Mechanical thrombectomy-assisted thrombolysis for acute symptomatic portal and superior mesenteric venous thrombosis

Idiopathic superior mesenteric venous thrombosis requiring bowel resection: a report of four cases

BACKGROUND

Superior mesenteric venous thrombosis (SMVT) is mostly treated with anticoagulation therapy; however, SMVT can lead to irreversible bowel ischemia and require bowel resection in the acute or subacute phase.

CASE PRESENTATION

We report four cases of SMVT that required careful observation and bowel resection. Case 1: A 71-year-old man presented with abdominal pain, diarrhea, and vomiting that showed a completely occluded SMV with thrombus and small bowel ischemia. Case 2: A 47-year-old man presented with abdominal pain, peritoneal irritation symptoms, and a completely occluded SMV with thrombus, ischemia of the small bowel, and massive ascites. Case 3: A 68-year-old man presented with abdominal pain and vomiting for several days and showed a partially occluded SMV with a thrombus, bowel ischemia, and massive ascites. Case 4: A 68-year-old man presented with acute abdominal pain and a partially occluded SMV with thrombus and bowel edema without ischemic changes. Anticoagulation therapy was administered; however, 3 days later, abdominal pain and bowel ischemia worsened. Bowel resection was performed in all cases.

CONCLUSIONS

Most idiopathic SMVT cases can be treated with anticoagulation therapy or endovascular thrombectomy. However, in cases with peritoneal irritation signs, these treatments may be ineffective, and bowel resection may be required.

Efficacy of endovascular treatment for completely occlusive acute-subacute portal and mesenteric vein thrombosis with severe complications in patients without cirrhosis

PURPOSE

Completely occlusive acute-subacute portal and mesenteric vein thrombosis (PVMVT) with severe complications is fatal. Endovascular treatments (EVTs) of acute-subacute PVMVT are not standardized. Thrombectomy combined with continuous catheter-directed thrombolysis is considered an effective treatment. Here, we aimed to evaluate the outcome of EVTs of completely occlusive acute-subacute PVMVT with severe complications in patients without cirrhosis.

MATERIALS AND METHODS

Nineteen patients (nine men and 10 women; age, 60.1 ± 16.8 years) with completely occlusive acute-subacute PVMVT were retrospectively assessed. Acute-subacute PVMVT was defined as symptom onset within 40 days, with no cavernous transformation observed on contrast-enhanced computed tomography. The patients were treated with EVTs, a combination of thrombectomy (including aspiration thrombectomy, plain old balloon angioplasty, single injection of thrombolytic agents, and stent placement) and continuous catheter-directed thrombolysis. Kaplan-Meier analyses were performed to assess all-cause mortality, acute-subacute PVMVT-related mortality, and portal vein (PV) patency. The degree of recanalization and patency of PV, complications, factors related to acute-subacute PVMVT-related mortality, and factors related to patency of PV were also evaluated.

RESULTS

The all-cause and acute-subacute PVMVT-related mortality rates were 36.8% (7/19) and 31.6% (6/19), respectively. Seven (36.8%) and 11 (57.9%) patients achieved complete and partial recanalization, respectively. Among the 18 patients who achieved recanalization, follow-up images after 608.7 ± 889.5 days confirmed recanalization in 83.3% (15/18) patients, and 53.3% (8/15) of these patients achieved patency of PV. Seven patients (36.8%) developed complications, and two (10.5%) required interventional treatment for complications. Deterioration of liver function significantly worsened the prognosis (P = 0.046), while anticoagulation therapy significantly maintained portal patency (P = 0.03).

CONCLUSION

This endovascular method for acute-subacute PVMVT, which combines thrombectomy and continuous catheter-directed thrombolysis EVT approach was effective for thrombus resolution. However, further studies must define conditions that improve patient prognosis.

Technical Feasibility of Suction Thrombectomy Using a Large-Bore Aspiration System in the Portomesenteric Venous System

PURPOSE

To assess technical feasibility and safety of portal vein thrombectomy with suction thrombectomy using a large-bore thrombectomy device for portomesenteric venous thrombosis (PMVT).

