institute, McGill University Health Centre, Canada
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Caiano LM, Riva N, Carrier M, Gatt A, Ageno W. Treatment of portal vein thrombosis: an updated narrative review. Minerva Med 2021; 112:713-725. [PMID: 33832217 DOI: 10.23736/s0026-4806.21.07526-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Portal vein thrombosis (PVT) is the most frequent among the splanchnic vein thrombosis, accounting for 90% of cases. More than half of PVT are provoked by liver cirrhosis, solid cancer or myeloproliferative neoplasms. The remaining cases are non-malignant non-cirrhotic PVT and include either unprovoked events or thrombosis secondary to other less common risk factors (e.g. abdominal surgery, intrabdominal inflammations/infections, or hormonal stimuli). Anticoagulant therapy in patients with acute symptomatic PVT should be started early after diagnosis, if no active bleeding, to obtain greater vessel recanalization and reduce the occurrence of portal-hypertension related complications. Gastroesophageal varices do not represent a contraindication to anticoagulant treatment, as long as adequate measures have been undertaken for the prophylaxis of gastroesophageal bleeding. Different treatment options (unfractionated or low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants [DOACs]) can be considered. In this narrative review we will discuss the treatment of PVT in the three most common scenarios (cirrhosis-associated, cancer-associated and non-malignant non-cirrhotic PVT). We will also discuss the role of the DOACs and summarise recent guidelines on this topic.
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Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta -
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Abstract
Die Pfortaderthrombose ist eine seltene Erkrankung, die eine Thrombose im Zustromgebiet der Pfortader in die Leber beschreibt bzw. in der Leber selbst in den entsprechenden Pfortaderästen lokalisiert ist. Oftmals liegt bereits eine chronische Lebererkrankung bzw. ein Malignom der Leber selbst oder unmittelbar benachbart liegender Organe vor; die Pfortaderthrombose kann aber auch bei Patienten auftreten, die keine entsprechende Vorerkrankung haben. Bei jeder neu diagnostizierten Pfortaderthrombose gilt es zu entscheiden, ob unmittelbar oder im Verlauf eine radiologisch-interventionelle Rekanalisation vorgenommen wird oder ein rein konservativer Therapieversuch mit Antikoagulanzien erfolgt. Aber auch chirurgische Verfahren, wie eine Shuntanlage oder die Notwendigkeit einer Lebertransplantation, müssen hierbei berücksichtigt werden. Für diesen Therapiealgorithmus ist die Kontaktaufnahme mit einem entsprechenden Zentrum sinnvoll. Die Therapieentscheidung muss die Ursache der Pfortaderthrombose und die Begleiterkrankungen adäquat berücksichtigen.
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Zanetto A, Barbiero G, Battistel M, Sciarrone SS, Shalaby S, Pellone M, Battistella S, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Management of portal hypertension severe complications. Minerva Gastroenterol (Torino) 2021; 67:26-37. [PMID: 33140623 DOI: 10.23736/s2724-5985.20.02784-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).
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Affiliation(s)
- Alberto Zanetto
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giulio Barbiero
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Michele Battistel
- Department of Medicine, Institute of Radiology, University Hospital of Padua, Padua, Italy
| | - Salvatore S Sciarrone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sarah Shalaby
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Monica Pellone
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Sara Battistella
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Martina Gambato
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Giacomo Germani
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Francesco P Russo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Patrizia Burra
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Marco Senzolo
- Unit of Gastroenterology and Multivisceral Transplant, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padua, Padua, Italy -
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Riva N, Ageno W. Direct oral anticoagulants for unusual-site venous thromboembolism. Res Pract Thromb Haemost 2021; 5:265-277. [PMID: 33733025 PMCID: PMC7938617 DOI: 10.1002/rth2.12480] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and SurgeryUniversity of MaltaMsidaMalta
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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Elhence A, Gamanagatti SR, Shalimar. Transjugular Intrahepatic Portosystemic Shunt for Non-malignant Portal Vein Thrombosis. PORTAL VEIN THROMBOSIS 2021:117-129. [DOI: 10.1007/978-981-33-6538-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:877-889. [PMID: 32947633 DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
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Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
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Zhang D, Xu S, Tian Y, Qi X. Editorial: acute non-cirrhotic and non-malignant portal vein thrombosis-who should be candidates for interventional treatment? Aliment Pharmacol Ther 2020; 52:725-728. [PMID: 32886391 DOI: 10.1111/apt.15902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
LINKED CONTENTThis article is linked to the Rössle et al papers. To view these articles, visit https://doi.org/10.1111/apt.15811 and https://doi.org/10.1111/apt.15930
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Affiliation(s)
- Dan Zhang
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Department of General Surgery, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Shixue Xu
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Yulong Tian
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Department of Interventional Radiology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xingshun Qi
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
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Rössle M, Bettinger D, Thimme R, Schultheiss M. Editorial: acute non-cirrhotic and non-malignant portal vein thrombosis--who should be candidates for interventional treatment? Authors' reply. Aliment Pharmacol Ther 2020; 52:729-730. [PMID: 32886377 DOI: 10.1111/apt.15930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Martin Rössle
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany.,PraxisZentrum für Gastroenterologie und Endokrinologie, Freiburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, University of Freiburg, Freiburg, Germany
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