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Barah A, Al-Hashimi I, Kassamali R, Aldebyani Q, Almokdad O, Elmagdoub A, Khader M, Rehman SU, Omar A. Catheter-Directed Thrombolysis in the treatment of acute Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy. Thromb J 2022; 20:57. [PMID: 36175959 PMCID: PMC9524041 DOI: 10.1186/s12959-022-00415-w] [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: 04/17/2021] [Accepted: 03/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background Portomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient’s clinical details, radiological findings, safety, and efficacy are reported. Cases presentation Two patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery. Conclusion PMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.
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Affiliation(s)
- Ali Barah
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar.
| | - Israa Al-Hashimi
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Rahil Kassamali
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Qayed Aldebyani
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Omran Almokdad
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Elmagdoub
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Khader
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Saad U Rehman
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Omar
- Clinical Imaging Department, Hamad Medical Corporation, Doha, Qatar
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Hu LS, Zhao Z, Li T, Li QS, Lu Y, Wang B. The Management of Portal Vein Thrombosis after Adult Liver Transplantation: A Case Series and Review of the Literature. J Clin Med 2022; 11:jcm11164909. [PMID: 36013148 PMCID: PMC9410203 DOI: 10.3390/jcm11164909] [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: 07/10/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Portal vein thrombosis (PVT) after adult liver transplantation (LT) is a rare but serious complication with no consensus on the ideal treatment. We report a case series and a comprehensive review of the literature on PVT after LT to discuss the therapeutic options. Methods: The clinical data of 360 adult patients (≥18 years of age) who underwent LT from January 2017 to January 2020 were reviewed, and a comprehensive search of PubMed and Web of Science was conducted. Patients diagnosed with PVT after LT were identified, and relevant risk factors and therapies were analyzed. Results: Among the 360 patients, 7 (1.94%) developed PVT after LT. Onset of PVT within one week after LT was found in six patients (85.71%). Four of the seven patients with PVT received systemic anticoagulation (low molecular weight heparin and warfarin) therapy. Minimally invasive interventional therapies combined with systemic anticoagulation (heparin and warfarin) were applied for three patients, two of whom died because of severe abdominal hemorrhage and liver failure. Of the 33 cases reported in the literature, minimally invasive interventional therapy combined with systematic anticoagulation or sclerotherapy were the most-used methods (20/33). Systemic anticoagulation was administered to four patients, and surgical operation (thrombectomy; portosystemic shunt and retransplantation) was performed for nine patients. Among these 33 patients, 4 eventually died. Conclusions: Interventional therapy combined with systemic anticoagulation is a good choice for the management of PVT after LT, and in our experience, systemic anticoagulation alone can also have a positive effect for early PVT patients.
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Acute mesenteric ischaemia: imaging and intervention. Clin Radiol 2019; 75:398.e19-398.e28. [PMID: 31320112 DOI: 10.1016/j.crad.2019.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/11/2019] [Indexed: 11/22/2022]
Abstract
Acute mesenteric ischaemia (AMI) is an abdominal emergency in which an acute reduction in mesenteric arterial supply threatens bowel viability and may result in bowel infarction, perforation, and death. Despite improvements in diagnosis and treatment over recent decades, mortality rates in AMI remain very high. This article discusses the aetiological classification, pathophysiology, and clinical aspects of AMI. The specific imaging characteristics of each aetiological type of AMI are detailed and the role of different imaging methods in the diagnosis of AMI is discussed. Surgery is the established treatment of choice for AMI, but there is increasing use of endovascular techniques in treating AMI in cases where there are no clinical features of peritonism or radiological evidence of irreversible ischaemia. This article reviews the evidence for different diagnostic and management strategies for patients with AMI and discusses the advantages and disadvantages of surgical and endovascular treatments. Endovascular techniques have been reported to have high technical success rates and favourable outcomes when compared to open surgery; however, patient selection bias and a paucity of data limit the conclusions that can be drawn.
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Catheter-Directed Thrombolysis for Portal Vein Thrombosis in Children: A Case Series. J Vasc Interv Radiol 2018; 29:1578-1583. [DOI: 10.1016/j.jvir.2018.07.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/23/2022] Open
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Abstract
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.
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Affiliation(s)
- Ricardo Quarrie
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH, USA
| | - Stanislaw P Stawicki
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH, USA
- OPUS 12 Foundation, Bethlehem, PA, USA
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Zeng Q, Fu QN, Li FH, Wang XH, Liu H, Zhao Y. Early initiation of argatroban therapy in the management of acute superior mesenteric venous thrombosis. Exp Ther Med 2017; 13:1526-1534. [PMID: 28413504 DOI: 10.3892/etm.2017.4103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/21/2016] [Indexed: 12/18/2022] Open
Abstract
Acute superior mesenteric venous thrombosis (ASMVT) is an intractable disease with poor prognosis. Argatroban, a direct thrombin inhibitor, may be a novel anticoagulant method in the therapy of ASMVT. The aim of the present study was to assess the efficacy and safety of early argatroban therapy in ASMVT patients. The current retrospective study reviewed a consecutive series of ASMVT patients receiving early argatroban therapy during hospitalization between March 2013 and April 2014, with 18 ASMVT patients included in the study. Of these, 16 patients without hepatic dysfunction underwent anticoagulant therapy with argatroban with a mean dose of 1.57±0.34 µg/kg/min and a mean duration of 12.2±3.7 days, while their activated partial thromboplastin time (aPTT) was elevated to 1.95±0.26 times the baseline value. In addition, 2 hepatic dysfunction patients received therapy with a dose of 0.41 µg/kg/min and 0.46 µg/kg/min, and with aPTT of 1.68 and 1.62 times the baseline value, respectively. Overall, 94% (n=17) of the patients presented clinical improvement, while 88% (n=16) of patients presented partially or completely dissolved thrombus in contrast-enhanced computed tomography images. The incidence of surgery and bowel resection was 6% (excluding 1 case with intestinal necrosis detected on admission). Furthermore, 11% (n=2) of patients experienced a bleeding episode, however no major bleeding or mortality occurred during hospitalization. During the follow-up, the mortality and the recurrence rate were 6% and 11%, respectively. In conclusion, early initiation of argatroban treatment may be an effective and safe therapy in ASMVT, manifesting efficient resolution of the thrombus, rapid improvement of symptoms, low incidence of bowel resection and bleeding complication, and low mortality rate.
