Acute extensive portal and mesenteric venous thrombosis after splenectomy: treated by interventional thrombolysis with transjugular approach

Abstract

Aim: To present a series of cases with symptomatic acute extensive portal vein (PV) and superior mesenteric vein (SMV) thrombosis after splenectomy treated by transjugular intrahepatic approach catheter-directed thrombolysis.

Methods: A total of 6 patients with acute extensive PV-SMV thrombosis after splenectomy were treated by transjugular approach catheter-directed thrombolysis. The mean age of the patients was 41.2 years. After access to the portal system via the transjugular approach, pigtail catheter fragmentation of clots, local urokinase injection, and manual aspiration thrombectomy were used for the initial treatment of PV-SMV thrombosis, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for three to six days. Adequate anticoagulation was given during treatment, throughout hospitalization, and after discharge.

Results: Technical success was achieved in all 6 patients. Clinical improvement was seen in these patients within 12-24 h of the procedure. No complications were observed. The 6 patients were discharged 6-14 d (8 +/- 2.5 d) after admission. The mean duration of follow-up after hospital discharge was 40 +/- 16.5 mo. Ultrasound and contrast-enhanced computed tomography confirmed patency of the PV and SMV, and no recurrent episodes of PV-SMV thrombosis developed during the follow-up period.

Conclusion: Catheter-directed thrombolysis via transjugular intrahepatic access is a safe and effective therapy for the management of patients with symptomatic acute extensive PV-SMV thrombosis.

Figure 1

Case 1: A 40-year-old man with low-grade fever, abdominal pain, distension, and nausea for 12 d. He had undergone splenectomy 4 wk previously. A: Selected axial image from before open splenectomy contrast-enhanced CT shows splenomegaly (arrows) and patent portal vein (curved arrow); B: Selected axial image from admission contrast-enhanced CT, on postoperative day 28, shows massive thrombus within the PV (arrow); C: Pre-treatment direct venography via transjugular approach access to the portal vein shows massive thrombosis of the PV extending into the SMV (arrows). Note the stump of the splenic vein (curved arrow); D: Follow-up direct portal venography via the infusion catheter, obtained 5 d after the catheter infusion of thrombolytics, shows patency of the main PV-SMV (arrows); E: CT image at the same level as in Figure 1B obtained 5 d after the interventional procedure, before the infusion catheter removal, shows the wide patent main PV (arrow). Note the infusion catheter within the PV (curved arrow).

Figure 2

Case 2: A 43-year-old man with epigastric pain, diarrhea, fever, and vomiting for 1 wk. He had undergone splenectomy 3 wk previously. A: Selected axial image from admission contrast-enhanced CT, on postoperative day 21, shows thrombus (arrow) within the SMV; B: Pre-treatment direct venography via transjugular approach access to the portal vein shows extensive thrombosis of the SMV extending into the main PV and intrahepatic branches (arrows); C: Follow-up direct portal venography via the infusion catheter (curved arrow), obtained 6 d after the catheter infusion of thrombolytics, shows patent PV and SMV with only minimal residual wall thrombus (arrows); D: CT image at the same level as in Figure 2A obtained 6 d after the catheter infusion of thrombolytics, before the infusion catheter removal, shows the wide patent SMV (arrow) with only minimal residual wall thrombus. Note the infusion catheter within the SMV (curved arrow).

Figure 3

Case 3: A 38-year-old woman with abdominal pain, nausea, distension, and vomiting for 3 d. She had undergone splenectomy 2 wk previously. A: Selected axial image from before open splenectomy contrast-enhanced CT shows splenomegaly (arrows) and patent portal vein (curved arrow); B: Selected axial image from admission contrast-enhanced CT, on postoperative day 14, shows extensive thrombus within the PV (arrows); C: Pre-treatment direct venography via transjugular approach access to the portal vein showing extensive PV (arrows) and SMV (curved arrows) thrombosis, without collateral drainage; D: Follow-up direct portal venography via the infusion catheter (curved arrow), obtained 5 d after the catheter infusion of thrombolytics, shows patent PV and SMV with residual thrombosis within the intrahepatic portal venous branches (arrow).

Figure 4

Case 4: A 42-year-old man with abdominal pain, diarrhea, and nausea for 2 wk. He had undergone splenectomy 4 wk previously. A: Selected axial image from admission contrast-enhanced CT demonstrates massive thrombus within the proximal of SMV (arrow) and the stump of the splenic vein (curved arrow); B: Pre-treatment direct venography via transjugular approach access to the portal vein showing extensive PV-SMV thrombosis (arrows), without collateral drainage; C: Immediate follow-up direct portal venography after catheter fragmentation and aspiration of the PV-SMV thrombosis, shows 75% reduction of thrombosis in the SMV and PV (arrow). The catheter infusion of thrombolytics was continued for 4 d and further improvement was confirmed by CT follow-up; D: Contrast-enhanced CT image at the same level as in Figure 4A obtained 5 d after completion of the interventional procedure shows a wide patent SMV (arrows).