MATERIALS AND METHODS

After receiving approval from institutional review board, patients undergoing PMVT treatment using a large-bore aspiration thrombectomy device (Inari FlowTriever or ClotTriever) between July 2019 and June 2021 were identified at 2 medical centers. Charts were reviewed for demographic information, imaging findings, and procedural details. PMVT was categorized using the Yerdel grading system. The thrombectomy procedure was performed via transjugular access through the existing or a new transjugular intrahepatic portosystemic shunt (TIPS) or transsplenic or transhepatic approach. Technical success was defined as successful clot reduction and restoration of portal venous flow at the conclusion of the procedure. Patient outcomes based on clinical presentation, adverse events, and thrombectomy-associated adverse events were recorded.

RESULTS

Twenty patients, with a median age of 58 years (range, 23-72 years), underwent large-bore aspiration thrombectomy, which was technically successful in 19 of 20 (95%) patients. In 9 of 20 (45%) patients, 9 of 20 (45%) patients, and 2 of 20 (10%) patients, the 20-F, 16-F, and 24-F devices were used, respectively. Fourteen patients had a pre-existing TIPS, and 6 patients had a TIPS created. In 5 of 20 (25%) patients, overnight lysis was performed in conjunction with Inari thrombectomy. Thrombus resolution with restoration of flow was achieved in 19 of 20 (95%) cases. There were no thrombectomy-associated adverse events. The mean follow-up time was 70 days (±113) at which time primary patency of the portal venous system was present in 16 of 20 (80%) patients.

CONCLUSIONS

Large-bore aspiration portal vein thrombectomy is feasible for PMVT.

Large-Bore Mechanical Thrombectomy for Subacute Portal Vein Thrombosis in Patient With Acute Bleeding

Portal vein thrombosis remains a clinical challenge with limited treatment options. A patient was admitted with decompensated nonalcoholic steatohepatitis and a history of recurrent esophageal and gastric variceal hemorrhages. Contrast-enhanced computed tomography revealed hepatic cirrhosis with concomitant and extensive thrombosis of the portal, splenic, and superior mesenteric veins. The patient was treated with transjugular intrahepatic portosystemic shunt and mechanical thrombectomy with the FlowTriever System (Inari Medical, Irvine, CA). Post-thrombectomy venography and follow-up computed tomography demonstrated patency and brisk flow. This case report shows that mechanical thrombectomy with the FlowTriever System is promising for treating extensive and subacute portal vein thrombosis.

Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective

OBJECTIVE

This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided.

BACKGROUND

Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation.

METHODS

Computerized literature search as well as discussion with experts in the field.

CONCLUSIONS

Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.

TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy

BACKGROUND AND AIMS

Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy.

APPROACH AND RESULTS

Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%.

CONCLUSIONS

TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.

Portal Vein Thrombosis: Diagnosis and Endovascular Management

BACKGROUND

 Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking.

METHODS

 The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted.

RESULTS

 Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization.

CONCLUSION

 Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus.

KEY POINTS

  · This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience..

CITATION FORMAT

· Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1642-0990.

Percutaneous Transhepatic AngioJet-assisted Mechanical Thrombectomy for the Treatment of Post-Transplant Portal Vein Thrombosis: A Case Report

Portal vein thrombosis (PVT) is an uncommon but serious complication after liver transplantation (LT). Treatments for PVT include thrombolysis, surgical treatment or percutaneous intervention. We here report a case of PVT after LT successfully treated by an AngioJet device using the percutaneous transhepatic approach. A 36-year-old male presented with substantial thrombosis of the portal vein/superior mesenteric vein 2 years after a liver transplant. He was managed with an Angiojet thrombectomy and subsequent stent placement. This approach may be a safe and effective treatment for PVT in post-orthotopic LT patients.

Early transcatheter thrombectomy and thrombolytic therapy in acute non-cirrhotic and non-malignant mesenteric vein thrombosis: Case report of two cases and literature review

•

Non-cirrhotic non malignant acute mescenteric thrombosis could lead to massive bowel ischaemia and is challenging to manage.