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Affiliation(s)
- Qiu Zeng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Qi-Ning Fu
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Feng-He Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Xue-Hu Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Hong Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Yu Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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Wijaya R, Ng JH, See AH, Kum SW. Open Thrombectomy for Primary Acute Mesentericoportal Venous Thrombosis—Should It Be Done? Ann Vasc Surg 2015; 29:1454.e21-5. [DOI: 10.1016/j.avsg.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 04/03/2015] [Accepted: 05/01/2015] [Indexed: 12/26/2022]
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Wani ZA, Bhat RA, Bhadoria AS, Maiwall R. Extrahepatic portal vein obstruction and portal vein thrombosis in special situations: Need for a new classification. Saudi J Gastroenterol 2015; 21:129-38. [PMID: 26021771 PMCID: PMC4455142 DOI: 10.4103/1319-3767.157550] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Extrahepatic portal vein obstruction is a vascular disorder of liver, which results in obstruction and cavernomatous transformation of portal vein with or without the involvement of intrahepatic portal vein, splenic vein, or superior mesenteric vein. Portal vein obstruction due to chronic liver disease, neoplasm, or postsurgery is a separate entity and is not the same as extrahepatic portal vein obstruction. Patients with extrahepatic portal vein obstruction are generally young and belong mostly to Asian countries. It is therefore very important to define portal vein thrombosis as acute or chronic from management point of view. Portal vein thrombosis in certain situations such as liver transplant and postsurgical/liver transplant period is an evolving area and needs extensive research. There is a need for a new classification, which includes all areas of the entity. In the current review, the most recent literature of extrahepatic portal vein obstruction is reviewed and summarized.
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Affiliation(s)
- Zeeshan A. Wani
- Department of Hepatology, Institute of Liver and Billiary Sciences, New Dehli, India
| | - Riyaz A. Bhat
- Department of Internal Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India,Address for correspondence: Dr. Riyaz A. Bhat, Internal Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India. E-mail:
| | - Ajeet S. Bhadoria
- Department of Epidemology, Institute of Liver and Billiary Sciences, New Dehli, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Billiary Sciences, New Dehli, India
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Wichman HJ, Cwikiel W, Keussen I. Interventional treatment of mesenteric venous occlusion. Pol J Radiol 2014; 79:233-8. [PMID: 25089163 PMCID: PMC4117677 DOI: 10.12659/pjr.890990] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 12/26/2022] Open
Abstract
Background Mesenteric venous thrombus may be an incidental finding during imaging studies and asymptomatic patients are treated conservatively or with anticoagulant therapy only. Patients with symptomatic acute thrombosis causing bowel ischemia require urgent treatment, which frequently includes extensive surgery. Interventional treatment may be an alternative. Purpose: To present results of interventional treatment in patients with symptomatic occlusion of the mesenteric veins. Material/Methods Eight patients, four men and four women aged 24–74 years (mean 53 years) were treated due to symptomatic portomesenteric venous occlusion of thrombotic origin. Transhepatic (n=5), trans-splenic (n=2), and transjugular (n=4) accesses were used. Patients were treated with mechanical thrombus fragmentation (n=4), pharmacological thrombolysis (n=3) and stent placement (n=8). Additional transjugular intrahepatic portosystemic shunt (TIPS) was created to facilitate the outflow from the treated veins (n=4). Results The majority of the patients required combination of different treatment methods. Resolution of symptoms with initial clinical success was achieved in seven of the eight patients, and one patient died the day after the procedure due to sepsis. Two other patients had procedure-related complications; one of them required embolization. Two patients had documented long-term clinical success with patent stents and no symptoms at one year following intervention. Conclusions Endovascular treatment of portomesenteric occlusion in patients with acute symptomatology showed good short-term clinical success rate.
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Affiliation(s)
- Heather J Wichman
- Department of Radiology, Covenant Medical Center, Waterloo, IA, U.S.A
| | - Wojciech Cwikiel
- Department of Interventional Radiology, Skane University Hospital, Lund, Sweden
| | - Inger Keussen
- Department of Interventional Radiology, Skane University Hospital and Lund University Hospital, Lund, Sweden
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10
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11
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The role of portal vein thrombosis in the clinical course of inflammatory bowel diseases: report on three cases and review of the literature. Gastroenterol Res Pract 2012; 2012:916428. [PMID: 23093957 PMCID: PMC3475311 DOI: 10.1155/2012/916428] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 09/01/2012] [Indexed: 12/13/2022] Open
Abstract
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.
