CASE 9778 Published on 20.03.2012

Endovascular treatment of acute extensive porto-spleno-mesenteric venous thrombosis

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Accogli S, Scalise P, Pancrazi F, Angelini G, Aringhieri G, Vannucci S, Bemi P, Cioni R, Bartolozzi C.

Department of Diagnostic and Interventional Radiology,
University Hospital of Pisa, Italy
Patient

55 years, male

Categories
Area of Interest Vascular ; Imaging Technique Catheter arteriography, Ultrasound-Colour Doppler, CT, Image manipulation / Reconstruction
Clinical History
A 55-year-old man affected by protein C and S deficiency came to our department complaining of abdominal pain, sickness and fever, 18days after open-surgery sigmoid-rectum resection for colorectal cancer. Therefore the patient underwent emergency abdominal Ultrasonography (US) and Computed Tomography (CT) examinations.
Imaging Findings
Emergency US and CT-scan showed widespread ascites and complete thrombosis of spleno-mesenteric-portal axis(Fig.1). Heparin EV therapy was begun, but after 4days symptoms worsened. Trans-femoral angiography was performed (Fig.2): superior-mesenteric artery (SMA) was patent but spleno-mesenteric-portal axis was not opacified, suggesting a thrombosis of portal, superior-mesenteric and splenic veins (PSMT).
Endovascular fibrinolysis was required, but neither trans-hepatic nor transjugular access were available due to ascites and extensive thrombosis. An indirect therapy was performed via SMA using a Simmons-catheter performing venous thrombolysis through the capillary circle.
Control angiography (4th day after treatment) showed a progressive improvement of venous return from the bowel wall(Fig.3); portal vein was not clearly recognized but its intra-parenchymal slender branches were appreciated.
6th-8th day after treatment CT-scan depicted collateral vessels formation and minimal recanalisation of superior mesenteric vein (SMV)(Fig.4).
Follow-up CT showed reduction in thrombosis extension and development of a portal cavernoma(Fig.5-6).
Recanalisation of chronic portal vein thrombosis through collateral peri-portal circulation was confirmed by Colour-Doppler-US follow-up (Fig.7-8).
Discussion
Acute extensive PSMT accounts for 5-10% of all abdominal ischaemic events. Since clinical presentation is often non-specific and highly variable, TPSM is frequently unrecognised, causing delayed diagnosis and high morbidity and mortality rates[1].
PSMT is usually related to an underlying hypercoagulable-state resulting from congenital thrombophilic conditions (antithrombin-III deficiency; protein C or S deficiency; antiphospholipid-antibody syndrome; factor V Leiden and prothrombin-gene mutation) which might be exacerbated by an elapsing event, such as pancreatitis or abdominal surgery[2, 3], like in our case.
Clinical expression might vary from asymptomatic to abdominal cramps, nausea, anorexia, vomiting, diarrhoea, and/or melaena [2]; potentially life-threatening severe manifestations include mesenteric ischaemia and variceal bleeding[4].
There is no universally accepted protocol for SPMT management and treatment[2].
Medical treatment is usually administered in all patients; in case of persistence/worsening of clinical symptoms, surgery or endovascular therapy is required.
Minimally invasive techniques, such as loco-regional fibrinolysis, have recently been introduced in therapeutical management of patients with worsening of clinical condition despite anticoagulation, in absence of bowel infarction or perforation[2, 4].
Endovascular thrombolytic agents might be administered directly (via percutaneous transhepatic or transjugular intrahepatic routes)or indirectly via SMA[3].
Indirect approach implies the puncture of femoral or radial artery with a 4-5F artery-sheath; Simmons or Cobra catheter is then inserted to perform celiac artery and SMA selective angiography and indirectly portal, superior-mesenteric and splenic venography.
Urokinase(50000 UI/h) and sodium-heparin(1000 UI/h) are selectively administered through an infusion catheter[4].
Arterial access advantages include simple technique and better dissolution of clots within capillaries and venules[2]. In particular, thrombolytic agents infusion into SMA is preferred since it allows to reach indirectly the capillary circulation and the smallest branches of the superior mesenteric vein(SMV), promoting lateral branches neoangiogenesis [2].
If compared with lysis performed through a direct access to the portal vein, intra-arterial delivery disadvantages include an increased risk of gastrointestinal bleeding, an increased incidence of complications at puncture site and the potential formation of portal cavernomas, as in our case.
Thrombolysis duration varies according to clinical condition and radiological findings. However, low-dose urokinase infusion, no simultaneous peripheral venous urokinase infusion and careful monitoring of coagulation-status during treatment is recommended to reduce haemorragic risk.
After treatment, venography and CT are required to demonstrate blood flow restoration within SMV;if clinical condition improvement is reported, thrombolysis might be administered discontinuously and anticoagulant oral intake might be undertaken.
A strict imaging follow-up with CT and Colour-Doppler-Ultrasound (after 1week, 1 and 6months, and than only CDUS annually) is mandatory to detect promptly any complications or disease recurrence[3].
Differential Diagnosis List
Acute extensive portal, superior-mesenteric and splenic veins thrombosis (PSMT)
Acute pancreatitis
Acute cholecystitis
Abdominal aortic aneurysm rupture
Bowel obstruction
Acute diverticulitis
Renal colic
Perforation of a hollow viscus
Final Diagnosis
Acute extensive portal, superior-mesenteric and splenic veins thrombosis (PSMT)
Case information
URL: https://www.eurorad.org/case/9778
DOI: 10.1594/EURORAD/CASE.9778
ISSN: 1563-4086