Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion

t-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis

Background:

Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.

Materials and Methods:

Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.

Results:

With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.

Conclusions:

Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Portal vein thrombosis: What surgeons need to know

KEY POINTS

(a) The lifetime risk of portal vein thrombosis (PVT) is approximately 1%; (b) The portal vein is formed by the union of the splenic and superior mesenteric veins posterior to the pancreas; (c) Imaging modalities most frequently used to diagnose PVT include sonography, computed tomography, and magnetic resonance imaging; (d) Malignancy, hepatic cirrhosis, surgical trauma, and hypercoagulable conditions are the most common risk factors for the development of PVT; (e) PVT eventually leads to the formation of numerous collateral vessels around the thrombosed portal vein; (f) First-line treatment for PVT is therapeutic anticoagulation-it helps prevent the progression of the thrombotic process; (g) Other therapeutic options include surgery and interventional radiographic procedures including mechanical thrombectomy and thrombolysis; (h) Portal biliopathy is a clinicopathologic entity characterized by biliary abnormalities due to portal hypertension secondary to PVT and appears to be more common in cases of extrahepatic PVT.

REPUBLISHED WITH PERMISSION FROM

Quarrie R, Stawicki SP. Portal vein thrombosis: What surgeons need to know. OPUS 12 Scientist 2008;2(3):30-33.

Paralytic Ileus due to Superior Mesenteric Venous Thrombosis after Transarterial Injection for Hepatocellular Carcinoma

A 69-year-old man was admitted to hospital with abdominal pain. In the four years prior to his presentation, he had undergone repeated transarterial chemoembolizations and injections for hepatocellular carcinoma. He underwent his 8th transcatheter arterial therapy one month prior to admission. Abdominal X-rays and contrast-enhanced computed tomography showed large amounts of small intestinal gas and venous thrombosis from the portal vein to the superior mesenteric vein, respectively. The thrombosis was reduced after anticoagulation therapy (heparin, antithrombin III, danaparoid sodium and warfarin). This is the first case report of paralytic ileus due to superior mesenteric venous thrombosis after transcatheter arterial therapy for hepatocellular carcinoma with an arterioportal shunt.

Functional and RNA expression profile of adenosine receptor subtypes in mouse mesenteric arteries

Concentration-response curves (CRCs) of adenosine receptor (AR) agonists, NECA (nonspecific), CCPA (A1 specific), CGS-216870 (A2A specific), BAY 60-6583 (A2B specific), and Cl-IB-MECA (A3 specific) for mesenteric arteries (MAs) from 4 AR knockout (KO) mice (A1, A2A, A2B, and A3) and their wild type (WT) were constructed. The messenger RNA expression of MAs from KO mice and WT were also studied. Adenosine (10 to 10 M) and NECA (10 to 10 M) induced relaxation in all mice except A2B KO mice, which only showed constriction by adenosine at 10 to 10 and NECA at 10 to 10 M. The CCPA induced a significant constriction at 10 and 10 M in all mice, except A1KO. BAY 60-6583 induced relaxation (10 to 10 M) in WT and no response in A2BKO except at 10 M. The CRCs for BAY 60-6583 in A1, A2A, and A3 KO mice shifted to the left when compared with WT mice, suggesting an upregulation of A2B AR. No responses were noted to CGS-21680 in all mice. Cl-IB-MECA only induced relaxation at concentration greater than 10 M, and no differences were found between different KO mice. The CRC for Bay 60-6583 was not significantly changed in the presence of 10 M of L-NAME, 10 M of indomethacin, or both. Our data suggest that A2B AR is the predominant AR subtype and the effect may be endothelial independent, whereas A1 AR plays a significant modulatory role in mouse MAs.