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12
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Catheter-directed continuous thrombolysis following aspiration thrombectomy via the ileocolic route for acute portal venous thrombosis: report of two cases. Surg Today 2012; 43:1310-5. [DOI: 10.1007/s00595-012-0343-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 05/17/2012] [Indexed: 12/17/2022]
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13
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Hall TC, Garcea G, Metcalfe M, Bilku D, Dennison AR. Management of acute non-cirrhotic and non-malignant portal vein thrombosis: a systematic review. World J Surg 2012; 35:2510-20. [PMID: 21882035 DOI: 10.1007/s00268-011-1198-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND No definitive evidence exists regarding the treatment of acute portal vein thrombosis (PVT). Treatment modalities described include conservative management, anticoagulation, thrombolysis, and thrombectomy. This review examines the impact of such treatment, its outcomes, and the complications resulting from the resultant portal hypertension. METHODS A Medline literature search was undertaken using the keywords portal vein thrombosis, anticoagulation, thrombolysis, and thrombectomy. The primary end point was portal vein recanalization. Secondary outcome measures were morbidity and the development of portal hypertension and its sequelae, including variceal bleeding. Data from articles relating to PVT in the context of cirrhosis, malignancy, or liver transplant were excluded. RESULTS Early systemic anticoagulation results in complete portal vein recanalization in 38.3% of cases and partial recanalization in 14.0% of cases. Spontaneous recanalization without treatment can only be expected in up to 16.7% of patients. Frequently this is only when associated with self-limiting underlying pathology and/or minimal thrombus extension. Thrombolysis can be associated with major complications in up to 60% of patients. CONCLUSIONS The natural history of acute PVT is poorly described. Spontaneous resolution of acute portal vein thrombosis is uncommon. Early anticoagulation results in a satisfactory rate of recanalization with minimal procedure-associated morbidity. Thrombolysis should be used with caution and only considered if the disease is progressive and signs of mesenteric ischemia are present. Further well-designed trials with precise outcome reporting are needed to improve our understanding of the disease.
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Affiliation(s)
- T C Hall
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, UK.
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Dewitte A, Biais M, Coquin J, Fleureau C, Cassinotto C, Ouattara A, Janvier G. [Diagnosis and management of acute mesenteric ischemia]. ACTA ACUST UNITED AC 2011; 30:410-20. [PMID: 21481561 DOI: 10.1016/j.annfar.2011.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 02/09/2011] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- A Dewitte
- Service d'anesthésie-réanimation II, CHU de Bordeaux, Maison du Haut-Lévêque, groupe hospitalier Sud, université Bordeaux-Segalen, avenue de Magellan, Pessac cedex, France.
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Abstract
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.
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Affiliation(s)
- Ian G Harnik
- Montefiore Medical Center, Bronx, NY 10467, USA.
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Na BS, John BM, Kim KB, Lee JS, Jo HW, Seock CH, Kim DH, Lee KS. Spontaneous Dissolution of Isolated Superior Mesenteric Vein Thrombosis in Acute Pancreatitis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:38-41. [DOI: 10.4166/kjg.2011.57.1.38] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Byung Soo Na
- Department of Internal Medicine, SungAe Hospital, Seoul, Korea
| | - Byung Min John
- Department of Internal Medicine, KwangMyung SungAe Hospital, Gwangmyeong, Korea
| | - Ki Bum Kim
- Department of Internal Medicine, SungAe Hospital, Seoul, Korea
| | - Je Soo Lee
- Department of Internal Medicine, SungAe Hospital, Seoul, Korea
| | - Hyun Woo Jo
- Department of Internal Medicine, KwangMyung SungAe Hospital, Gwangmyeong, Korea
| | - Chang Hyeon Seock
- Department of Internal Medicine, KwangMyung SungAe Hospital, Gwangmyeong, Korea
| | - Dong Hui Kim
- Department of Internal Medicine, KwangMyung SungAe Hospital, Gwangmyeong, Korea
| | - Ki Sung Lee
- Department of Internal Medicine, KwangMyung SungAe Hospital, Gwangmyeong, Korea
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Renner P, Kienle K, Dahlke MH, Heiss P, Pfister K, Stroszczynski C, Piso P, Schlitt HJ. Intestinal ischemia: current treatment concepts. Langenbecks Arch Surg 2010; 396:3-11. [PMID: 21072535 DOI: 10.1007/s00423-010-0726-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Accepted: 11/03/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Mesenteric ischemia is a condition well-known among physicians treating patients with abdominal symptoms. Even so, mortality rates have not decreased significantly over the last decades. The purpose of this article is to review current treatment concepts of acute and chronic mesenteric ischemia. RESULTS Early diagnosis is one of the most important features that determine a patient's prognosis. Conventional angiography and multidetector computed tomography are therefore appropriate to quickly diagnose mesenteric ischemia, the latter being commonly more available. Once a patient presents with signs of peritonitis, instant laparotomy is indicated, and infarcted bowel segments need to be resected, followed by a second-look operation if necessary. If bowel necrosis is clinically not suspected, different approaches should be applied according to source and nature of mesenteric ischemia. Besides established surgical treatment concepts, more and more interventional procedures are developed and evaluated. However, superiority of these new techniques could only be shown for selected patient groups so far. In chronic mesenteric ischemia, interventional approaches seem to be an attractive alternative in patients who are in a condition too bad to undergo surgery. Patients with colonic ischemia are treated best in a conservative manner and by resolving the underlying cause, if identified. CONCLUSION Patients with acute mesenteric ischemia are still at highest risk for a fatal course of disease. New diagnostic and therapeutic developments have not been tested in larger studies yet, neither has any of these methods led to an increased survival in studies published so far. Taken together, mesenteric ischemia requires high awareness, earliest possible diagnosis, and treatment by an experienced interdisciplinary team of gastroenterologists, radiologists, and surgeons.
