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Hu L, Adegboye J, Chang AT, Hanna M, Jaremko K. Uncomplicated epidural removal in a patient on a therapeutic heparin infusion: a case report. Reg Anesth Pain Med 2025; 50:375-378. [PMID: 38821537 DOI: 10.1136/rapm-2024-105577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Unanticipated postoperative thrombotic complications can occur in complex patients who receive preoperative epidurals. Therefore, it is imperative that we consider the risks and benefits of epidural management in the setting of therapeutic anticoagulation. We present a case of epidural catheter removal on a heparin infusion, due to the extreme risk of holding anticoagulation for any duration. CASE REPORT A woman with hilar cholangiocarcinoma presented after uncomplicated hepatectomy, bile duct resection and hepaticojejunostomy, with a thoracic epidural for analgesia. On postoperative day 1, she developed a total portal vein thrombosis, requiring emergent open thrombectomy, transhepatic stenting and high-dose heparin infusion while the epidural was indwelling. The patient was deemed to have a profound risk of re-thrombosis if heparin were paused. Therefore, a multidisciplinary discussion between hepatobiliary surgery, critical care, neurosurgery, haematology, acute pain service and the patient's family ensued regarding epidural management. Options included catheter-directed thrombolytics to her stent while holding systemic anticoagulation, sterilely leaving the epidural catheter in place indefinitely, injecting prothrombotic agent into the epidural prior to removal, or removing the catheter without holding anticoagulation. Due to the risk of re-thrombosis in the portal vein and liver infarction, the heparin infusion was decreased to achieve the lowest therapeutic anti-Xa level, and the epidural was removed. The patient was continuously monitored in the intensive care unit without any adverse events. CONCLUSION A multidisciplinary discussion is paramount to weigh the risk of epidural haematoma if a catheter is removed on therapeutic anticoagulation against catastrophic thrombosis if anticoagulation is paused.
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Affiliation(s)
- Lizbeth Hu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Janet Adegboye
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Angela Tung Chang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Ueda T, Saito H, Shirai S, Sugihara F, Fujitsuna R, Matsumoto T, Hayashi H, Kumita SI. Endovascular Treatment for Acute Portal Vein Thrombosis. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2025; 10:e20230027. [PMID: 40384906 PMCID: PMC12078051 DOI: 10.22575/interventionalradiology.2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/27/2023] [Indexed: 05/20/2025]
Abstract
Acute portal vein thrombosis is characterized by nonspecific abdominal pain, causing severe morbidity and mortality. Prompt diagnosis is crucial to avoid short-term complications such as intestinal infarction, sepsis, and death. The therapeutic goal is to prevent thrombus extension into the mesenteric veins and intestinal ischemia complications. Systemic anticoagulation is the standard treatment. However, endovascular treatments such as thrombolysis, thrombectomy, balloon angioplasty, stent placement, and transjugular intrahepatic portosystemic shunt placement have been performed in patients who are refractory to anticoagulation therapy or at a high risk of intestinal ischemia. This review discusses the clinical and diagnostic considerations in acute portal vein thrombosis, focusing on current endovascular treatments that are effective and safe. However, prospective data are required to compare endovascular treatment techniques and assess their outcomes.
