Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis

Abstract

Aim: To summarize our methods and experience with interventional treatment for symptomatic acute-subacute portal vein and superior mesenteric vein thrombosis (PV-SMV) thrombosis.

Methods: Forty-six patients (30 males, 16 females, aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were accurately diagnosed with Doppler ultrasound scans, computed tomography and magnetic resonance imaging. They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutaneous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization).

Results: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased significantly. Symptoms in these 45 patients were improved dramatically without severe operational complications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment. In 3 patients with interventional treatment, thrombi re-formed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful.

Conclusion: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acute-subacute PV-SMV thrombosis.

Figure 1

The figure shows a male, 43-year-old patient, 2 mo after splenectomy, with abdominal fullness for 6 d. He had thrombolysis through a transjugular intrahepatic portosystemic shunt (TIPS). A: Direct PV-SMV angiography showed extensive thrombosis in the PV and SMV. Contrast agent remained. No lateral branch angiogenesis (arrow); B: Mash and suck thrombi with intermittent injection of urokinase and heparin sodium. Repeated angiography 30 min after thrombolysis showed blood reperfusion in the PV-SMV and normal PV-SMV branches (arrow). Symptoms disappeared.

Figure 2

The figure shows a female, 22 year old patient who had abdominal pain for 17 d. A: A CT scan showed a high density of superior mesenteric vein thrombosis (characteristic of subacute thrombosis) (arrow); B: A Cobra catheter was inserted via the femoral artery into the superior mesenteric artery. Indirect angiography showed extensive thrombosis in the PV-SMV. Angiographic contrast agent remained (arrow); C: Indwelling catheters for 8 d. Angiography showed partial blood reperfusion in the PV-SMV. PV branches in the liver were intact (arrow). Symptoms were relieved.

Figure 3

A 24 year old male with abdominal pain for 8 d. A: The CT scan showed a low density SMV thrombosis (arrow); B: An enhanced CT scan still showed a low density of thrombosis (arrow). This fulfilled the symptoms and signs of acute thrombosis; C: An extended Cobra catheter was introduced into the superior mesenteric artery via the radial artery. The indirect angiography shows extensive thrombosis in the PV-SMV without lateral branch angiogenesis (arrow); D: Indwelling catheters for 10 d. The indirect angiography showed that the lateral vessels of the PV-SMV had significantly increased (arrow). Symptoms were relieved.