•

Conventional PV or SMV exploration is associated with significant blood lost, physiological disturbances and may need repeated procedures.

•

Catheter directed thrombolysis and thrombectomy provide minimal invasive option to restore patency of PV or SMV.

•

Literature review found high success rate and favourable outcome.

•

Catheter directed therapy should be the first line therapy.

Aim

To present two cases of acute non-cirrhotic and non-malignant mesenteric vein thrombosis (MVT) treated with early transcatheter thrombectomy and thrombolysis with tissue plasminogen activator (tPA) and to review the literature on transcatheter thrombectomy and thrombolytic therapy of such condition.

Methods

Two cases of acute MVT treated with transhepatic transcatheter thrombectomy and thrombolysis in addition to systemic anticoagulation upon diagnosis are presented. In addition, a Pubmed literature search was undertaken using keywords acute mesenteric vein thrombosis, thrombolysis and thrombectomy. The inclusion criteria were studies examining the impacts of transcatheter thrombolysis and thrombectomy in the management of acute MVT.

Results

Early transcatheter thrombectomy and thrombolysis achieves technical success in both patients and result in nearly complete recanalization of the venous system, with no recurrent thrombosis to date in follow up. Both patients do not require extensive bowel resection despite extensive thrombus on presentation. However, both patients develop intra-abdominal bleeding requiring blood transfusion and embolization of the transcatheter tract.

Conclusion

Catheter-directed first approach provides a minimal invasive approach for management of non-malignant and non-cirrhotic acute mesenteric thrombosis. It offers the benefits of rapid venous recanalization and avoid massing bowel resection despite extensive thrombosis. Subsequent progression into chronic MVT was also reduced. However, the procedure could lead to bleeding from puncture site and hence embolization of the catheter tract is advised during catheter removal.

Acute Distress Respiratory Syndrome and Cardiac Shock after AngioJet Thrombectomy for Acute Occlusion of an Aortic Endograft

Partial thrombosis or total occlusion of aortic or limb graft are possible complications after endovascular aneurysm repair. Different strategies for therapeutic management are available; these include open surgical techniques or endovascular treatments. The choice of the treatment depends on the patient's clinical conditions and on the timing of the thrombosis. Bypass still remains the first choice in case of chronic occlusion but in the last 10 years, the use of percutaneous mechanical/rheolytic thrombectomy systems is increasing. These devices can be used in case of acute or subacute onset of native arterial and venous thrombosis or embolism and in case of graft occlusion. AngioJet is a percutaneous rheolytic mechanical thrombectomy system. Through a pressurized saline solution jet, a low-pressure zone is made up and the thrombus is fragmented and aspirated by the device. Different transient adverse effects caused by lysis of the thrombus are described such as hemoglobinuria but in some cases the release of high doses of the thrombus degradation products such as heme and adenosine diphosphate can lead to fatal consequences for the patient. We reported a case of an acute onset of acute distress respiratory syndrome, pulmonary edema, cardiac shock, and renal failure following AngioJet thrombectomy in an 81-year-old man with an acute occlusion of an aortic endograft.

Percutaneous Pharmaco-Mechanical Thrombectomy of Acute Symptomatic Superior Mesenteric Vein Thrombosis

Purpose

To evaluate the safety and the efficacy of percutaneous pharmaco-mechanical thrombectomy (PPMT) of acute superior mesenteric vein (SMV) thrombosis.

Methods

A database of patients treated between 2011 and 2018 with acute venous mesenteric ischemia (VMI) was reviewed. VMI was diagnosed in the presence of SMV thrombosis and CT evidence of jejunal thickening. All patients presented with mild to moderate peritonism, which allowed surgery to be postponed. Initial treatment consisted of heparinization. PPMT was indicated in case of worsening abdominal pain despite anticoagulation and was performed via a transjugular or transhepatic approach, using a rotational aspiration thrombectomy catheter, followed by transcatheter thrombolysis. Clinical success was defined as symptoms resolution. Technical success was defined as patency of > 50% of SMV at venography and resolution of jejunal thickening. Patients were discharged on lifelong oral anticoagulation (INR 2.5–3.5). Follow-ups were performed using CT and color Doppler ultrasound.