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Affiliation(s)
- Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Sayaka Shirai
- Department of Radiology, Nippon Medical School Hospital, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Japan
| | | | - Taiga Matsumoto
- Department of Radiology, Nippon Medical School Hospital, Japan
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Mansour N, Heinrich K, Zhang D, Winkelmann M, Ingenerf M, Gold L, Klambauer K, Rudelius M, Klauschen F, von Bergwelt-Baildon M, Ricke J, Heinemann V, Westphalen CB, Kunz WG. Patient eligibility for trials with imaging response assessment at the time of molecular tumor board presentation. Cancer Imaging 2024; 24:70. [PMID: 38849902 PMCID: PMC11157753 DOI: 10.1186/s40644-024-00708-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/11/2024] [Indexed: 06/09/2024] Open
Abstract
PURPOSE To assess the eligibility of patients with advanced or recurrent solid malignancies presented to a molecular tumor board (MTB) at a large precision oncology center for inclusion in trials with the endpoints objective response rate (ORR) or duration of response (DOR) based on Response Evaluation Criteria in Solid Tumors (RECIST version 1.1). METHODS Prospective patients with available imaging at the time of presentation in the MTB were included. Imaging data was reviewed for objectifiable measurable disease (MD) according to RECIST v1.1. Additionally, we evaluated the patients with MD for representativeness of the identified measurable lesion(s) in relation to the overall tumor burden. RESULTS 262 patients with different solid malignancies were included. 177 patients (68%) had MD and 85 (32%) had non-measurable disease (NMD) at the time point of MTB presentation in accordance with RECIST v1.1. MD was not representative of the overall tumor burden in eleven patients (6%). The main reasons for NMD were lesions with longest diameter shorter than 10 mm (22%) and non-measurable peritoneal carcinomatosis (18%). Colorectal cancer and malignant melanoma displayed the highest rates of MD (> 75%). In contrast, gastric cancer, head and neck malignancies, and ovarian carcinoma had the lowest rates of MD (< 55%). In case of MD, the measurable lesions were representative of the overall tumor burden in the vast majority of cases (94%). CONCLUSION Approximately one third of cancer patients with advanced solid malignancies are not eligible for treatment response assessment in trials with endpoints ORR or DOR at the time of MTB presentation. The rate of patients eligible for trials with imaging endpoints differs significantly based on the underlying malignancy and should be taken under consideration during the planning of new precision oncology trials.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Danmei Zhang
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lukas Gold
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantin Klambauer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Martina Rudelius
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Frederick Klauschen
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Volker Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany.
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Valla DC. Hepatic vein thrombosis and PVT: A personal view on the contemporary development of ideas. Clin Liver Dis (Hoboken) 2024; 23:e0246. [PMID: 38988821 PMCID: PMC11236412 DOI: 10.1097/cld.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/10/2024] [Indexed: 07/12/2024] Open
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Gao F, Wang L, Pan J, Yin Y, Wang J, Xu X, Xu S, Mancuso A, Qi X. Efficacy and safety of thrombolytic therapy for portal venous system thrombosis: A systematic review and meta-analysis. J Intern Med 2023; 293:212-227. [PMID: 36208172 DOI: 10.1111/joim.13575] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS The role of thrombolytic therapy in patients with portal venous system thrombosis (PVST) remains ambiguous. This study aimed to systematically collect available evidence and evaluate the efficacy and safety of thrombolysis for PVST. METHODS Eligible studies were searched via PubMed, EMBASE, and Cochrane Library databases. Among the cohort studies, meta-analyses were performed to assess the outcomes of PVST patients receiving thrombolysis. Pooled proportions were calculated. Among the case reports and case series, logistic regression analyses were performed to identify the risk factors for outcomes of PVST patients receiving thrombolysis. Odds ratios (ORs) were calculated. RESULTS Among the 2134 papers initially identified, 29 cohort studies and 131 case reports or case series were included. Based on the cohort studies, the pooled rates of overall response to thrombolytic therapy, complete recanalization of PVST, bleeding events during thrombolysis, further bowel resection, thrombosis recurrence, and 30-day mortality were 93%, 58%, 18%, 3%, 1%, and 4%, respectively. Based on the case reports and case series, acute pancreatitis (OR = 0.084), history of liver transplantation (OR = 13.346), and interval between onset of symptoms and initiation of thrombolysis ≤14 days (OR = 3.105) were significantly associated with complete recanalization of PVST; acute pancreatitis (OR = 6.556) was significantly associated with further bowel resection; but no factors associated with the overall response to thrombolytic therapy, bleeding events during thrombolysis, thrombosis recurrence, and 30-day mortality were identified or could be calculated. CONCLUSION Early initiation of thrombolysis should be effective for the treatment of PVST. But its benefits for PVST secondary to acute pancreatitis are weakened.
