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AJR 2000; 175:732-734
© American Roentgen Ray Society

Technical Innovation

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
Top
 Introduction
Subject and Methods
 Results
 Discussion
 References
 
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
Top
 Introduction
 Subject and Methods
Results
 Discussion
 References
 
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.



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  		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).

 


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  		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.



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  		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.

 


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  		Fig. 1D. —37-year-old man with spontaneous splanchnic and portal venous thromboses. Splenic venogram obtained after thrombolysis shows flow into left portal vein.

 


Results
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 Introduction
 Subject and Methods
 Results
Discussion
 References
 
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.



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  		Fig. 1E. —37-year-old man with spontaneous splanchnic and portal venous thromboses. CT scan obtained 12 days after thrombolysis shows patent superior mesenteric vein (arrow).

 


Discussion
Top
 Introduction
 Subject and Methods
 Results
 Discussion
References
 
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
Top
 Introduction
 Subject and Methods
 Results
 Discussion
 References
 

  1. Gertsch P, Matthews J, Lerut J, Luder P, Blumgart LH. Acute thrombosis of the splanchnic veins. Arch Surg 1993;128:341 -345[Abstract]
  2. Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg Clin North Am 1997;77:327 -338[Medline]
  3. McManimon S, Ryu RK, Durham JD. Mesenteric venous thrombosis. Tech Vasc Intervent Radiol 1998;1:209 -215
  4. 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]
  5. 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]
  6. 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]
  7. 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]
  8. 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]
  9. 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]

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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
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[Abstract] [Full Text] [PDF]

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