Mesenteric ischemia

This article reviews the presentation, diagnosis, evaluation, and treatment of the various forms of mesenteric ischemia, including acute and chronic ischemia. In addition, nonocclusive mesenteric ischemia and median arcuate ligament compressive syndrome are covered. The goals are to provide a structured and evidence-based framework for the evaluation and management of patients with these intestinal ischemia syndromes. Special attention is given to avoiding typical pitfalls in the diagnostic and treatment pathways. Operative techniques are also briefly discussed, including an evidence-based review of newer endovascular techniques.

Omental vein catheter thrombolysis for acute porto-mesenteric vein thrombosis

Mesenteric venous thrombosis (MVT) is an uncommon clinical condition with potential high morbidity. We report here a patient who presented with acute-onset MVT and bowel infarction, which was successfully ameliorated with intramesenteric vein thrombolytic therapy.

The role of portal vein thrombosis in the clinical course of inflammatory bowel diseases: report on three cases and review of the literature

Inflammatory bowel diseases are associated with an increased risk of vascular complications. The most important are arterial and venous thromboembolisms, which are considered as specific extraintestinal manifestations of inflammatory bowel diseases. Among venous thromboembolism events, portal vein thrombosis has been described in inflammatory bowel diseases. We report three cases of portal vein thrombosis occurring in patients with active inflammatory bowel disease. In two of them, hepatic abscess was present. Furthermore, we performed a systematic review based on the clinical literature published on this topic.

[Diagnosis and management of acute mesenteric ischemia]

The prevalence of significant splanchnic arterial stenoses is increasing, but remains mostly asymptomatic due to abundant collateral circulation. Acute insufficiency of mesenteric arterial blood flow accounts for 60 to 70% of cases of mesenteric ischemia and results mostly from a superior mesenteric embolus. Despite major advances have been achieved in understanding the pathogenic mechanisms of bowel ischemia, its prognosis remains dismal with mortality rates about 60%. The diagnosis of acute mesenteric ischemia depends upon a high clinical suspicion, especially in patients with known risk factors. Rapid diagnosis is essential to prevent intestinal infarction. However, early signs and symptoms of mesenteric ischemia are non specific, and definitive diagnosis often requires radiologic examinations. Early and liberal implementation of angiography has been the major advance over the past 30 years which allowed increasing diagnostic accuracy of acute mesenteric ischemia. CT and MR-based angiographic techniques have emerged as alternatives less invasive and more accurate to analyse splanchnic vessels and evaluate bowel infarction. The goal of treatment of patients with acute mesenteric ischemia is to restore intestinal oxygenation as quickly as possible after initial management that includes rapid hemodynamic monitoring and support. Surgery should not be delayed in patients suspected of having intestinal necrosis.

[A case of superior mesenteric venous thrombosis due to protein C deficiency in a patient with duodenal ulcer bleeding]

Mesenteric venous thrombosis is a clinically very rare disease, and may cause bowel infarction and gangrene. Difficulty in the diagnosis the disease due to its non-specific symptoms and low prevalence can cause a clinically fatal situation. Mesenteric venous thrombosis may be caused by both congenital and acquired factors, and protein C deficiency, which is a very rare genetic disorder, is one of many causes of mesenteric thrombosis. The authors experienced a case of mesenteric venous thrombosis caused by protein C deficiency in a patient with duodenal ulcer bleeding, so here we report a case together with literature review.

Mesenteric venous thrombosis

First differentiated from arterial causes of acute mesenteric ischemia 75 years ago, acute mesenteric venous thrombosis (MVT) is an uncommon disorder with non-specific signs and symptoms, the diagnosis of which requires a high index of suspicion. The location, extent, and rapidity of thrombus formation determine whether intestinal infarction ensues. Etiologies, when identified, usually can be separated into local intra-abdominal factors and inherited or acquired hypercoagulable states. The diagnosis is most often made by contrast-enhanced computed tomography, though angiography and exploratory surgery still have important diagnostic as well as therapeutic roles. Anticoagulation prevents clot propagation and is associated with decreased recurrence and mortality. Thrombectomy and thrombolysis may preserve questionably viable bowel and should be considered under certain circumstances. Evidence of infarction mandates surgery and resection whenever feasible. Although its mortality rate has fallen over time, acute MVT remains a life-threatening condition requiring rapid diagnosis and aggressive management. Chronic MVT may manifest with complications of portal hypertension or may be diagnosed incidentally by noninvasive imaging. Management of chronic MVT is directed against variceal hemorrhage and includes anticoagulation when appropriate; mortality is largely dependent on the underlying risk factor.