Results

Population consisted of eight males, aged 37–81 (mean 56.5 years). Causes for thrombosis were investigated. Urokinase infusion time ranged from 48 to 72 h (3,840,000–5,760,000 IU). Clinical and technical success was obtained in all cases. One patient experienced bleeding from the superior epigastric artery and was treated with embolization. One patient died of multi-organ failure after 35 days, despite resolution of SMV thrombosis. In no case was surgery required after PPMT; mean hospitalization was 14.1 days (9–24). Mean follow-up of remaining seven patients was 37.7 months (12–84 months).

Conclusion

PPMT of acute SMV thrombosis seems safe and effective, with an 87.5% long-term survival rate and a 12.5% major complication rate.

Agitation thrombolysis combined with catheter-directed thrombolysis for the treatment of non-cirrhotic acute portal vein thrombosis

AIM

To evaluate the safety and efficacy of agitation thrombolysis (AT) combined with catheter-directed thrombolysis (CDT) for the treatment of non-cirrhotic acute portal vein thrombosis (PVT).

METHODS

Nine patients with non-cirrhotic acute PVT who underwent AT combined with CDT were analyzed retrospectively. Portography was carried out via the transjugular intrahepatic portosystemic (commonly known as TIP) or percutaneous transhepatic (commonly known as PT) route, followed by AT combined with CDT. Complications of the procedure, and the changes in clinical symptoms, hemodynamics of the portal vein and liver function were recorded. Follow-up was scheduled at 1, 3 and 6 mo after treatment, and every 6 mo thereafter, or when the patients developed clinical symptoms related to PVT. Color Doppler ultrasound and contrast-enhanced computed tomography/magnetic resonance imaging were performed during the follow-up period to determine the condition of the portal vein.

RESULTS

AT combined with CDT was successfully performed. The portal vein was reached via the TIP route in 6 patients, and via the PT route in 3 patients. All clinical symptoms were relieved or disappeared, with the exception of 1 patient who died of intestinal necrosis 9 d after treatment. Significant differences in the changes in portal vein hemodynamics were observed, including the maximum lumen occupancy of PVT, portal vein pressure and flow velocity between pre- and post-treatment (P < 0.05). During the follow-up period, recurrence was observed in 1 patient at 19 mo after the procedure, and the portal vein was patent in the remaining patients.

CONCLUSION

AT combined with CDT is a safe and effective method for the treatment of non-cirrhotic acute PVT.

Acute Portal Vein Thrombosis: Current Trends in Medical and Endovascular Management

Acute portal vein thrombosis (PVT) is a relatively rare diagnosis with a nonspecific clinical presentation. Imaging plays an important role in establishing the diagnosis as well as the etiology and complications of acute PVT. Prompt diagnosis is essential to prevent catastrophic short-term complications including bowel infarction, sepsis, and possible death; missed diagnosis can also result in the long-term sequelae of portal hypertension. Differentiation of acute from chronic PVT is crucial as management strategies differ. Currently, guidelines for treating acute PVT recommend immediate initiation of systemic anticoagulation. Catheter-directed therapy may be used in combination with systemic anticoagulation in the setting of bowel ischemia or as an adjunct in patients with a contraindication to systemic anticoagulation. In this review article, we discuss the diagnosis and clinical features of acute PVT, focusing on current medical and endovascular management strategies including mechanical thrombectomy and fibrinolytic therapy.

