EUS GUIDED CONTINUOUS CATHETER THROMBOLYSIS OF PORTAL VENOUS SYSTEM

Portal vein thrombosis (PVT) is an unusual thrombotic condition associated with significant morbidity and mortality. Treatment of PVT currently ranges from observation to anticoagulation or thrombolytic therapy. Thrombolytic therapy can be considered in those with thrombus extension or worsening pain while on therapeutic anticoagulation. It is usually performed under fluoroscopy by interventional radiologist.

We describe first case report of successful EUS guided catheter thrombolysis.

An 18 years old lady presented with intractable upper abdominal pain and vomiting for last 3 days. Abdominal ultrasound showed extensive thrombosis of portal venous system. A CT scan showed the extension of thrombus from superior mesenteric vein without bowel infarction. She was started on anticoagulants. The intractable pain persisted and options of portal vein thrombolysis were considered. EUS guided thrombolysis was the only available option. The thrombus was extensive and EUS demonstrated two patent parts of the lumen of portal venous system. One was seen near the splenic hilum in the splenic vein and the second part (of patent lumen) was noted in the lower part of superior mesenteric vein (SMV). Steps of catheter insertion into the SMV

1. SMV was punctured through the pancreas with a 22 gauge EUS FNA needle

2. A 0.018 inch guide wire was placed into a tributary of superior mesenteric vein

3. A tapered tip cannula was advanced over the wire and cannula was positioned in the vein

4. The scope was removed while leaving the cannula in place and the cannula was routed through the nose and a syringe pump was fitted for infusion of thrombolytic agent. Continuous catheter guided thrombolytic therapy was started with streptokinase at a dose of 30000 IU/hr with systemic anticoagulation with low molecular weight heparin 6o mg subcutaneously per day.

She responded with resolution of thrombus and improvement in abdominal pain.