AJR 2000; 175:732-734
© American Roentgen Ray Society
Mesenteric and Portal Venous Thrombosis Treated by Transjugular Mechanical Thrombolysis
Daniel Y. Sze1,
Gerard J. O'Sullivan1,2,
Denise L. Johnson3 and
Michael D. Dake1
1
Division of Cardiovascular and Interventional Radiology, Stanford University
Medical Center, 300 Pasteur Dr., Ste. H3600, Stanford, CA 94305-5642.
2
Present address: Division of Vascular and Interventional Radiology,
Rush-Presbyterian-St. Luke's Medical Center, 1725 W. Harrison St., Ste. 400,
Chicago, IL 60612.
3
Department of General Surgery, Stanford University Medical Center, Stanford,
CA 94305-5655.
Received December 17, 1999;
accepted after revision February 2, 2000.
Address correspondence to D. Y. Sze.
Introduction
Acute mesenteric ischemia from venous thrombosis is rare, and even when
recognized, carries a grim prognosis. Improved imaging of the portal and
splanchnic venous systems has increased clinical awareness, yet treatment
remains problematic. Resection of infarcted bowel and aggressive
anticoagulation continue to be the standard of care although the mortality
rate in patients with extensive thrombosis remains as high as 76%
[1,
2]. Case reports have described
successful catheter-directed or systemic thrombolysis
[3,4,5,6,7],
but these techniques greatly magnify the already high risk of gastrointestinal
hemorrhage. We report a case of massive thrombosis of the portal, superior
mesenteric, and splenic veins. An attempt at intraarterial thrombolysis
resulted in substantial gastrointestinal hemorrhage. A new method of
treatment—transjugular portal access and mechanical
thrombolysis—proved to be a safe and effective alternative.
Subject and Methods
A 37-year-old man with a history of hepatitis B presented to a community
hospital with severe abdominal pain, vomiting, and anorexia. CT of the abdomen
identified thrombosis of the portal and superior mesenteric veins
(Fig. 1A). Angiography revealed
patent superior mesenteric and splenic arteries. Venous phase images confirmed
complete thrombosis of the superior mesenteric vein with partially occlusive
thrombus in the splenic and portal veins
(Fig. 1B). Intraarterial
thrombolysis via the superior mesenteric artery was commenced with urokinase
(Abbokinase; Abbott Laboratories, North Chicago, IL) at 100,000 U/hr and
systemic IV heparin. After 16 hr, the patient developed hematochezia and
coffee-grounds emesis, and the infusions were discontinued. The patient's
hematocrit fell from 48% to 25% over 2 days.
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —37-year-old man with spontaneous splanchnic and portal venous
thromboses. CT scan obtained at presentation shows thrombosed main trunk of
superior mesenteric vein (arrow). Note thick-walled ischemic jejunum
(arrowheads).
|
|
View larger version (154K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —37-year-old man with spontaneous splanchnic and portal venous
thromboses. Venous phase of splenic arteriogram shows thrombus in main portal
vein (arrow) and no inflow from superior mesenteric vein. Note
occlusion of anterior right portal vein (arrowhead).
|
|
On transfer to our institution, the patient was acidotic and
hemodynamically unstable. Imaging to assess the effect of urokinase was not
pursued. The patient underwent exploratory laparotomy, and 1.4 m of necrotic
jejunum was resected. A small amount of thrombus was successfully expressed
from the divided branches of the superior mesenteric vein. The liver did not
appear cirrhotic, and no portosystemic collateral vessels were identified. A
primary duodenoileal anastomosis was performed, and IV heparin was restarted.
Pathologic examination of the resected specimen confirmed transmural
infarction, vascular congestion, and extravasation of RBC.
