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

Abstract

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.

Keywords: Cirrhosis; intervention; narrative review; portal vein thrombosis (PVT).

Figure 1

Case 1: M, 62, with NASH cirrhosis and HCC in the left lobe of the liver status post left lobe of the liver resection. Patient developed PVT. (A and B) demonstrating main portal vein thrombosis extending in to the SMV (both marked by arrow). (C) is a portal venogram through transhepatic access in frontal projection. It shows complete occlusion of the main portal vein with partially occlusive thrombus extending in to the confluence and SMV (marked by arrows). (D) was obtained after lacing the portal venous thrombus with alteplase and balloon venoplasty. It reveals diminutive recanalized portal vein with poor intrahepatic flow. (E) obtained after Angiojet (8 French catheter) mechanical thrombectomy. It shows marked improvement in the intra and extrahepatic portal vein flow. (F) is a color Doppler ultrasound obtained after six months confirming patency of the portal vein. NASH, nonalcoholic steatohepatitis; HCC, hepatocellular carcinoma; SMV, superior mesenteric vein; PVT, portal venous thrombosis.

Figure 2

Case 2: M, 69, with ETOH cirrhosis and bleeding gastric varices requiring Sengstaken Blakemore tube in the stomach and esophagus. (A and B) are coronal CT scans of upper abdomen revealing partially occlusive thrombus in the portal vein and large gastric varices (marked by arrows). (C) is a splenoportal venogram obtained by catheter through the trans splenic route. It reveals partially occlusive thrombus in the main portal vein and poorly visualized intrahepatic portal venous branches, specifically in the right lobe (marked by arrow) due to chronic partial occlusion. (D) reveals presence of large gastric varix (marked by arrow) with left and posterior gastric afferent veins. (E) is a portal venogram after balloon venoplasty and mechanical thrombectomy with Angiojet thrombectomy device and TIPS placement. It reveals presence of thrombus in the main portal vein (marked by arrow) proximal to the TIPS. (F) shows FlowTriever2 catheter and disk (marked by white arrow) and a 20 French FlowTriever 20 aspiration catheter (marked by black arrow). (G) is splenoportal venogram status post mechanical thrombectomy, revealing complete resolution of the thrombus in the main portal vein and persistence of gastric varices after removal of the Sengstaken Blakemore tube. (H) is splenoportal venogram obtained after PARTO procedure with occlusion of the descending inferior phrenic vein with amplatz vascular plug (marked by black arrow) and embolization of the afferent posterior gastric veins with amplatz vascular plugs (marked by white arrows) after embolization of the varix with gelfoam slurry. Venogram reveals complete non visualization of the gastric varices and patent main portal vein. TIPS, transjugular intrahepatic portosystemic shunt; ETOH, ethanol; PARTO, plug-assisted retrograde transvenous obliteration.

Figure 3

Proposed treatment algorithm for portal vein thrombosis in cirrhosis. MT, mechanical thrombectomy; CDT, catheter-directed thrombolysis; TIPS, transjugular intrahepatic portosystemic shunt.