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Affiliation(s)
- Fangbo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Jiahui Pan
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Yuhang Yin
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Jing Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Gastroenterology, The 960th Hospital of the PLA, Jinan, China
| | - Xiangbo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, China
| | - Shixue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Andrea Mancuso
- Medicina Interna 1, ARNAS Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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Wei Q, Mei S, Fu Z, Wang X, Han C, Chen J, Liu P, Chen B, Fang X, Jia C, Zheng S, Xu X. Preventive use of low molecular weight heparin in portal vein system thrombosis after splenectomy without portal hypertension. Heliyon 2022; 8:e12482. [PMID: 36590482 PMCID: PMC9800429 DOI: 10.1016/j.heliyon.2022.e12482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/03/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Background/aim Portal vein system thrombosis (PVST) is a serious complication after splenectomy, and many researches focus on how to prevent PVST these years. The current study aimed to explore an effectively method to prevent PVST occur after splenectomy. Methods Records of patients performed with splenectomy from January 2018 to December 2020 were reviewed. Clinical parameters, including patient history, physical examination, and the results of laboratory investigations, were analyzed. Results One hundred and eighty patients (127 females) were included. Twenty-four patients were confirmed PVST by Color Doppler ultrasonography and CTA (thrombus group) and the others were not (non-thrombus group). One hundred and twenty patients were performed with laparoscopic splenectomy (LS) and 53 were open splenectomy (OS). Seventeen PVST were found in LS patients and 7 PVST were found in OS patients (P = 0.974). The average time of thrombosis was 4.48 ± 2.9 days after operation. The proportion of postoperative preventive use of low molecular weight heparin (LMWH) in non-thrombus group was higher than that in thrombus group (27.6% vs. 8.3%, P = 0.045). Compared with the non-thrombus group, the thrombus group showed significantly higher serum alanine transaminase (ALT) and aspartate transaminase (AST) 7 days after splenectomy (79.67 ± 39.1 U/L vs. 29.34 ± 2.5 U/L, P = 0.001; 192.4 ± 145.8 U/L vs. 30.54 ± 3.0 U/L, P < 0.001). Conclusion Laparoscopic splenectomy does not seem to increase the occurrence of PVST in patients without portal hypertension. Early postoperative preventive use of LMWH after splenectomy may prevent the formation of PVST.
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Affiliation(s)
- Qiang Wei
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310006, China,Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China,Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Shengmin Mei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zhifei Fu
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Xiaodong Wang
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310006, China
| | - Chengzuo Han
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China,Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Jun Chen
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310006, China,Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China,Zhejiang University School of Medicine, Hangzhou, 310058, China
| | - Peng Liu
- Organ Transplantation Center, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Bin Chen
- Information Center, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xin Fang
- Department of Vascular Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Changku Jia
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao Xu
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310006, China,Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China,Zhejiang University School of Medicine, Hangzhou, 310058, China,Corresponding author.
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Salei A, El Khudari H, McCafferty BJ, Varma RK. Portal Interventions in the Setting of Venous Thrombosis or Occlusion. Radiographics 2022; 42:1690-1704. [PMID: 36190859 DOI: 10.1148/rg.220020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.