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Affiliation(s)
- Philipp Renner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauss Allee 11, 93053, Regensburg, Germany
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Ponziani FR, Zocco MA, Tortora A, Gasbarrini A. Is there a role for anticoagulants in portal vein thrombosis management in cirrhotic patients? Expert Opin Pharmacother 2010; 11:1479-87. [PMID: 20446862 DOI: 10.1517/14656561003749264] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Francesca Romana Ponziani
- Catholic University of Rome, Department of Internal Medicine, Largo A. Gemelli 8, 00168 Rome, Italy.
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Thomas RM, Ahmad SA. Management of acute post-operative portal venous thrombosis. J Gastrointest Surg 2010; 14:570-7. [PMID: 19582513 DOI: 10.1007/s11605-009-0967-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 06/22/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Portal vein thrombosis can be a devastating, but often overlooked, complication of hepatobiliary procedures. Symptoms of acute portal vein thrombosis range from nondescript abdominal pain to septic shock secondary to mesenteric ischemia. DISCUSSION The surgeon must be cognizant of these symptoms and the potential for portal vein thrombosis after any hepatobiliary procedures as an expedient diagnosis and treatment is necessary in order to prevent thrombus propagation, bowel ischemia, and death. This report outlines the symptoms, diagnosis, and a review of the literature on the treatment of acute portal vein thrombosis after hepatobiliary surgery with a special note made regarding a case of portal vein thrombosis after pancreatectomy and autologous islet cell transplantation.
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Affiliation(s)
- Ryan M Thomas
- Department of Surgery, Division of Surgical Oncology, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
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Transradial approach for transcatheter selective superior mesenteric artery urokinase infusion therapy in patients with acute extensive portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol 2009; 33:80-9. [PMID: 20033163 DOI: 10.1007/s00270-009-9777-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Accepted: 12/01/2009] [Indexed: 12/23/2022]
Abstract
The purpose of this investigation was to assess the feasibility and effectiveness of transradial approach for transcatheter superior mesenteric artery (SMA) urokinase infusion therapy in patients with acute extensive portal and superior mesenteric venous thrombosis. During a period of 7 years, 16 patients with acute extensive thrombosis of the portal (PV) and superior mesenteric veins (SMV) were treated by transcatheter selective SMA urokinase infusion therapy by way of the radial artery. The mean age of the patients was 39.5 years. Through the radial sheath, a 5F Cobra catheter was inserted into the SMA, and continuous infusion of urokinase was performed for 5-11 days (7.1 +/- 2.5 days). Adequate anticoagulation was given during treatment, throughout hospitalization, and after discharge. Technical success was achieved in all 16 patients. Substantial clinical improvement was seen in these 16 patients after the procedure. Minor complications at the radial puncture site were observed in 5 patients, but trans-SMA infusion therapy was not interrupted. Follow-up computed tomography scan before discharge demonstrated nearly complete disappearance of PV-SMV thrombosis in 9 patients and partial recanalization of PV-SMV thrombosis in 7 patients. The 16 patients were discharged 9-19 days (12 +/- 6.0 days) after admission. Mean duration of follow-up after hospital discharge was 44 +/- 18.5 months, and no recurrent episodes of PV-SMV thrombosis developed during that time period. Transradial approach for transcatheter selective SMA urokinase infusion therapy in addition to anticoagulation is a safe and effective therapy for the management of patients with acute extensive PV-SMV thrombosis.
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Cenedese A, Monneuse O, Gruner L, Tissot E, Mennesson N, Barth X. Initial management of extensive mesenteric venous thrombosis: retrospective study of nine cases. World J Surg 2009; 33:2203-8. [PMID: 19672653 DOI: 10.1007/s00268-009-0168-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The development of mesenteric venous thrombosis (MVT) does not necessarily require surgical intervention. The aim of this study was to assess the efficacy of avoiding early operative intervention, which can lead to significant sacrifice of the small bowel. METHODS Patients with MVT were identified using the inpatient registry for the years between 2003 and 2007. Each patient's past medical history, history of prior deep venous thrombosis or hypercoagulable state, clinical and biologic presentation, and computed tomography (CT) results were analyzed. The proportion of ischemic bowel observed on the CT scans was compared with the length of the bowel resected. RESULTS Nine patients were admitted for extensive MVT during the time period evaluated (six men, three women). All CT scans demonstrated signs of severe bowel ischemia, with a mean ischemic bowel proportion of 21% (range 5-45%). Four patients received medical management alone. Five patients underwent surgery. The mean admission time for these patients prior to the operation was 14.8 days (6-36 days). Surgery was required only in cases of intestinal perforation. The mean length of the bowel resections was 33 cm (20-45 cm). At 6 months after admission, none of the patients required parenteral nutrition. The mean follow-up evaluation period was 27 months (15-38 months). One patient died secondary to amyotrophic lateral sclerosis during the follow-up. CONCLUSIONS Initial nonsurgical management comprised of inpatient observation on a surgical ward along with systemic anticoagulation must be considered an alternative treatment strategy for MVT. This strategy delays surgery and therefore avoids short bowel syndrome.
