The ABCD of portal vein thrombosis: a systematic approach

Abstract

Portal vein thrombosis refers to complete or partial obstruction of the portal venous system, in the intrahepatic or extrahepatic venous tract or even in the splenic or superior mesenteric veins. This common and potentially fatal condition can develop in various clinical contexts, especially those of liver cirrhosis, hepatocellular carcinoma, and other solid tumors. Certain characteristics, such as the time since the onset of the thrombus (acute or chronic), its biology (hematic or tumoral), the presence of collateral vessels, and the magnetic resonance imaging aspects, are important components of a thorough, careful analysis, as well as informing decisions regarding the appropriate therapeutic strategy. Here, we present a brief review of the anatomy of the portal venous system and a systematic approach to analyzing the condition, using a mnemonic (ABCD, for age, biology, collaterals, and diffusion). We discuss the various imaging methods and illustrate our discussion with images selected from the case files archived at our facility.

Portal Vein Thrombosis in Cirrhosis

“…On DWI, tumor thrombi appear hyperintense on DWI and hypointense on the apparent diffusion coefficient (ADC) map, which is similar to the adjacent primary tumor [67]. However, results are conflicting about the utility of DWI for diagnosis of malignant PVT, and thus, more extensive studies are required before recommending DWI for evaluation of suspected malignant PVT [68][69][70].…”

The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management

“…In the chronic form, the thrombosed vessel can be hypodense, containing linear areas of calcification within the thrombus. In addition, CT and MR can depict features of portal hypertension, including ascites, splenomegaly, and portosystemic shunts [ 39 , 58 ].…”

“…In the chronic form, the thrombosed vessel can be hypodense, containing linear calcifications, obliterated or shrunk, with cavernous transformation [ 39 , 58 ]. In candidates for LT, calcifications in the portal vein should be actively investigated, because they indicate a more fragile vessel and can hinder surgical anastomoses creation [ 58 ]. Splenomegaly and splenic artery aneurysms are also relevant findings readily depicted by CT ( Figure 5 ).…”

A 65-year-old man with melena and a blood disorder

“…19,20 Ultrasonography is recommended in the acute setting to investigate new or worsening ascites in patients with bleeding esophageal varices, if there is suspicion of portal vein thrombosis, or to investigate portal hypertension if there is no known history of liver disease. 21 In patients with advanced cirrhosis (Child-Pugh class B or C), placement of a transjugular intrahepatic portosystemic shunt within the first 3 days after presentation was shown to reduce the risks of further bleeding and death at 1 year. 18,[22][23][24][25] In general, the major drawback of this treatment is overt hepatic encephalopathy, which occurs in about one-third of patients.…”