Coagulation factor V gene 1691G>A polymorphism as an indicator for risk and prognosis of lower extremity deep venous thrombosis in Chinese Han population

The purpose of this study was to explore the negative influence coagulation factor V (FV) 1691G>A polymorphism had on the risk and prognosis of lower extremity deep venous thrombosis (LDVT) in Chinese Han population.A total of 348 patients with LDVT (LDVT group) and 398 healthy individuals (control group) were selected to further this study. A polymerase chain reaction-restriction fragment length polymorphism method was used to analyze the FV gene 1691G>A polymorphism; coagulation and anticoagulation indexes of patients with LDVT were detected as a result. A 3-year follow-up and logistic regression analysis were conducted to determine the corresponding correlations between FV gene and LDVT.In comparison with the control group, the frequencies of GA and AA genotypes and A allele of 1691G>A polymorphism significantly increased in the LDVT group. Also, in comparison with patients with LDVT carrying GG genotype of FV gene 1691G>A polymorphism, the following activities reduced significantly: prothrombin time, activated partial thromboplastin time, fibrinogen, protein C, and protein S, while activated protein C resistance and lupus anticoagulant positive rate increased in patients carrying A allele (GA + AA). Logistic regression analysis indicated that FV gene 1691G>A polymorphism, total cholesterol, low-density lipoprotein cholesterol, and LDVT family histories were all closely related with LDVT and were subsequent independent risk factors for LDVT. Moreover, patients with LDVT carrying A allele (GA + AA) had both higher patency and recurrence rates than those carrying GG genotype.FV gene 1691G>A polymorphism may be associated with both the risk and prognosis of LDVT, potentially being a useful index for monitoring LDVT prognosis and risk.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Are Effective Predictors of Prognosis in Patients with Acute Mesenteric Arterial Embolism and Thrombosis

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been shown to be valuable prognostic markers for a variety of pathological conditions including solid tumors, sepsis, and others. However, the prognostic values of the NLR and PLR in patients with acute mesenteric arterial embolism (AMAE) and acute mesenteric arterial thrombosis (AMAT) have not been elucidated. The aim of this study was to determine the predictive value of the NLR and PLR for poor prognosis in patients with AMAE and AMAT.

METHODS

A total of 137 patients with AMAE (n = 77) or AMAT (n = 60) were divided into a poor outcome group (cases of intestinal necrosis or death) and a better outcome group (cases without intestinal necrosis who survived successfully), according to prognosis. Neutrophil, platelet, and lymphocyte counts were recorded before pharmacotherapy or surgery. The NLR and PLR were calculated, and logistic regression analysis was performed to test their prognostic values.

RESULTS

The cutoff values for NLR and PLR were 11.05 and 156.26, respectively. The PLR was linearly associated with the NLR (R = 0.769, P < 0.001). NLR (odds ratio [OR] = 6.835, 95% confidence interval [CI] = 2.282-20.469, P = 0.001), PLR (OR = 4.871, 95% CI = 1.627-14.587, P = 0.005), and coronary heart disease (OR = 3.388, 95% CI = 1.156-9.929, P = 0.026) were found to be independent prognostic factors for the patients.

CONCLUSIONS

NLR ≥ 11.05, PLR ≥ 156.26, and coronary heart disease were shown to be risk factors for poor prognosis in patients with AMAE and AMAT. According to these factors, patients can be divided into 3 prognostic groups: good, NLR < 11.05 with PLR < 156.26; moderate, NLR < 11.05 with PLR ≥ 156.26 or NLR ≥ 11.05 with PLR < 156.26; and poor, NLR ≥ 11.05 with PLR ≥ 156.26.

Pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition grafts for cancer: a meta-analysis