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Affiliation(s)
- Alice Cenedese
- Digestive and Emergency Surgery Department, Pavillon G Viscéral, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.
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Catheter-Directed Tissue Plasminogen Activator Infusion and Concurrent Systemic Anticoagulation With Heparin to Treat Portal Vein Thrombosis Post Orthoptic Liver Transplantation. Transplantation 2009; 88:595-6. [DOI: 10.1097/tp.0b013e3181b11fa7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
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.
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Latzman GS, Kornbluth A, Murphy SJ, Legnani P, George J, Guller J, Lewin S, Carroccio A, Harris MT. Use of an intravascular thrombectomy device to treat life-threatening venous thrombosis in a patient with Crohn's disease and G20210A prothrombin gene mutation. Inflamm Bowel Dis 2007; 13:505-8. [PMID: 17206666 DOI: 10.1002/ibd.20037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Nakai M, Sato M, Sahara S, Kawai N, Kimura M, Maeda Y, Ibata Y, Higashi K. Transhepatic catheter-directed thrombolysis for portal vein thrombosis after partial splenic embolization in combination with balloon-occluded retrograde transvenous obliteration of splenorenal shunt. World J Gastroenterol 2006; 12:5071-4. [PMID: 16937510 PMCID: PMC4087417 DOI: 10.3748/wjg.v12.i31.5071] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 66-year-old woman underwent partial splenic embolization (PSE) for hypersplenism with idiopathic portal hypertension (IPH). One week later, contrast-enhanced CT revealed extensive portal vein thrombosis (PVT) and dilated portosystemic shunts. The PVT was not dissolved by the intravenous administration of urokinase. The right portal vein was canulated via the percutaneous transhepatic route under ultrasonic guidance and a 4 Fr. straight catheter was advanced into the portal vein through the thrombus. Transhepatic catheter-directed thrombolysis was performed to dissolve the PVT and a splenorenal shunt was concurrently occluded to increase portal blood flow, using balloon-occluded retrograde transvenous obliteration (BRTO) technique. Subsequent contrast-enhanced CT showed good patency of the portal vein and thrombosed splenorenal shunt. Transhepatic catheter-directed thrombolysis combined with BRTO is feasible and effective for PVT with portosystemic shunts.
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Affiliation(s)
- Motoki Nakai
- Department of Radiology, Hidaka General Hospital, Gobo Shi, Wakayama 644-8655, Japan.
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Kim HS, Patra A, Khan J, Arepally A, Streiff MB. Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J Vasc Interv Radiol 2006; 16:1685-91. [PMID: 16371536 DOI: 10.1097/01.rvi.0000182156.71059.b7] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To evaluate clinical outcomes after percutaneous treatment of superior mesenteric vein (SMV) thrombosis. MATERIALS AND METHODS A retrospective chart review was conducted of all patients with SMV thrombosis treated with percutaneous catheter-directed thrombectomy/thrombolysis. The demographics of the study population, potential causative factors contributing to SMV thrombosis, and morbidity and mortality associated with therapy were assessed. RESULTS Eleven patients (mean age, 44.3 years +/- 12.8) with SMV thrombosis were treated with percutaneous transhepatic catheter-directed thrombectomy/thrombolysis. Potential causative factors included recent major abdominal surgery, thrombophilic conditions, pancreatitis, and repetitive abdominal trauma. The mean duration between the onset of symptoms and percutaneous treatment was 8.6 days +/- 6.5. Computed tomography confirmed the clinical diagnosis in nine patients (81.8%). One patient (9.1%) had a bleeding complication, which was treated by chest tube drainage without long-term sequelae. One patient (9.1%) with refractory SMV thrombosis died of sepsis and multiple organ failure. No recurrent episode of SMV thrombosis or mortality was documented during a mean follow-up of 42 months +/- 22.5. CONCLUSIONS Percutaneous transhepatic catheter-directed thrombectomy/thrombolysis for SMV thrombosis is associated with a rapid improvement in symptoms and low incidences of long-term morbidity and mortality. Percutaneous thrombectomy and thrombolysis should be considered in all patients with acute SMV thrombosis without evidence of bowel necrosis.
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Affiliation(s)
- Hyun S Kim
- Division of Vascular and Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, Maryland 21205, USA.
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Hollingshead M, Burke CT, Mauro MA, Weeks SM, Dixon RG, Jaques PF. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol 2005; 16:651-61. [PMID: 15872320 DOI: 10.1097/01.rvi.0000156265.79960.86] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Michael Hollingshead
- Department of Radiology, University of North Carolina Chapel Hill, 27599-7510, USA
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Takahashi N, Kuroki K, Yanaga K. Percutaneous Transhepatic Mechanical Thrombectomy for Acute Mesenteric Venous Thrombosis. J Endovasc Ther 2005; 12:508-11. [PMID: 16048384 DOI: 10.1583/04-1335mr.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Naoto Takahashi
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
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Hidajat N, Stobbe H, Griesshaber V, Felix R, Schroder RJ. Imaging and radiological interventions of portal vein thrombosis. Acta Radiol 2005; 46:336-43. [PMID: 16136689 DOI: 10.1080/02841850510021157] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- N Hidajat
- Central Department of Diagnostic and Interventional Radiology, Hospital Peine, Academic Teaching Hospital of the University of Hannover, Germany.
