Portal Vein Thrombosis: Diagnosis and Endovascular Management

Abstract

Background Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking. Methods The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted. Results Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization. Conclusion Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus. Key Points: Citation Format

Diagnosis and Management of Acute and Chronic Portomesenteric Venous Thrombosis

“…37 48 Most cirrhotic patients with symptomatic PVT, be it acute or chronic will require creation of a TIPS to maintain portal vein patency and to manage the underlying portal hypertension. 3 37 The reported technical success rate for TIPS creation in cirrhotic patients with chronic PVT is 95%, with a reported overall shunt patency rate of 80–90% at 1 year. 3 Shunt patency rates have improved with the use of the VIATORR (W.L.…”

“…3 37 The reported technical success rate for TIPS creation in cirrhotic patients with chronic PVT is 95%, with a reported overall shunt patency rate of 80–90% at 1 year. 3 Shunt patency rates have improved with the use of the VIATORR (W.L. Gore) stent-grafts.…”

“…11 23 41 Self-expandable, non-covered nitinol stents are ideal for these procedures, 43 but balloon-expandable stents may also be used. 3 41 42 The use of stent-grafts has been described, however, these stents are usually indicated in patients with an acute thrombus component during recanalization or in cases of venous perforation during intervention. 39 41 42 If there is preservation of the peripheral intrahepatic portal vein branches, a transhepatic or trans-splenic approach is ideal for recanalization and the stent is usually placed in the main portal vein trunk.…”

“…17,38 The accepted first-line management strategy of PVT in patients with cirrhosis is systemic anticoagulation. 3 Most available reports have shown that rates of portal vein recanalization are higher in patients who are treated with anticoagulants. 3 No anticoagulant regimen has proven to be better.…”

“…9 11 14 Cross-sectional imaging is key to diagnosis. 3 8 15 Indications for treatment are determined by clinical presentation and severity of symptoms. 11 Treatment depends on the etiology of the thrombosis, the location of the obstruction, and the stage of clinical presentation.…”