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Affiliation(s)
- Aliaksei Salei
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Husameddin El Khudari
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Benjamin J McCafferty
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
| | - Rakesh K Varma
- From the Division of Interventional Radiology, Department of Radiology, University of Alabama at Birmingham Heersink School of Medicine, 619 19th St S, Birmingham, AL 35249
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Gao FB, Wang L, Zhang WX, Shao XD, Guo XZ, Qi XS. Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis. World J Gastrointest Surg 2022; 14:1082-1085. [PMID: 36185556 PMCID: PMC9521475 DOI: 10.4240/wjgs.v14.i9.1082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/01/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
Acute portal venous system thrombosis (PVST) can cause acute mesenteric ischemia and even intestinal infarction, which are potentially fatal, and requires recanalization in a timely fashion. Herein, we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation. Initially, anticoagulation with enoxaparin sodium for 4 d was ineffective, and then systemic thrombolysis for 7 d was added. After that, his abdominal pain completely disappeared, and portal vein system vessels became gradually patent. Long-term anticoagulation therapy was maintained. In conclusion, 7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.
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Affiliation(s)
- Fang-Bo Gao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Le Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Wen-Xiu Zhang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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Interventional recanalization therapy in patients with non-cirrhotic, non-malignant portal vein thrombosis: comparison between transjugular versus transhepatic access. Abdom Radiol (NY) 2022; 47:1177-1186. [PMID: 35020007 PMCID: PMC8863683 DOI: 10.1007/s00261-022-03411-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
Purpose To compare the safety and outcome of transjugular versus percutaneous technique in recanalization of non-cirrhotic, non-malignant portal vein thrombosis. Methods We present a retrospective bicentric analysis of 21 patients with non-cirrhotic, non-malignant PVT, who were treated between 2016 and 2021 by interventional recanalization via different access routes (percutaneous [PT] vs. transjugular in transhepatic portosystemic shunt [TIPS] technique). Complication rates with a focus on periprocedural bleeding and patency as well as outcome were compared. Results Of the 21 patients treated (median age 48 years, range of 19–78), seven (33%) patients had an underlying prothrombotic condition. While 14 (57%) patients were treated for acute PVT, seven (43%) patients had progressive thrombosis with known chronic PVT. Nine patients underwent initial recanalization via PT access and twelve via TIPS technique. There was no significant difference in complete technical success rate according to initial access route (55.5% in PT group vs. 83.3% in TIPS group, p = 0.331). However, creation of an actual TIPS was associated with higher technical success in restoring portal venous flow (86.6% vs. 33.3%, p = 0.030). 13 (61.9%) patients received thrombolysis. Nine (42.8%) patients experienced hemorrhagic complications. In a multivariate analysis, thrombolysis (p = 0.049) and PT access as the first procedure (p = 0.045) were significant risk factors for bleeding. Conclusion Invasive recanalization of the portal vein in patients with PVT and absence of cirrhosis and malignancy offers a good therapeutic option with high recanalization and patency rates. Bleeding complications result predominantly from a percutaneous access and high amounts of thrombolytics used; therefore, recanalization via TIPS technique should be favored.
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Cheng Q, Tree K. Systematic Review of Thrombolysis Therapy in the Management of Non-Cirrhosis-Related Portal Vein Thrombosis. J Gastrointest Surg 2021; 25:1579-1590. [PMID: 33452971 DOI: 10.1007/s11605-020-04624-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To review available evidence to assess the efficacy and safety of thrombolysis therapy for non-cirrhosis-related portal vein thrombosis (PVT) that has not improved with anti-coagulation. METHODS A literature search of databases MEDLINE, EMBASE, PUBMED, Cochrane and World Wide Web identified studies after 2000 utilizing portal vein thrombolysis in non-cirrhotic patients, with a minimum of 5 patients. Nine studies met criteria with 134 patients. The primary outcome evaluated was radiological re-canalization of the portal vein and symptomatic improvement post treatment. Secondary data points obtained included morbidity, mortality, thrombolysis approach and technique. RESULTS The re-canalization rate following thrombolysis was 84% (0.67-1.02 CI 95%) and the symptomatic improvement rate 86% (0.70-1.01 CI 95%). The major complication rate was 7% (0.01-0.14 CI 95%) and the overall complication rate 25% (0.08-0.41 CI 95%). The direct and systemic thrombolysis approach showed no significant re-canalization rates with an odds ratio of 0.78 (0.24-2.55 CI 95%, P = 0.68). Thrombectomy in conjunction with thrombolysis demonstrated no improved patency or symptom relief with an odds ratio of 1 (0.17-6.03 CI 95%, P = 1.00). CONCLUSION Thrombolysis is an effective and safe therapy for portal vein thrombosis in non-cirrhotic patients where systemic anti-coagulation has failed. The heterogenicity of study thrombolysis protocols limits the evaluation of secondary outcomes, and future data should be standardized to determine the role of the thrombolysis access route and thrombectomy.