Is there a role for anticoagulants in portal vein thrombosis management in cirrhotic patients?

IMPORTANCE OF THE FIELD

Portal vein thrombosis (PVT) is one of the principal complications of liver cirrhosis. The estimated prevalence is < 1% in patients with a compensated disease; this increases to 8 - 25% in candidates for liver transplantation. Many determinants may influence PVT clinical presentation and its outcome.

AREAS COVERED IN THIS REVIEW

We report the actual knowledge regarding management of PVT and analyze the different therapeutic approaches, focusing particularly on the use of anticoagulants and their implications in the complex clinical setting of liver cirrhosis. We also describe the possible available preemptive strategies, as an early prophylactic management based on clinical, biochemical or radiological parameters may in the future reduce PVT incidence and complications, ameliorating patients' outcome.

WHAT THE READER WILL GAIN

The importance of an accurate PVT diagnosis and its implications in PVT management; a description of the different available therapeutic tools, their efficacy and their possible risks in different typologies of patients; the principal elements to choose a correct individualized therapy for PVT patients.

TAKE HOME MESSAGE

The challenge for clinicians is the early identification of PVT, in order to prevent frightening complications, such as variceal bleeding or mesenteric infarction, and to provide the best therapeutic management.

Acute mesenteric ischemia after cardio-pulmonary bypass surgery

Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.

Progress in the diagnosis and treatment of acute mesenteric ischemia

Acute mesenteric ischemia (AMI) is a life-threatening vascular emergency that requires early diagnosis and intervention to adequately restore mesenteric blood flow and prevent bowel necrosis and patient's death. The underlying cause of AMI is varied, and the prognosis depends on the precise pathologic findings. Despite the progress in understanding the pathogenesis of mesenteric ischemia and the development of modern treatment modalities, AMI remains a diagnostic challenge for clinicians, and the delay in diagnosis contributes to the continued high mortality rate. Early diagnosis and prompt effective treatment are essential to improve the clinical outcome.

Abdominal Pain in the Elderly

Elderly patients who have abdominal pain remain one of the most challenging patient populations. Signs and symptoms of serious disease are often nonspecific. Atypical presentations are common in elderly patients. In addition, the higher incidence of serious pathology in this population requires emergency physicians to be vigilant and thorough in their work-up. Vascular catastrophes are more likely to be seen in this population, and a broad differential diagnosis needs to be considered.

Portal Vein Thrombosis after Laparoscopic Colectomy: Thrombolytic Therapy via the Superior Mesenteric Vein

Portal vein thrombosis is a rare but well-reported complication after laparoscopic surgery. We present a case of portomesenteric venous thrombosis that occurred 8 days after a laparoscopic-assisted right hemicolectomy. Systemic anticoagulation failed to improve symptoms. The early postoperative state precluded the use of transarterial thrombolytic therapy. Transjugular intra-hepatic catheter-directed infusion of urokinase into the superior mesenteric vein resulted in clearance of thrombus and resolution of symptoms. The published data on laparoscopy-induced splanchnic venous thrombosis and transjugular intrahepatic intramesenteric thrombolysis are discussed.

Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis

PURPOSE

The purpose of this study was to evaluate the utility of transcatheter thrombolytic therapy in 20 patients with acute or subacute (symptoms <40 days) portal and/or mesenteric vein thrombosis with severe symptoms, deteriorating clinical condition, and/or persistent symptoms despite anticoagulation.

