Interventional treatment of mesenteric venous occlusion

Endovascular management of portal vein obstruction in hepatobiliary cancer patients

BACKGROUND AND OBJECTIVES

The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms.

METHODS

Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method.

RESULTS

The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts.

CONCLUSION

Endovascular recanalization with stent placement is safe with high technical and clinical success.

AngioJet-assisted transvenous-transhepatic mechanical thrombectomy in the portal vein

Purpose

To evaluate AngioJet-assisted transvenous portal vein (PV) thrombectomy for non-cirrhotic patients with total portal vein and mesenteric vein thrombosis (PVMVT).

Material and methods

From 2015 to 2016 four patients (3 male, mean 43.9 years, range 33-52 years) with acute (3 cases) and acute-on-chronic (1 case) PVMVT underwent transvenous thrombolysis. All patients received initial AngioJet (Boston Scientific, Natick, MA, USA) thrombectomy followed by continuous catheter directed thrombolysis with Urokinase (Medac, Wedel, Germany) for 22-52 hours. Transjugular intrahepatic portosystemic shunts (TIPS), using Viatorr stent grafts (W.L. Gore and Associates, AZ, USA; mean diameter: 10 mm, length: 60-80 mm), were implanted in all patients. Patients were followed clinically and with imaging (mean 646 days, range 392 to 936 days).

Results

Technical success was 100%. Therapeutic success was achieved in 75% of cases. AngioJet-assisted thrombectomy substantially reduced thrombus load in the acute cases, while only slight improvement was achieved in the acute-on-chronic case. Continuous thrombolysis subtotally re-established PV flow in the acute cases, while only minimal improvement was seen in the acute-on-chronic case. Following TIPS implantation complete PV recanalisation could be achieved in all acute cases. In the acute-on-chronic case initial stagnant PV flow was seen; however, PV and TIPS re-occluded 10 days after implantation. During follow-up PV remained patent in acute cases.

Conclusions

AngioJet-assisted thrombectomy was technically feasible and uncomplicated in all of our patients. The initial results suggest that AngioJet-assisted thrombectomy facilitates recanalisation in acute and severe cases of PVMVT.

Treatment of acute portomesenteric venous thrombosis with thrombectomy through a transjugular intrahepatic portosystemic shunt: a single-center experience

Background Acute portomesenteric venous thrombosis (PMVT) is a potentially life-threatening condition and urgent treatment is required. Purpose To retrospectively evaluate the efficacy and safety of treating acute PMVT by the creation of a transjugular intrahepatic portosystemic shunt (TIPS) followed by thrombectomy. Material and Methods Six patients (all men, age range = 39-51 years) presenting with acute PMVT were treated with transjugular thrombectomy (TT) through a TIPS created in the same session. The intervention included iterated venography through the TIPS one to three times within the first week after diagnosis and repeated thrombectomy if needed (n = 5). Results Recanalization was successful with persistent blood flow through the main superior mesenteric vein, portal vein, and TIPS in all six patients. Five patients were treated primarily with thrombectomy through a TIPS with clinical improvement. The final patient was initially treated with surgical thrombectomy and bowel resection. TIPS and TT was performed two days after surgery due to re-thrombosis but the patient deteriorated and died of multi-organ failure. Procedure-related complications were transient hematuria (n = 3) and transient encephalopathy (n = 2). In-hospital time was <14 days in four of the five patients with primary TIPS and TT. No sign of re-thrombosis was noted during follow-up (mean = 18 months, range = 8-28 months). Conclusion Thrombectomy through a TIPS is feasible and can be effective in recanalization and symptom-relief in acute PMVT.

The role of endovascular therapy in acute mesenteric ischemia

Background

Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes.

Methods

An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016.

The following variables were extracted

number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel.

Results

Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively.

Conclusions

Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

Clinical efficacy of agitation thrombolysis via transjugular access for treatment of acute portal vein thrombosis

AIM: To evaluate the clinical efficacy of agitation thrombolysis via transjugular access for the treatment of acute portal vein thrombosis.

METHODS: Thirteen patients with acute portal vein thrombosis treated from October 2012 to March 2015 at our hospital were analyzed retrospectively. The portal vein was approached via the transjugular intrahepatic portosystemic route, followed by agitation thrombolysis to resolve the thrombi. The need for transjugular intrahepatic portosystemic shunt (TIPS) was based on the presence of portal hypertension, and then a catheter was indwelled into the thrombi. The success rate, thrombolytic therapeutic time and effect, and complications were observed. Computed tomography and Doppler ultrasound were performed to follow the patency of the portal vein and TIPS stent.

RESULTS: Agitation thrombolysis were successfully created in 12 patients. Of 8 patients who underwent TIPS, 1 underwent wide resection due to confirmed extensive intestinal necrosis on postoperative day 2; however, the patient died 9 d later. In the remaining 11 patients, the portal vein was recanalized > 90% as revealed by CT findings. There was a significant difference in lumen occupancy between pre- and post-operation (P < 0.01). The clinical symptoms such as abdominal pain, ascites, and gastrointestinal bleeding were all relieved or disappeared. The complications were mainly as follows: intraoperative subcapsular bleeding in one patient; death due to intestinal necrosis in one patient; hepatic encephalopathy at 3 mo in one patient with TIPS; and hematuria during thrombolysis in one patient. During follow-up, TIPS stent stenosis was noted in one patient at 7 mo and treated by balloon angioplasty.

CONCLUSION: Agitation thrombolysis via transjugular access for the treatment of acute portal vein thrombosis is safe and effective.

Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities

Mesenteric ischemia (MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI (CMI), with the first being subdivided into four categories. Therefore, acute MI (AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography (CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.