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Affiliation(s)
- Qiuye Cheng
- Department of Surgery, Blacktown Hospital, 14 Blacktown Rd, Blacktown, NSW, 2148, Australia. .,Discipline of Surgery, University of Western Sydney, Sydney, Australia.
| | - Kevin Tree
- Department of Surgery, Blacktown Hospital, 14 Blacktown Rd, Blacktown, NSW, 2148, Australia. .,Discipline of Surgery, University of Western Sydney, Sydney, Australia.
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Transhepatic Pharmacomechanical Thrombectomy of Symptomatic Acute Noncirrhotic, Nonmalignant Portomesenteric Venous Thrombosis: Midterm Results. AJR Am J Roentgenol 2021; 217:418-425. [PMID: 34036807 DOI: 10.2214/ajr.20.23150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of transhepatic pharmacomechanical thrombectomy of symptomatic acute portomesenteric venous thrombosis. MATERIALS AND METHODS. Transhepatic pharmacomechanical thrombectomy (catheter-directed thrombolysis with mechanical thrombectomy) was performed in the treatment of nine patients with symptomatic acute noncirrhotic, nonmalignant porto-mesenteric venous thrombosis. The medical records, imaging examinations, technique of transhepatic pharmacomechanical thrombectomy, and clinical outcomes were reviewed. RESULTS. The mean follow-up period was 23.1 months (range, 8-34) months. Successful recanalization of the portomesenteric venous thrombosis, restoration of hepatopetal portal flow, clinically significant improvement in the signs and symptoms of acute mesenteric ischemia, and prevention of bowel resection were achieved in all patients. The most frequent minor complication (in three patients) was minor hemorrhage through the transhepatic access track. No procedure-related major complications occurred during hospitalization. No patient had rethrombosis or complications related to portal hypertension due to portomesenteric venous thrombosis. One patient died of massive pulmonary embolism on the 7th day after treatment. Cavernous transformation of the right portal vein occurred in one patient. CONCLUSION. Transhepatic pharmacomechanical thrombectomy is a safe and effective method of treatment of symptomatic acute portomesenteric venous thrombosis and prevention of bowel infarction.
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Abstract
Die Pfortaderthrombose ist eine seltene Erkrankung, die eine Thrombose im Zustromgebiet der Pfortader in die Leber beschreibt bzw. in der Leber selbst in den entsprechenden Pfortaderästen lokalisiert ist. Oftmals liegt bereits eine chronische Lebererkrankung bzw. ein Malignom der Leber selbst oder unmittelbar benachbart liegender Organe vor; die Pfortaderthrombose kann aber auch bei Patienten auftreten, die keine entsprechende Vorerkrankung haben. Bei jeder neu diagnostizierten Pfortaderthrombose gilt es zu entscheiden, ob unmittelbar oder im Verlauf eine radiologisch-interventionelle Rekanalisation vorgenommen wird oder ein rein konservativer Therapieversuch mit Antikoagulanzien erfolgt. Aber auch chirurgische Verfahren, wie eine Shuntanlage oder die Notwendigkeit einer Lebertransplantation, müssen hierbei berücksichtigt werden. Für diesen Therapiealgorithmus ist die Kontaktaufnahme mit einem entsprechenden Zentrum sinnvoll. Die Therapieentscheidung muss die Ursache der Pfortaderthrombose und die Begleiterkrankungen adäquat berücksichtigen.