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Guglielmi A, Fior F, Halmos O, Veraldi GF, Rossaro L, Ruzzenente A, Cordiano C. Transhepatic fibrinolysis of mesenteric and portal vein thrombosis in a patient with ulcerative colitis: A case report. World J Gastroenterol 2005; 11:2035-8. [PMID: 15801002 PMCID: PMC4305733 DOI: 10.3748/wjg.v11.i13.2035] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To present a case of acute mesenteric and portal vein thrombosis treated with thrombolytic therapy in a patient with ulcerative colitis in acute phase and to review the literature on thrombolytic therapy of mesenteric-portal system. Treatment of acute portal vein thrombosis has ranged from conservative treatment with thrombolysis and anticoagulation therapy to surgical treatment with thrombectomy and/or intestinal resection.
METHODS: We treated our patient with intraportal infusion of plasminogen activator and then heparin through a percutaneous transhepatic catheter.
RESULTS: Thrombus resolved despite premature interruption of the thrombolytic treatment for neurological complications, which subsequently resolved.
CONCLUSION: Conservative management with plasminogen activator, could be considered as a good treatment for patients with acute porto-mesenteric thrombosis.
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Affiliation(s)
- Alfredo Guglielmi
- First Department of General Surgery, University of verona, Borgo Trento Hospital, P.le Stefani 1, 37126 Verona, Italy.
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Stambo GW, Grauer L. Transhepatic Portal Venous Power-Pulse Spray Rheolytic Thrombectomy for Acute Portal Vein Thrombosis After CT-Guided Pancreas Biopsy. AJR Am J Roentgenol 2005; 184:S118-9. [PMID: 15728000 DOI: 10.2214/ajr.184.3_supplement.0184s118] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Glenn W Stambo
- Division of Vascular and Interventional Radiology, Department of Radiology, SDI Radiologists, St. Joseph's Hospital and Medical Center, 4516 N Armenia Ave., Tampa, FL 33607, USA.
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Espeel B, Gérard C, Mansvelt B, Bertrand C, Vermonden J. [Extensive mesenteric venous thrombosis treatment by regional thrombolysis]. ACTA ACUST UNITED AC 2005; 24:274-7. [PMID: 15792561 DOI: 10.1016/j.annfar.2004.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2004] [Accepted: 12/13/2004] [Indexed: 12/11/2022]
Abstract
Two cases of mesenteric venous thrombosis with portal extension are reported. The first patient was treated right away by local intra-arterial thrombolysis, the second one benefited from local venous thrombolysis immediately after intestinal resection. No significant complication was observed.
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Affiliation(s)
- B Espeel
- Service de réanimation polyvalente, centre hospitalier Jolimont-Lobbes, hôpital de Jolimont, 159, rue Ferrer, 7100 Haine-Saint-Paul, Belgique.
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Fernández-Marcote Menor EM, Opio Maestro VA. [Spontaneous resolution of extensive superior mesenteric and portal vein thrombosis. A case report]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 27:470-2. [PMID: 15388052 DOI: 10.1016/s0210-5705(03)70506-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- Joseph P Martinez
- Department of Surgery, Division of Emergency Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Henao EA, Bohannon WT, Silva MB. Treatment of portal venous thrombosis with selective superior mesenteric artery infusion of recombinant tissue plasminogen activator. J Vasc Surg 2004; 38:1411-5. [PMID: 14681650 DOI: 10.1016/s0741-5214(03)01052-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- E A Henao
- Division of Vascular Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX 79430-8312, USA
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Hsieh MS, Lin ZY, Chuang WL, Chang WY. Long-term follow-up of partial thrombosis of the superior mesenteric vein in a cirrhotic patient with hepatocellular carcinoma: a case report. Kaohsiung J Med Sci 2003; 19:233-7. [PMID: 12822680 DOI: 10.1016/s1607-551x(09)70429-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Superior mesenteric venous thrombosis (SMVT) is an uncommon but potentially life-threatening disorder. We describe a cirrhotic patient with hepatocellular carcinoma who had partial SMVT for at least 28 months. Our experience may help in the management of such patients. The partial SMVT was not treated at the time of discovery because there was no evidence of bowel infarction. Moreover, the patient had a tendency to bleed severely and was in a poor condition. SMVT was followed using regular ultrasonography and the pattern of SMVT did not change significantly during the follow-up period. A symptom that may have been related to SMVT was abdominal colic pain after meals, which was sometimes followed by diarrhea and / or nausea and vomiting. There was no evidence of bowel ischemia or infarction during follow-up. Abdominal discomfort can be successfully treated using anticholinergic drugs with or without analgesia.
