Approach to different thrombolysis techniques and timing of thrombolysis in the management of portal vein thrombosis in cirrhotic patients

Abstract

Thrombolysis is not currently recommended in cirrhotic patients with acute portal vein thrombosis (PVT) in most guidelines, because of the exceedingly limited data and the perceived high risk of bleeding adverse events. However, in the few studies including patients with cirrhosis, the rate of success was high and that of adverse events was similar in patients with or without cirrhosis. Hence, thrombolysis might be a rescue therapeutic option in patients with cirrhosis and acute, symptomatic thrombosis of the portal venous system, unresponsive to anticoagulation, provided a suitable timing is kept, less than 30 days and, if possible, less than 14 days from the acute onset of portal vein thrombosis. In this review perspective article, I discuss the several potential approaches of thrombolysis, either local or systemic, alone or combined with mechanical procedures for thrombus removal, or as a complement to Transjugular Intrahepatic Portosystemic Shunt placement, with a focus on the more suitable timing of thrombolysis. However, the very limited available data preclude from performing firm recommendations, and decision to carry out thrombolysis must take into account both the occurrence of major contraindications and the current critical clinical setting. In the next future, large high-quality multicentre studies will hopefully be able to settle more firm indications and preferable techniques.

Portal Vein Thrombosis: State-of-the-Art Review

“…Alternatives to anticoagulant therapy include thrombolysis of the clot with streptokinase or tissue plasminogen activator administered locally through a catheter passed either trans-hepatically trans-jugular vein or percutaneously trans-hepatically. In patients with cirrhosis and acute symptomatic thrombosis of the portal system who do not respond to anticoagulation, thrombolytic therapy may be a salvage treatment option if appropriately timed, within 30 days and, preferably, within 14 days of the acute onset of portal vein thrombosis [ 128 ].…”