MATERIALS AND METHODS

This retrospective study examined 12 male patients and eight female patients seen over a period of 11 years. The average age was 37.6 years. Four of the patients had previously undergone liver transplantation. An anatomic classification system was established to describe the extent of thrombus at the time of diagnosis. Patients were treated with thrombolytic therapy via the transhepatic route, common femoral vein route, and/or superior mesenteric artery route. Improvement in symptoms, avoidance of bowel resection, complications, and radiographic evidence of clot resolution were the main clinical outcomes.

RESULTS

Fifteen of the 20 patients exhibited some degree of lysis of the thrombus. Three patients had complete resolution, 12 had partial resolution, and five had no resolution. Eighty-five percent of patients (n = 17) had resolution of symptoms. Sixty percent of patients (n = 12) developed a major complication. No patients required bowel resection after thrombolytic therapy. One patient died with gastrointestinal hemorrhage and septic shock 2 weeks after thrombolytic therapy. Other major complications included bleeding and conditions requiring transfusion. No patients developed new portal or mesenteric thromboses. Two of the patients who received transplants eventually required repeat transplantation.

CONCLUSIONS

Transcatheter thrombolysis was beneficial in avoiding patient death, resolving thrombus, improving symptoms, and avoiding bowel resection. However, there was a high complication rate, indicating that this therapy should be reserved for patients with severe disease. Further evaluation of these techniques and outcomes should continue to be pursued.

Percutaneous Transhepatic Mechanical Thrombectomy for Acute Mesenteric Venous Thrombosis

PURPOSE

To present the management of symptomatic acute mesenteric venous thrombosis using a percutaneous thrombectomy device followed by resection of necrotic intestine.

CASE REPORT

A 60-year-old woman developed acute abdomen and melena. Diffuse and extensive mesenteric and portal vein thromboses were diagnosed by computed tomography. Percutaneous transhepatic mechanical thrombectomy with an Oasis thrombectomy device removed approximately 80% of the thrombus in the portal and superior mesenteric veins. The patient underwent laparotomy immediately after thrombectomy, in which 100 cm of necrotic intestine was resected. Catheter-directed urokinase thrombolysis was performed for 3 days to address residual thrombi. The result was excellent, and the patient recovered without short bowel syndrome.

CONCLUSIONS

The hydrodynamic thrombectomy system is a quick, reliable, efficient device that may offer an alternative to thrombolysis and surgical thrombectomy. Combining mechanical thrombectomy devices and surgery can be used to treat symptomatic acute mesenteric venous thrombosis.

Imaging and radiological interventions of portal vein thrombosis

Portal vein thrombosis (PVT) is diagnosed by imaging methods. Once diagnosed by means of ultrasound, Doppler ultrasound can be performed to distinguish between a benign and malignant thrombus. If further information is required, magnetic resonance angiography or contrast-enhanced computed tomography is the next step, and if these tests are unsatisfactory, digital subtraction angiography should be performed. Many papers have been published dealing with alternative methods of treating PVT, but the material is fairly heterogeneous. In symptomatic non-cavernomatous PVT, recanalization using local methods is recommended by many authors. Implantation of transjugular intrahepatic portosystemic shunt is helpful in cirrhotic patients with non-cavernomatous PVT in reducing portal pressure and in diminishing the risk of re-thrombosis. In noncirrhotic patients with recent PVT, some authors recommend anticoagulation alone. In chronic thrombotic occlusion of the portal vein, local measures may be implemented if refractory symptoms of portal hypertension are evident.

[Spontaneous resolution of extensive superior mesenteric and portal vein thrombosis. A case report]

We present a case of subacute extensive thrombosis of the superior mesenteric vein, the venous branches of the jejunal vein, the portal vein at the hilum and its intrahepatic branches, with complete recanalization of the blood flow in the affected vessels without thrombolytic treatment. We provide a detailed description of the clinical and etiological investigations and outcome.