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Affiliation(s)
- Men-Shun Hsieh
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Uflacker R. Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis. Tech Vasc Interv Radiol 2003; 6:59-69. [PMID: 12772131 DOI: 10.1053/tvir.2003.36433] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Renan Uflacker
- Department of Radiology, Medical University of South Carolina, Charleston, SC 29245, USA
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Parker HH, Bynoe RP, Nottingham JM. Thrombosis of the portal venous system after splenectomy for trauma. THE JOURNAL OF TRAUMA 2003; 54:193-6. [PMID: 12544919 DOI: 10.1097/00005373-200301000-00027] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Harris H Parker
- Department of Surgical Education, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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Tabriziani H, Frishman WH, Brandt LJ. Drug therapies for mesenteric vascular disease. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:306-14. [PMID: 12350243 DOI: 10.1097/00132580-200209000-00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Hossein Tabriziani
- Department of Medicine, St. Barnabas Hospital Center, Bronx, New York, USA
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42
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Goldberg SN, Ahmed M, Weinstein J, Hare B, Bloch S, Sheiman RG. Low-power transverse ultrasonic treatment of portal vein thrombosis in an animal model. J Vasc Interv Radiol 2002; 13:915-21. [PMID: 12354826 DOI: 10.1016/s1051-0443(07)61775-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The authors have recently developed a small-diameter, thin, flexible ultrasonic catheter device that permits the removal of thrombus by low-power transverse ultrasonic cavitation energy. In this study, the authors sought to determine whether this device could be used to eliminate portal vein thrombosis in an animal model. MATERIALS AND METHODS In five anesthetized pigs, a total of six occlusions of the left portal vein were achieved with use of autologous clot with (n = 2) or without (n = 4) thrombin injection (250 U) introduced via a 7-F transhepatic catheter/sheath system. Angiographic examination documented complete occlusion of this vessel. The 75-cm-long, 21-gauge ultrasonic catheter (Resolution) was introduced into the clot under angiographic guidance via the transhepatic sheath. Transverse-wave ultrasonic energy was then delivered from the distal 5 cm of the probe at 3.5 W +/- 10% power for up to 6 minutes. Repeat angiographic studies were performed to document patency. After the procedure, gross and histopathologic examinations were performed. RESULTS Restoration of patency of the main left portal vein was documented in all cases at angiography, with no evidence of residual clot fragments in the major branches. However, side branches demonstrated small thrombotic plugs on pathologic examination. No complications such as perforation of the vessel adjacent to the active ultrasonic tip were encountered. Virtually all thrombolysis was documented to occur within the first minute of energy application. At gross pathologic examination, there was no evidence of damage to the portal vein, and histopathologic examination demonstrated minimal intimal disruption without damage to the media. CONCLUSIONS This preliminary animal study suggests the feasibility of a percutaneous transhepatic approach to the treatment of portal vein thrombosis with use of low-power ultrasonic cavitation energy. With further study, this method may have potential for the treatment of thrombotic disease, thereby offering novel therapy to patients with thrombotic vascular occlusions.
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Affiliation(s)
- S Nahum Goldberg
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Bradbury MS, Kavanagh PV, Bechtold RE, Chen MY, Ott DJ, Regan JD, Weber TM. Mesenteric venous thrombosis: diagnosis and noninvasive imaging. Radiographics 2002; 22:527-41. [PMID: 12006685 DOI: 10.1148/radiographics.22.3.g02ma10527] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Michelle S Bradbury
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1088, USA
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Kercher KW, Sing RF, Watson KW, Matthews BD, LeQuire MH, Heniford BT. Transhepatic thrombolysis in acute portal vein thrombosis after laparoscopic splenectomy. Surg Laparosc Endosc Percutan Tech 2002; 12:131-6. [PMID: 11948303 DOI: 10.1097/00129689-200204000-00013] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Portal vein thrombosis is a relatively rare clinical entity that can result in substantial morbidity and mortality. Because of the risk of intestinal infarction, acute symptomatic portal vein thrombosis requires prompt intervention. Traditional treatment has included anticoagulation and/or systemic thrombolytic therapy. We report the successful management of acute portal vein thrombosis with percutaneous transphepatic thrombolytic therapy. In addition to the potential for improving regional clot lysis through direct infusion of the thrombolytic agent, this method may result in fewer systemic side effects than occur with other available treatment modalities.
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Affiliation(s)
- Kent W Kercher
- Department of Radiology, Carolinas Medical Center, Charlotte, North Carolina, USA
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Tateishi A, Mitsui H, Oki T, Morishita J, Maekawa H, Yahagi N, Maruyama T, Ichinose M, Ohnishi S, Shiratori Y, Minami M, Koutetsu S, Hori N, Watanabe T, Nagawa H, Omata M. Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation. J Gastroenterol Hepatol 2001; 16:1429-33. [PMID: 11851847 DOI: 10.1046/j.1440-1746.2001.02557.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- A Tateishi
- Departments of Gastroenterology, Radiology and Surgical Oncology, University of Tokyo, Tokyo, Japan.
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Warshauer DM, Lee JK, Mauro MA, White GC. Superior mesenteric vein thrombosis with radiologically occult cause: a retrospective study of 43 cases. AJR Am J Roentgenol 2001; 177:837-41. [PMID: 11566684 DOI: 10.2214/ajr.177.4.1770837] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Our purpose was to examine the clinical presentation, imaging appearance, etiology, and clinical outcome in patients who had acute thrombosis of the superior mesenteric vein with radiologically occult cause. CONCLUSION The most common predisposing factors in superior mesenteric vein thrombosis with radiologically occult cause are recent abdominal surgery, infection, and hypercoagulable states. Although no correlation was noted between risk factor and outcome, the presence of bowel wall thickening and mesenteric congestion on CT or MR imaging was associated with the development of bowel ischemia. Prognosis is good in this group of patients, with a mortality of only 7%, although bowel ischemia was noted in 21%.
