t-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis

Abstract

Background: Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting. Materials and Methods: Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access. Results: With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up. Conclusions: Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Keywords

CT guidance portal vein access - rheolytic mechanical thrombectomy - superior mesenteric vein thrombosis, t-PA power-pulse spray

Publication History

Article published online:
26 July 2021

• References

• 1 Goldberg MF, Kim HS. Treatment of acute superior mesenteric vein thrombosis with percutaneous techniques. AJR Am J Roentgenol 2003; 181: 1305-7
• 2 Hollingshead M, Burke CT, Mauro MA, Weeks SM, Dixon RG, Jaques PF. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis. J Vasc Interv Radiol 2005; 16: 651-61
• 3 Liu FY, Wang MQ, Fan QS, Duan F, Wang ZJ, Song P. Interventional treatment for symptomatic and acute-subacute portal and superior mesenteric vein thrombosis. World J Gastroenterol 2009; 15: 5028-34
• 4 Rivitz SM, Geller SC, Hahn C, Waltman AC. Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion. J Vasc Interv Radiol 1995; 6: 219-23 discussion 224-8
• 5 Hedayati N, Riha GM, Kougias P, Huynh TT, Chang C, Bechara C. et al. Prognostic factors and treatment outcome in mesenteric vein thrombosis. Vasc Endovascular Surg 2008; 42: 217-24
• 6 Grendell JH, Ockner RK. Mesenteric venous thrombosis. Gastroenterology 1982; 82: 358-72
• 7 Sze DY, O’Sullivan GJ, Johnson DL, Dake MD. Mesenteric and portal venous thrombosis treated by transjugular mechanical thrombolysis. AJR Am J Roentgenol 2000; 175: 732-4
• 8 Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Fan QS. Acute symptomatic mesenteric venous thrombosis: Treatment by catheter-directed thrombolysis with transjugular intrahepatic route. Abdom Imaging 2011; 36: 390-8
• 9 Yang S, Liu B, Ding W, He C, Wu X, Li J. Acute superior mesenteric venous thrombosis: Transcatheter thrombolysis and aspiration thrombectomy therapy by combined route of superior mesenteric vein and artery in eight patients. Cardiovasc Intervent Radiol 2015; 38: 88-99
• 10 Rosen MP, Sheiman R. Transhepatic mechanical thrombectomy followed by infusion of TPA into the superior mesenteric artery to treat acute mesenteric vein thrombosis. J Vasc Interv Radiol 2000; 11: 195-8
• 11 Hechelhammer L, Crook DW, Widmer U, Wildermuth S, Pfammatter T. Thrombosis of a superior mesenteric vein aneurysm; transarterial thrombolysis and transhepatic aspiration thrombectomy. Cardiovasc Intervent Radiol 2004; 27: 551-5
• 12 Chawla YK, Bodh V. Portal vein thrombosis. J Clin Exp Hepatol 2015; 5: 22-40
• 13 Midia M, Razavi M. Splanchnic venous thrombosis: Challenges and opportunities. Endovasc Today 2014; July 56-60
• 14 Takahashi N, Kuroki K, Yanaga K. Percutaneous transhepatic mechanical thrombectomy for acute mesenteric venous thrombosis. J Endovasc Ther 2005; 12: 508-11
• 15 Saad WE, Madoff DC. Percutaneous portal vein access and transhepatic tract hemostasis. Semin Interv Radiol 2012; 29: 71-80
• 16 Habib A, Desai K, Hickey R, Thornburg B, Vouche M, Vogelzang R. et al. Portal vein recanalization-transjugular intrahepatic portosystemic shunt using the transsplenic approach to achieve transplant candidacy in patients with chronic portal vein thrombosis. J Vasc Interv Radiol 2015; 26: 499-506
• 17 Zhou W, Choi L, Lin PH, Dardik A, Eraso A, Lumsden AB. Percutaneous transhepatic thrombectomy and pharmacologic thrombolysis of mesenteric venous thrombosis. Vascular 2007; 15: 41-5
• 18 Fontaine AB, Verschyl A, Hoffer E, Borsa J, Dowd M. Use of CT-guided marking of the portal vein in creation of 150 transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 1997; 8: 1073-7
• 19 Ferro C, Rossi UG, Bovio G, Dahamane M, Centanaro M. Transjugular intrahepatic portosystemic shunt, mechanical aspiration thrombectomy, and direct thrombolysis in the treatment of acute portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol 2007; 30: 1070-4
• 20 Haskal ZJ, Edmond J, Brown R. Mesenteric venous thrombosis. N Engl J Med 2002; 346: 1252-3
• 21 Seghal M, Haskal ZJ. Use of transjugular intrahepatic portosystemic shunts during lytic therapy of extensive portal splenic and mesenteric venous thrombosis: Long-term follow-up. J Vasc Interv Radiol 2000; 11: 61-5
• 22 Lopera JE, Correa G, Brazzini A, Ustunsoz B, Patel S, Janchai A. et al. Percutaneous transhepatic treatment of symptomatic mesenteric venous thrombosis. J Vasc Surg 2002; 36: 1058-61
• 23 Stambo GW, Grauer L. Transhepatic portal venous power-pulse spray rheolytic thrombectomy for acute portal vein thrombosis after CT-guided pancreas biopsy. AJR Am J Roentgenol 2005; 184 (03) Suppl S118-9