Primary Catheter-Directed Thrombolysis For Porto-Mesenteric Venous Thrombosis (PMVT) In Non-Cirrhotic Patients.

Purpose: To report our technique, treatment strategy and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients.Methods: 16 non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004-2020. 8 patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000-30,000 IU/hour concomitant with heparin 300-400 IU/hour), catheter aspiration and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/hour) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in 8 patients. A total of up to 20.4 million IU urokinase was infused for 1-30 days’ treatment duration. TIPS was created in 3 patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall 1- and 2-year primary and secondary patency were both 74.0% and 84.6% respectively. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT . TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.

Vaginal Bleeding As The Presenting Manifestation of Post-Hepatectomy/-Splenectomy Portal-Mesenteric Venous Thrombosis

Background: Portal-mesenteric venous thrombosis is not uncommon after hepatectomy or splenectomy but is under-recognized because of non-specific symptoms and lack of awareness of the clinicians. However, misdiagnosis or delayed treatment may have fatal consequences. Case Presentation: A 57-year-old menopausal woman with the medical history of hepatocellular carcinoma, stage I, underwent laparoscopic partial hepatectomy (S4) and splenectomy 2 months before the presentation of progressive vaginal spotting and vague abdominal pain. Dysfunctional uterine bleeding was suspected initially, but subsequent contrast-enhanced computed tomography due to concern for post-procedure complications revealed thrombosis in the portal vein and superior mesenteric vein. The patient received anticoagulant therapy, and her symptoms gradually resolved. Conclusions: To the best of our knowledge, vaginal variceal bleeding secondary to portal-mesenteric venous thrombosis has never been reported, but it can be the presenting manifestation for this condition. It should be considered in the differential diagnosis of patients who present with vague abdominal symptoms after hepatectomy or splenectomy.

Mesenteric Venous Thrombosis in a Referral Hospital in East Africa: A Retrospective Study of Four Cases

Introduction: Acute mesenteric venous thrombosis is a rare condition with the most common site of thrombosis development being the superior mesenteric vein. Patients predisposed to this condition tend to develop a disruption to Virchow’s triad of endothelial injury, stasis and hypercoagulability. In the acute form the presentation is with bowel ischaemia and so a diagnosis before bowel gangrene develops remains a challenge. The limited experience with this condition in the East African region shows that a delayed diagnosis due to limited investigative capacity results in patients’ experiencing acute renal failure and a high mortality. This review describes the aetiology, clinical features and management of acute mesenteric venous ischaemia. Methods: A descriptive retrospective review of four patients over an 18-month period. Demographic and clinical data was extracted from the patients’ clinical files and manual analysis using a spreadsheet was performed. Results: Over an 18-month period, four patients were reported. All patients had a delay in diagnosis with acute symptoms persisting for 5 days up to 21 days. Two patients died within 30-days post-operatively of complications which included short bowel syndrome and acute kidney failure. Two patients survived developing complications from short bowel syndrome and another the complications of acute kidney injury requiring haemodialysis. Conclusions: A delay in diagnosis of acute MVT characterises this short case series. This resulted in all cases presenting with gangrenous bowel and hence the high mortality. Venous clot propagation is prevented with anticoagulation which is associated with decreased mortality and recurrence. Thrombolysis and thrombectomy should be considered in certain circumstances to prevent bowel of questionable viability. In the last four decades the mortality from MVT has decreased and currently stands at 10-20% however there is no sufficient literature in East Africa to make this judgement.