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Affiliation(s)
- D M Warshauer
- Department of Radiology, University of North Carolina School of Medicine, Campus Box 7510, Old Clinic Bldg., Manning Dr., Chapel Hill, NC 27599-7510, USA
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Morasch MD, Ebaugh JL, Chiou AC, Matsumura JS, Pearce WH, Yao JS. Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 2001; 34:680-4. [PMID: 11668324 DOI: 10.1067/mva.2001.116965] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Mesenteric venous thrombosis (MVT) and its clinical spectrum have become better defined following improvements in diagnostic imaging. Historically, MVT has been described as a morbid clinical entity, but this may not necessarily be true. Often, an underlying disease process that predisposes a patient to MVT can be found and potentially treated. This study was designed to evaluate the diagnostics and management of MVT and to review long-term results of treatment. PATIENTS Thirty-one patients in whom MVT was diagnosed between 1985 and 1999 were retrospectively reviewed. Survivors were contacted for follow-up. There were 15 men and 16 women. Ages ranged from 22 to 80 years (mean, 49.1 years). Thirteen patients had documented hypercoagulability, 10 had a history of previous abdominal surgery, 6 had a prior thrombotic episode, and 4 had a history of cancer. MVT presented as abdominal pain (84%), diarrhea (42%), and nausea/vomiting (32%). Computed tomography (CT) was considered diagnostic in 18 (90%) of 20 patients who underwent the test. CT diagnosed MVT in 15 (100%) of 15 patients presenting with vague abdominal pain or diarrhea. Angiography demonstrated MVT in only five (55.5%) of nine patients. RESULTS Seven of 31 patients died within 30 days (< 30-day mortality rate, 23%). Twenty-two patients (72%) were initially treated with heparin. Nine patients were not heparinized: four of them died, and two were later given warfarin sodium (Coumadin). Of the 31 patients, only one received lytic therapy. Three patients became symptom free without anticoagulation. Ten patients (32%) underwent bowel resection. Overall, 19 (79%) of 24 survivors were treated with long-term warfarin therapy. Long-term follow-up was obtained in 24 patients (mean, 57.7 months). Twenty-one (88%) of 24 survived in follow-up. CONCLUSION The diagnosis of MVT should be suspected when acute abdominal symptoms develop in patients with prior thrombotic episodes or a documented coagulopathy. CT scanning appears to be the primary diagnostic test of choice. Anticoagulation is recommended. If diagnosed and treated early, MVT is not likely to progress to gangrenous bowel. Recent mortality rates for MVT are lower than previously published, perhaps because of earlier diagnosis and aggressive treatment or possibly because we now readily diagnose a more benign form of the disease, which is due to widespread use of CT scanning.
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Affiliation(s)
- M D Morasch
- Division of Vascular Surgery, Department of Surgery, Northwestern University Medical School, Chicago, IL 60611, USA
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Brunaud L, Antunes L, Collinet-Adler S, Marchal F, Ayav A, Bresler L, Boissel P. Acute mesenteric venous thrombosis: case for nonoperative management. J Vasc Surg 2001; 34:673-9. [PMID: 11668323 DOI: 10.1067/mva.2001.117331] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Initial treatment in the management of acute mesenteric vein thrombosis (MVT) is controversial. Some authors have proposed a surgical approach, whereas others have advocated medical therapy (anticoagulation). In this study, we analyzed and compared the results obtained with surgical and medical treatment to determine the best initial management for this disease. METHODS We retrospectively reviewed the records of patients treated for MVT in a secondary care surgical department from January 1987 to December 1999. Before January 1995, our departmental policy was to perform surgery in patients with suspected MVT. Since January 1995, we have preferred a medical approach when achievable. Each patient in this study was assessed for diagnosis, initial management (laparotomy or anticoagulation), morbidity, mortality, duration of hospitalization, the need for secondary operation, portal hypertension, and survival rates. RESULTS Twenty-six patients were treated, 14 before January 1995 (group 1) and 12 since January 1995 (group 2). Morbidity, mortality, secondary operation, portal hypertension, and 2-year survival rates were 34.6%, 19.2%, 15.3%, 19.2%, and 76.9%, respectively. No statistical difference was observed between the two groups. The mean duration of hospitalization was 51.6 days in group 1 and 23.2 days in group 2 (P < .05). Among the 12 patients treated by means of laparotomy with bowel resection, 10 patients (83%) had mucosal necrosis without transmural necrosis at pathologic study. CONCLUSION Nonoperative management for acute MVT is feasible when the initial diagnosis with a computed tomography scan is certain and when the bowel infarction has not led to transmural necrosis and bowel perforation. The morbidity, mortality, and survival rates are similar in cases of surgical and nonoperative management. The length of hospital stay is shorter when patients are treated with a nonoperative approach. A nonoperative approach, when indicated, avoids the resection of macroscopically infarcted small bowel (without transmural necrosis) in cases that are potentially reversible with anticoagulation alone.
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Affiliation(s)
- L Brunaud
- Department of Visceral and Endocrine Surgery, University Hospital NANCY Brabois, Vandoeuvre les Nancy, France.
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Antoch G, Taleb N, Hansen O, Stock W. Transarterial thrombolysis of portal and mesenteric vein thrombosis: a promising alternative to common therapy. Eur J Vasc Endovasc Surg 2001; 21:471-2. [PMID: 11352527 DOI: 10.1053/ejvs.2001.1355] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- G Antoch
- Department of General and Vascular Surgery, Marien-Hospital Duesseldorf, Rochusstrasse 2, 40479 Duesseldorf, Germany
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