The use of interposition grafts for portal-superior mesenteric vein (PV-SMV) reconstruction during pancreatoduodenectomy (PD) with venous resection (VR) for localized periampullary tumors is a controversial topic. The present meta-analysis aimed to evaluate the perioperative and long-term outcomes in patients who received interposition grafts for PV-SMV reconstruction after PD with VR. The correlative databases were systematically searched to identify relevant trials comparing vein grafts versus no vein grafts during PD with VR. 14 studies including 257 patients with vein grafts and 570 patients without vein grafts were extracted. The meta-analysis indicated no difference in perioperative morbidity, mortality, or thrombosis between the two groups, but the vein graft group was associated with a significantly increased venous thrombosis rate (≥ 6 months) (odds ratio [OR] = 2.75; 95% confidence interval [CI], 1.32–5.73; P = .007). The autologous vein group subgroup analysis also revealed a significantly increased vein thrombosis rate (OR = 3.13; 95% CI, 1.45–6.76; P = .004) between the two groups. Meanwhile, the prosthetic vein group subgroup analysis indicated no difference. Additionally, the oncological value of vein grafts during PD for pancreatic cancer survival was analyzed and revealed no difference in 1-year, 3-year, or 5-year survival between the two groups. Using interposition grafts for PV-SMV reconstruction is safe and effective, and has perioperative outcomes and long-term survival rates compared to those with no vein grafts during PD with VR. However, the lower long-term vein patency rate in patients with vein grafts indicate that interposition grafts may be more likely to lose function.

A systematic review of portomesenteric vein thrombosis after sleeve gastrectomy

BACKGROUND

Portomesenteric vein thrombosis (PMVT) is considered an uncommon complication in general surgery; nevertheless, with the growing popularity of sleeve gastrectomy (SG) as a bariatric procedure we have seen an increase in the occurrence of this complication.

OBJECTIVES

To elucidate the question if it is a procedure-related complication and explore the modalities of prevention and treatment of this complication, a systematic review of available literature regarding PMVT events after SG was conducted.

METHODS

Our systematic review yielded 28 studies enclosing 89 patients. Perioperative data was collected from each study and analyzed.

RESULTS

The incidence of PMVT after SG ranged from .37% to 1%, 65% of the patients were female, and the mean body mass index was 41.63 kg/m². Perioperative co-morbidities including hypertension, diabetes, and dyslipidemia were recorded in 39.7%, 41.63%, and 38.23% of cases respectively. Tachycardia and fever were reported only in 23.9% and 20.89%, respectively, and hereditary thrombophilia studies were positive in 30.43% of cases. The rate of acute major complications after PMVT was 14.6% (13 cases), and mortality was reported in 3 cases (average 3.37%).

CONCLUSION

PMVT seems to be an uncommon multifactorial disease, with unpredictable symptoms and varieties of the treatments options, but additional studies are required to further define optimal management and prevention algorithms.

Combination Therapy of Interventional Radiology and Surgery for Infarction of the Small Intestine Caused by Portal Vein and Mesenteric Vein Thrombosis: A Patient Report

We report the case of a man in his 70s who suffered from intestinal infarction caused by acute portal vein and mesenteric vein thrombosis (PVMVT). Combination therapy with percutaneous transcatheter thrombectomy and surgical bowel resection was successfully performed, and a satisfactory outcome was achieved. Intestinal infarction caused by PVMVT can be fatal and has a high mortality rate even if surgical resection is performed. The combination therapy of interventional radiology and surgery might be a safe and effective method for patients with this life-threatening condition.

[Recent thrombosis of splanchnic veins : Two case reports of catheter-assisted local thrombolysis and thrombus aspiration]

Recent non-cirrhotic and non-malignant splanchnic vein thrombosis is now defined as extrahepatic portal vein thrombosis with or without involvement of the mesenteric vein according to the Baveno VI consensus from 2015. An early diagnosis is often challenging due to unspecific symptoms with abdominal pain or diarrhea but extremely important because of the potential acute and chronic complications, such as mesenteric ischemia and portal hypertension; therefore, rapid treatment is crucial. We present two cases of severe splanchnic vein thrombosis, which were treated with catheter-directed local thrombolysis and thrombus aspiration. These minimally invasive catheter-directed techniques have recently been successfully used in selected patients. A review of the literature is provided in this article. In summary, the management of splanchnic vein thrombosis must be individually planned for each patient and should be performed at experienced centers, which can provide all therapeutic options. In selected cases with the correct indications transjugular transhepatic catheter-directed local thrombolysis is a safe option with a good outcome.