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Lemma A, Åberg F, Mäkisalo H, Vikatmaa P, Mentula P, Leppäniemi A, Sallinen V. Predictors of insufficient recanalization and portal hypertensive complications after treatment of non-cirrhotic, non-malignant portal vein thrombosis - a population-based study. Scand J Gastroenterol 2020; 55:1324-1332. [PMID: 32976739 DOI: 10.1080/00365521.2020.1823465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES In acute portal vein thrombosis (PVT), a six-month anticoagulation treatment achieves complete recanalization in only 35%-45% of patients, but the predictors of poor treatment responses are unclear. We examined treatment outcomes in PVT and aimed to identify predictors of incomplete recanalization and portal hypertensive complications. MATERIALS AND METHODS This retrospective study comprised patients diagnosed with PVT between 2006 and 2015. Key exclusion criteria were liver cirrhosis, malignancy, and age <18. RESULTS The final cohort comprised 145 patients, of whom 132 (92%) were primarily treated with anticoagulation. The 5-year cumulative incidence of complete recanalization was 42% and of portal hypertensive complications, 31%. Independent predictors of insufficient recanalization were sub-acute or chronic thrombosis (hazard ratio (HR) 3.1, 95% CI 1.6-5.8), while acute pancreatitis was a protective factor (HR 0.3, 95% CI 0.2 - 0.7). Independent predictors of incident portal hypertensive complications were as cites at baseline (HR 3.3, 95% CI 1.7-6.7), sub-acute or chronic thrombosis (HR 2.9, 95% CI 1.6-5.3), extension of thrombosis to the splenic or mesenteric vein (HR 2.6, 95% CI 1.2-5.7), myeloproliferative disease (HR 3.0, 95% CI 1.4-6.5), and anemia (HR 2.1, 95% 1.1-3.9), while acute pancreatitis was a protective factor (HR 0.1, 95% CI 0.03-0.5). CONCLUSIONS Etiology and age of thrombosis are associated with treatment responses in PVT. The presence of ascites at baseline, etiology, and extent of thrombosis, a non-acute thrombosis and anemia, are associated with the risk of portal hypertensive complications. Etiology and extent of thrombosis should be taken into account when determining the treatment (method) for PVT.
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Affiliation(s)
- Aurora Lemma
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Fredrik Åberg
- Department of Transplantation and Liver Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland.,The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Heikki Mäkisalo
- Department of Transplantation and Liver Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
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14
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Zhang D, Xu S, Tian Y, Qi X. Editorial: acute non-cirrhotic and non-malignant portal vein thrombosis-who should be candidates for interventional treatment? Aliment Pharmacol Ther 2020; 52:725-728. [PMID: 32886391 DOI: 10.1111/apt.15902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
LINKED CONTENTThis article is linked to the Rössle et al papers. To view these articles, visit https://doi.org/10.1111/apt.15811 and https://doi.org/10.1111/apt.15930
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Affiliation(s)
- Dan Zhang
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Department of General Surgery, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Shixue Xu
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Yulong Tian
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
- Department of Interventional Radiology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xingshun Qi
- SVT Interest Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China
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15
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Rössle M, Bettinger D, Trebicka J, Klinger C, Praktiknjo M, Sturm L, Caca K, Mücke VT, Radecke K, Engelmann C, Zipprich A, Heinzow H, Meyer C, Tappe U, Appenrodt B, Schmidt A, Lange C, Strassburg C, Zeuzem S, Grandt D, Schmidt H, Moessner J, Berg T, Lammert F, Thimme R, Schultheiß M. A prospective, multicentre study in acute non-cirrhotic, non-malignant portal vein thrombosis: comparison of medical and interventional treatment. Aliment Pharmacol Ther 2020; 52:329-339. [PMID: 32506456 DOI: 10.1111/apt.15811] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate medical versus interventional treatment (transjugular thrombus fragmentation, local thrombolysis with or without stent implantation) in patients with acute non-cirrhotic, non-malignant portal vein thrombosis (PVT). METHODS This