Mesenteric ischemia

MI remains a highly lethal entity. Improving survival requires an aggressive, multidisciplinary approach. High-risk patients with severe abdominal pain and a paucity of physical findings should be undergo emergent imaging in a search for this disease. Improvements in laboratory tests and advances in imaging techniques may improve the ability to diagnose MI earlier in its course, before irreversible damage has occurred. Many treatment modalities are available and should be tailored to each individual case. By recognizing and preventing ischemia-reperfusion injury,the cycle of protracted complications may be broken. A decrease in the mortality from MI finally is occurring. Early recognition and aggressive treatment finally may allow clinicians to have a marked impact on patient survival.

Treatment of Superior Mesenteric and Portal Vein Thrombosis with Direct Thrombolytic Infusion via an Operatively Placed Mesenteric Catheter

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.

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Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator

Portal and mesenteric venous thrombosis is an uncommon condition that is usually treated with systemic anticoagulation. Catheter-directed thrombolysis via the superior mesenteric artery may be a viable adjunct to treatment of this potentially morbid condition. We present a case of portal and mesenteric venous thrombosis treated with systemic anticoagulation and catheter-directed infusion of tissue plasminogen activator via the superior mesenteric artery.

Diagnosis and management of intestinal ischaemic disorders

Although intestinal ischaemia is an infrequent event, early recognition and appropriate treatment can reduce the potential for a devastating outcome

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

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

Drug therapies for mesenteric vascular disease

Mesenteric vascular disease has been increasingly diagnosed in the past 25 years. This rise in incidence has been attributed to the advanced mean age of the population and increasing number of critically ill patients, and to a greater clinical recognition of the condition. While surgical revascularization and resection has long been the standard of treatment, medical management also plays an important role. Early diagnosis before irreversible bowel damage, which may occur within 6 to 8 hours after insult, is the goal of successful medical treatment without surgical intervention. Even in the presence or irreversible bowel ischemia, perioperative medical treatment may reduce the progression of further ischemia, and bowel resection may be limited. This article outlines the appropriate medical management of ischemic disorders of the intestine, with an emphasis on the drug treatments presently used in clinical practice and those being studied in the laboratory.

Noninvasive assessment of portomesenteric venous thrombosis: current concepts and imaging strategies

Rapid, noninvasive imaging strategies, especially multidetector spiral CT and CT angiography (CTA) as well as gadolinium-enhanced MR angiography (MRA), have facilitated early diagnosis of splanchnic venous thrombosis, a potentially lethal cause of intestinal ischemia. Single breath-hold volumetric acquisitions permit superior temporal and contrast resolution while eliminating motion artifact and suppressing respiratory misregistration. Increased spatial resolution is aided by thinner slice collimation. These cross-sectional imaging techniques are becoming a preferred noninvasive alternative to conventional selective mesenteric angiography with delayed imaging for venous evaluation and should be considered the primary diagnostic modalities for evaluating patients with high clinical suspicion of nonsurgical mesenteric ischemia.

Mesenteric venous thrombosis: diagnosis and noninvasive imaging

Mesenteric venous thrombosis is an uncommon but potentially lethal cause of bowel ischemia. Several imaging methods are available for diagnosis, each of which has advantages and disadvantages. Doppler ultrasonography allows direct evaluation of the mesenteric and portal veins, provides semiquantitative flow information, and allows Doppler waveform analysis of the visceral vessels; however, it is operator dependent and is often limited by overlying bowel gas. Conventional contrast material-enhanced computed tomography (CT) allows sensitive detection of venous thrombosis within the central large vessels of the portomesenteric circulation and any associated secondary findings; however, it is limited by respiratory misregistration, motion artifact, and substantially decreased longitudinal spatial resolution. Helical CT and CT angiography, especially when performed with multi-detector row scanners, and magnetic resonance (MR) imaging, particularly gadolinium-enhanced MR angiography, enable volumetric acquisitions in a single breath hold, eliminating motion artifact and suppressing respiratory misregistration. Helical CT angiography and three-dimensional gadolinium-enhanced MR angiography should be considered the primary diagnostic modalities for patients with a high clinical suspicion of mesenteric ischemia. Conventional angiography is reserved for equivocal cases at noninvasive imaging and is also used in conjunction with transcatheter therapeutic techniques in management of symptomatic portal and mesenteric venous thrombosis.

Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation

Mesenteric vein thrombosis is generally difficult to diagnose and can be fatal. A case of extensive thrombosis of the mesenteric and portal veins was diagnosed early and successfully treated in a 26-year-old man with Down syndrome who was admitted to hospital because of abdominal pain, severe nausea and high fever. Ultrasonography revealed moderate ascites, and there was minimal flow in the portal vein (PV) on the Doppler examination. Computed tomography (CT) showed remarkable thickening of the walls of the small intestine and extensive thrombosis of the mesenteric, portal and splenic veins. Because neither intestinal infarction nor peritonitis was seen, combined thrombolysis and anticoagulation therapy without surgical treatment was chosen. Urokinase was administered intravenously and later through a catheter in the superior mesenteric artery. Heparin and antibiotics were given concomitantly. The patient's symptoms and clinical data improved gradually. After 10 days, CT revealed that collateral veins had developed and the thrombi in the distal portions of the mesenteric veins had dissolved, although the main trunk of the PV had not recanalized. The only risk factor of thrombosis that was detected was decreased protein S activity.

Catheter-directed thrombolysis with transjugular access in portal vein thrombosis secondary to pancreatitis

A case of portal vein thrombosis (PVT) secondary to pancreatitis is presented. Patient was treated with catheter-directed thrombolysis using urokinase solution. Because the percutaneous transhepatic approach is associated with higher risk of hemorrhage we used the catheter-directed thrombolysis via the transjugular intrahepatic access to restore the patency of the thrombosed portal vein. This case shows that catheter-directed thrombolysis with transjugular approach can be effectively used in the treatment of PVT.

Transjugular intrahepatic portosystemic shunt approach and local thrombolysis for treatment of early posttransplant portal vein thrombosis

Early portal vein thrombosis is a rare but severe posttransplant complication that may lead to graft and/or patient loss. Transjugular intrahepatic portosystemic shunting and local thrombolysis may represent an easy solution to this major complication of liver transplantation.

A retrospective study of diagnosis and management of mesenteric vein thrombosis

BACKGROUND

Mesenteric vein thrombosis (MVT) is an uncommon type of intestinal ischemia associated with significant mortality and morbidity because of its delay in diagnosis.

METHODS

A retrospective analysis of 9 patients treated surgically for MVT during 1982 to 1997 was performed.

RESULTS

Nine patients underwent surgical therapy for intestinal ischemia due to MVT. The most common presenting symptom was abdominal pain with bloody diarrhea in 3 patients; preoperative diagnosis of MVT was suspected in 2. Radiologic tests included plain roentgenograms, computed axial tomography, and ultrasound. Time to surgery ranged from 3 hours to 7 days after admission. All patients underwent resection of infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. No patient underwent a second-look operation. The postoperative morbidity and mortality rates were 55% and 11%, respectively.

CONCLUSION

Diagnosis of intestinal ischemia from MVT is often delayed, and strong clinical suspicion and aggressive treatment are necessary in its management.

Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy

Characteristics and outcomes of recent portal or mesenteric venous thrombosis are ill-known. We intended to compare these features with those of patients with portal cavernoma, and also to assess the incidence of recanalization of recent thrombosis on anticoagulation therapy. All patients seen between 1983 and 1999 were enrolled into this retrospective study if recent portal or mesenteric venous thrombosis or portal cavernoma had been documented, and if cancer of the liver, pancreas, or bile duct, intrahepatic block including cirrhosis, and obstruction of the hepatic veins had been ruled out. The proportion of recent thrombosis was 7% in patients seen before 1990 and 56% after 1994 (P <.05). Patients with recent thrombosis (n = 33) or cavernoma (n = 108) did not differ with regard to age, sex ratio, or prevalence of prothrombotic states and of previous thrombotic events. In patients with recent thrombosis, septic pylephlebitis was more common and the incidence of gastrointestinal bleeding was lower (2.4 vs. 12.7/100 patient-years). Recanalization occurred in 25 of 27 patients given anticoagulation and 0 of 2 patients not given anticoagulation. The probability of recanalization was related to the extent of thrombosis (P =.003). In conclusion, mesenteric or portal venous thrombosis is increasingly recognized at an early stage. The features differentiating recent thrombosis and cavernoma are related to silent onset precluding early recognition and therapy in the latter. Frequent association with prothrombotic states and frequent recanalization on anticoagulation support the recommendation of early anticoagulation therapy in all patients with recent portal vein thrombosis.

AGA technical review on intestinal ischemia. American Gastrointestinal Association

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 25, 1999, and by the AGA Governing Board on November 25, 1999.

Limitations of percutaneous techniques in the treatment of portal vein thrombosis

New therapeutic alternatives to portal vein thrombosis (PVT) include the percutaneous, transhepatic infusion of fibrinolytic agents, balloon dilatation, and stenting. These maneuvers have proven to be effective in some cases with acute, recent PVT. We have treated two patients with acute PVT via transhepatic or transjugular approaches and by using pharmacologic and mechanical thrombolysis and thrombectomy. Although both patients clinically improved, morphologic results were only fair and partial rethrombosis was observed. The limitations of percutaneous procedures in the recanalization of acute PVT in noncirrhotic patients are discussed.

Portal, mesenteric, and splenic vein thromboses after splenectomy in a patient with chronic myeloid leukemia variant with thrombocythemic onset

Portal, mesenteric, or splenic vein thrombosis is a very uncommon complication with significant mortality in the patients undergoing splenectomy for hematologic disorders. We report a 49-year-old woman who developed portal, superior mesenteric, and splenic vein thromboses after splenectomy. Four years before the event, she presented with a marked thrombocytosis and was diagnosed to have chronic myeloid leukemia variant with thrombocythemic onset as evidence by Philadelphia (Ph1) chromosome and a b3a2 BCR/ABL transcript. Six weeks after splenectomy, she developed severe epigastric pain. The diagnosis of thromboses of portal, mesenteric, and splenic veins was made by computed tomography scan and Doppler sonogram. She was successfully treated with antegrade intraarterial urokinase therapy via superior mesenteric artery and long-term anticoagulant therapies. To our knowledge, our patient is the first case of portal, mesenteric, and splenic vein thromboses after splenectomy in a patient with CML variant with thrombocythemic onset successfully treated with antegrade intraarterial thrombolytic therapy followed by anticoagulant therapies.

Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy

Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.

Percutaneous mesenteric venous thrombectomy and thrombolysis: successful treatment followed by liver transplantation

Mesenteric vein thrombosis (MVT) is a rare cause of intestinal ischemia. Because of its nonspecific symptoms, diagnosis is often delayed. We describe a patient with liver cirrhosis who developed acute MVT while waiting for liver transplantation. Surgical intervention carried a high risk because of her underlying cirrhosis. Mesenteric venous thrombectomy and thrombolysis were performed with an AngioJet (Possis Medical, Minneapolis, MN) thrombectomy device and streptokinase infusion through transjugular route. The patient subsequently received an orthotopic liver transplant. We also present a review of the literature about the occurrence and treatment options for MVT.

Acute mesenteric ischemia

The morbidity and mortality of acute mesenteric ischemia have remained high over the past 30 years despite heightened sensitivity to the diagnosis. Because the duration of the ischemic episode is the most significant determinant of outcome, an aggressive diagnostic and treatment protocol must be maintained. Although this stance may precipitate a number of negative angiographic studies, such an approach is the only opportunity for salvage in these critically ill patients.