Although improved, the patient remained acidotic and produced copious
ascites. Because of this evidence of persistent ischemia, mechanical
thrombolysis was proposed to improve splanchnic venous outflow. Because the
transhepatic route is associated with a greater risk of hemorrhage,
particularly in the presence of ascites and anticoagulation, a transjugular
approach was used [3]. With the
patient still under general anesthesia, a wedged carbon dioxide portogram was
obtained, opacifying only the left portal vein. A Rosch-Uchida set (Cook,
Bloomington, IN) was used to gain access to the left portal vein, and the
tract was dilated to 6 mm in diameter with an angioplasty balloon (Marshall;
Boston Scientific, Watertown, MA). A 10-French sheath (Cook) was passed
through the tract and into the portal vein. The portosystemic gradient could
not be measured because of the extensive thrombosis.
Over a 0.018-inch guidewire (Hi-Torque Flex-T; Mallinckrodt, St. Louis,
MO), an AngioJet device (AV-60 catheter; Possis Medical, Minneapolis, MN) was
used to aspirate as much thrombus as possible from the main portal vein. To
remove residual mural thrombus, a 12 x 60 mm Wallstent (Boston
Scientific) was then deployed in the tract and portal vein to provide a
conduit into which the residual thrombus was swept with an angioplasty
balloon.
Venography of the superior mesenteric and splenic veins confirmed
thrombosis in both veins, with poorly formed collateral drainage
(Fig. 1C). The AngioJet device
was reintroduced through a 6-French angled guide-catheter (Cordis/Johnson
& Johnson, Miami, FL), and thrombus in these large-caliber veins was
aspirated using a helical sweeping pattern. In addition, the device was used
in four tributaries of the superior mesenteric vein. A total of 1000 mL of
effluent was collected. Antegrade flow was reestablished in the splenic vein,
main trunk of the superior mesenteric vein, main portal vein, and left portal
vein (Fig. 1D). The
portosystemic gradient was 5 mm Hg after the thrombolysis, and the stent was
intentionally left undilated to encourage flow into the left portal vein.
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —37-year-old man with spontaneous splanchnic and portal venous
thromboses. Transjugular superior mesenteric venogram obtained after bowel
resection and manual expression of superior mesenteric vein branch thrombus
confirms complete occlusion and poor collateral drainage.
|
|
Results
The patient's hemodynamic status and pH stabilized quickly, and the planned
"second-look" laparotomy was canceled. The hospital stay was
prolonged because of adult respiratory distress syndrome, but abdominal
symptoms did not recur. CT performed 12 days after the procedure revealed
persistent thrombus in a branch of the superior mesenteric vein and in the
right portal vein, but no evidence of bowel ischemia
(Fig. 1E). Follow-up sonography
at 3, 19, and 70 days after the procedure confirmed patency of the treated
segments. The patient was maintained on IV heparin until oral warfarin could
be given 2 weeks later. Hematologic workup revealed protein S deficiency.
After discharge, the patient returned to normal activities, regained lost body
weight, and remained asymptomatic during 16 months of follow-up.
Discussion
Acute thrombosis of the splanchnic veins is a rare and often misdiagnosed
condition. Arterial ischemia is approximately 15 times more common than venous
ischemia [2], and symptoms such
as pain, nausea, vomiting, diarrhea, and distention are nonspecific. The
extent of thrombosis correlates with outcome, and in patients with complete
thrombosis of splenic, superior mesenteric, and portal veins, mortality
remains 76% despite therapy
[1]. Partial or chronic
thromboses are associated with higher survival rates.
Bowel infarction obligates surgical resection, but ischemia may respond to
percutaneous therapies. IV thrombolysis for portal thrombosis was first
reported in 1971, followed by reports of catheter-directed thrombolysis using
a variety of access routes [3].
Infusion catheters have been introduced into the superior mesenteric vein at
the time of bowel resection [4]
via a percutaneous transhepatic route
[5] or via a transjugular route
[6]. An alternative route of
treatment is via the superior mesenteric artery. Although a few successful
case reports have appeared [7],
lysis of any venous thrombus by infusion into the feeding artery is
unpredictable because of preferential flow into collaterals.
