Amine Benmassaoud1, Laith AlRubaiy1, Dominic Yu2, Pratima Chowdary3, Mallika Sekhar4, Pathik Parikh1, Jemima Finkel1, Teik Choon See5, James O'Beirne1,6, Joanna A Leithead7, David Patch1. 1. The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK. 2. Department of Radiology, Royal Free London NHS Trust, London, UK. 3. KD Haemophilia and Thrombosis Centre, Royal Free London NHS Trust, London, UK. 4. Department of Haematology, Royal Free London NHS Trust, London, UK. 5. Department of Interventional Radiology, Addenbrooke's Hospital, Cambridge, UK. 6. Department of Hepatology, Sunshine Coast University Hospital, Birtinya, QLD, Australia. 7. Liver Unit, Addenbrooke's Hospital, Cambridge, UK.
Abstract
BACKGROUND: Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension. AIM: To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia. METHODS: We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed. RESULTS: Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%). CONCLUSIONS: Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.
BACKGROUND: Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension. AIM: To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia. METHODS: We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed. RESULTS: Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%). CONCLUSIONS: Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.
Authors: Lukas Sturm; Dominik Bettinger; Christoph Klinger; Tobias Krauss; Hannes Engel; Jan Patrick Huber; Arthur Schmidt; Karel Caca; Robert Thimme; Michael Schultheiss Journal: PLoS One Date: 2021-12-20 Impact factor: 3.240