prospective, observational study enrolled 65 patients with acute (<28 days since begin of symptoms, no cavernoma) PVT in nine centres. Thirty patients received medical treatment and 35 patients received interventional treatment. PVT was graded into grade 1: short thrombosis and incomplete occlusion of the vessel lumen and grade 2: extended thrombosis or complete occlusion. Treatment response was classified as partial or complete, if thrombosis was reduced by one grade or to <25% of the vessel diameter respectively. RESULTS Partial and complete response rates were 7% and 30% in the medical compared to 17% and 54% (P < 0.001) in the interventional treatment group. In the multivariate analysis, interventional treatment showed a strong positive (OR 4.32, P < 0.016) and a myeloproliferative aetiology a negative (OR 0.09, P = 0.006) prediction of complete response. Complications were rare in the medical group and consisted of septicaemia and upper gastrointestinal bleeding of unknown origin in one patient each. Interventional treatment was accompanied by mild and self-limiting bleeding complications in nine patients, moderate intra-abdominal bleeding requiring transfusions (2 units) in one patient and peritoneal bleeding requiring surgical rescue in one patient. Four patients in each group developed intestinal gangrene requiring surgery. One patient died 52 days after unsuccessful interventional treatment. CONCLUSIONS Compared to medical treatment alone, interventional treatment doubled response rates at the cost of increased bleeding complications.
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Wei Q, He Z, Wang K, Li C, Al Ameri A, Zheng S, Xu X. Prediction model based on blood urea nitrogen and the leukocyte count for intestinal necrosis in patients with portal vein system thrombosis: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:326. [PMID: 32355770 PMCID: PMC7186628 DOI: 10.21037/atm.2020.02.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Portal vein system thrombosis (PVST) is a serious and potentially fatal disease. No definite parameter can predict intestinal necrosis in patients with PVST to justify early surgical intervention. The current study aimed to explore a simple and accurate model to predict the occurrence of intestinal necrosis in patients with PVST. Methods Records of patients admitted to our emergency department with PVST from January 2010 to October 2018 were reviewed. Clinical parameters, including patient history, physical examination, and the results of laboratory investigations, were analyzed. Results Sixty-nine patients (27 females) were included. All patients were admitted to our emergency department because of abdominal pain. Fourteen patients required exploratory laparotomy, and intestinal necrosis was confirmed. Seven patients received thrombolytic therapy, and the other 48 patients had completed anticoagulation successfully. According to multivariate logistic regression, high blood urea nitrogen (BUN) (OR: 1.413, P=0.048) and the leukocyte count (OR: 1.180, P=0.005) were associated with intestinal necrosis, and a prediction model for intestinal necrosis (PMIN) based on the BUN and leukocyte count was established. Conclusions The PMIN score could effectively predict intestinal necrosis in patients with PVST.
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Affiliation(s)
- Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zenglei He
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Kun Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Changbiao Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Abdulahad Al Ameri
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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17
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Valla DC. Recent developments in the field of vascular liver diseases. Liver Int 2020; 40 Suppl 1:142-148. [PMID: 32077611 DOI: 10.1111/liv.14348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 12/25/2019] [Indexed: 12/13/2022]
Abstract
Knowledge in the field of vascular liver disease is continuously expanding. The present update will discuss recent data on i) the Abernethy malformation in adults; ii) portal vein thrombosis in cirrhosis; iii) advancing expertise in recanalization of the portal vein and iv) experience in using direct oral anticoagulants in the field of vascular liver disease.
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Affiliation(s)
- Dominique C Valla
- Service d'hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris and Inserm, Clichy la Garenne, France
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