Rescue from liver transplantation: TIPSS and thrombectomy successfully treat a case of acute Budd-Chiari syndrome complicated by portal vein thrombosis

We report the rare case of a female who presented with fulminant liver failure secondary to acute Budd-Chiari syndrome and complete portal vein thrombosis. She met the criterion for liver transplant and was transferred to our care for assessment and further management. Transplant was deemed a too-high risk and so rescue therapy was undertaken using mechanical thrombectomy and transjugular intrahepatic portosystemic shunt insertion to decompress the portal system. The patient made a full recovery. This is a rare case report of a patient meeting liver transplant criteria secondary to acute Budd-Chiari syndrome and complete portal vein thrombosis, which was managed successfully entirely by radiological means; this technique could be used to avoid or act as a bridge to liver transplantation in the future.

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.

Clinical Management of Acute Portal/Mesenteric Vein Thrombosis

Background

Acute thrombosis of the portal vein (PV) and/or the mesenteric vein (MV) is a rare but potentially life-threatening disease. A multitude of risk factors for acute portal vein thrombosis (PVT)/mesenteric vein thrombosis (MVT) have been identified, including liver cirrhosis, malignancy, coagulation disorders, intra-abdominal infection/inflammation, and postoperative condition.

Methods

This article analyses the treatment options for acute PVT/MVT.

Results

Initially, the clinical management should identify patients with an intra-abdominal focus requiring immediate surgical intervention (e.g. bowel ischaemia). Subsequently, emphasis is placed on the recanalization of the PV/MV or at least the prevention of thrombus extension to avoid long-term complications of portal hypertension. Several therapeutic options are currently available, including anticoagulation therapy, local/systemic thrombolysis, interventional or surgical thrombectomy, and a combination of these procedures. Due to the lack of prospective randomized studies, a comparison between these therapeutic approaches regarding the efficacy of PV/MV recanalization is difficult, if not impossible.

Conclusion

In patients with acute PVT/MVT, an individualized treatment based on the clinical presentation, the underlying disease, the extent of the thrombosis, and the patients' comorbidities is mandatory. Therefore, these patients should be considered for an interdisciplinary therapy in specialized centres with the option to utilise all therapeutic approaches currently available.

Small bowel stricture as a late sequela of superior mesenteric vein thrombosis

•

64-year-old man admitted with abdominal pain and rectal bleeding found to have thrombosis of portal and superior mesenteric veins on abdominal CT.

•

Managed conservatively but returned seven months later with obstruction requiring segmental small bowel resection.

•

Case demonstrates that mesenteric vein thrombosis can be reversed by effective anticoagulation.

•

Patients escaping early bowel resection due to bowel infarction may still require resection later due to stricture.

Introduction

The increasing frequency of use of CT in patients with acute abdomen is likely to improve the diagnosis of rarely occurring conditions/causes such as superior mesenteric vein thrombosis (MVT). Despite its severe consequences, MVT often presents with nonspecific clinical features.

Presentation of case

AD, a 64-year-old man was an emergency admission with vague abdominal discomfort of two weeks duration, acute upper abdominal pain, loose stools, fresh rectal bleeding and vomiting. A contrast enhanced abdominal CT showed thrombosis of the proximal portal vein and the entire length of the superior mesenteric vein (SMV) with small bowel ischaemia extending from the terminal ileum to the mid jejunal loops. Tests for paroxysmal nocturnal haemoglobinuria and Janus kinase 2 mutation yielded negative results. AD was readmitted seven months later with small bowel obstruction requiring segmental small bowel resection with end-to-end anastomosis. Abdominal CT had shown complete resolution of MVT but a small bowel stricture.

Discussion

Thrombosis limited to mesenteric veins results in earlier and more frequent development of infarction compared to portal combined with mesenteric venous thrombosis. Most patients may be successfully treated with anti-coagulation therapy alone. However, surgery may be required to deal with intestinal infarction or late sequela of MVT.

Conclusion

This case demonstrates that MVT can be reversed by effective anticoagulation. However, the price paid for a mild to moderate effect on the bowel may be significant stricture later on. Patients escaping early bowel resection due to massive MVT leading to bowel infarction may still require resection later due to stricture.