A major obstacle to the use of thrombolytic agents is the risk of
gastrointestinal hemorrhage. In a review of 53 patients with acute thrombosis,
28% presented with upper and 23% with lower gastrointestinal bleeding
[2]. Whether administered IV or
locally, thrombolytics could be catastrophic in these patients. In the case
presented here, the referring physicians were forced to discontinue
thrombolytic infusion because of life-threatening hemorrhage. In high-risk
patients, a mechanical method of recanalization is especially attractive.
Mechanical devices approved for dialysis access are potentially effective, but
only in vessels large enough to accommodate them. Pharmacologic thrombolysis
may still play a role in treatment of smaller vessels.
We have also used the AngioJet successfully in four patients with occluded
transjugular intrahepatic portosystemic shunts whose thromboses propagated
into portal and mesenteric veins, including two patients who were actively
bleeding [8]. One other
successful case of mechanical thrombolysis using the AngioJet, followed by
catheter-directed venous thrombolysis, was reported in a patient who then
required liver transplantation
[3]. Limited effect of another
mechanical thrombolysis device (amplatz Thrombectomy Device; Microvena, White
Bear Lake, MN) has also been reported
[8,
9]. In all these cases,
including the one currently described, mechanical thrombolysis was
incompletely successful, and the use of balloons and pharmacologic
thrombolytics provided additional benefit.
Long-term survival of patients with mesenteric venous thrombosis is
disappointing. In patients with acute mesenteric venous thrombosis, the 3-year
survival rate is only 36% [2].
In part, this reflects the high rate of recurrence in this population, ranging
from 14% to 71% [1]. Mesenteric
venous thrombosis may be the sentinel and only presentation of a
hypercoagulable state. Adequate surgical resection and anticoagulation clearly
increase disease-free survival, but most thrombotic disorders are not
currently reversible.
References
-
Gertsch P, Matthews J, Lerut J, Luder P, Blumgart LH. Acute
thrombosis of the splanchnic veins. Arch Surg
1993;128:341
-345[Abstract/Free Full Text]
-
Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg
Clin North Am 1997;77:327
-338[Medline]
-
McManimon S, Ryu RK, Durham JD. Mesenteric venous thrombosis.
Tech Vasc Intervent Radiol
1998;1:209
-215
-
Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Results of portal
thrombectomy and splanchnic thrombolysis for the surgical management of acute
mesentericoportal thrombosis. Br J Surg
1997;84:129
-132[Medline]
-
Yankes JR, Uglietta JP, Grant J, Braun SD. Percutaneous
transhepatic recanalization and thrombolysis of the superior mesenteric vein.
AJR
1988;151:289
-290[Free Full Text]
-
Rivitz SM, Geller SC, Hahn C, Waltman AC. Treatment of acute
mesenteric venous thrombosis with transjugular intramesenteric urokinase
infusion. J Vasc Interv Radiol
1995;6:219
-223[Medline]
-
Poplausky MR, Kaufman JA, Geller SC, Waltman AC. Mesenteric venous
thrombosis treated with urokinase via the superior mesenteric artery.
Gastroenterology
1996;110:1633
-1635[Medline]
-
Sze DY, Vestring T, Liddell RP, et al. Recurrent TIPS failure
associated with biliary fistulae: treatment with PTFE-covered stents.
Cardiovasc Intervent Radiol
1999;22:298
-304[Medline]
-
Uflacker R. Mechanical thrombectomy in acute and subacute
thrombosis with use of the Amplatz device: arterial and venous applications.
J Vasc Interv Radiol
1997;8:923
-932[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. W. James, C. Rabl, A. C. Westphalen, P. F. Fogarty, A. M. Posselt, and G. M. Campos
Portomesenteric Venous Thrombosis After Laparoscopic Surgery: A Systematic Literature Review
Arch Surg,
June 1, 2009;
144(6):
520 - 526.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. M. Warshauer, J. K. T. Lee, M. A. Mauro, and G. C. White II
Superior Mesenteric Vein Thrombosis with Radiologically Occult Cause: A Retrospective Study of 43 Cases
Am. J. Roentgenol.,
October 1, 2001;
177(4):
837 - 841.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Subject and Methods
