optimal management of splenic/portal vein thrombosis

Optimal Management of Optimal Management of SplenicSplenic/Portal Vein /Portal Vein

Thrombosis Thrombosis

David David MauchleyMauchleyUniversity of ColoradoUniversity of Colorado

OverviewOverview

Portal Vein Thrombosis Portal Vein Thrombosis (PVT)(PVT)

EtiologyEtiologyPresentation/Clinical Presentation/Clinical AspectsAspectsDiagnosisDiagnosisManagementManagement

Cirrhotic vs. nonCirrhotic vs. non--cirrhoticcirrhoticMedical vs. InvasiveMedical vs. Invasive

SplenicSplenic Vein Thrombosis Vein Thrombosis (SVT)(SVT)

Etiology Etiology Presentation/Clinical Presentation/Clinical AspectsAspectsDiagnosisDiagnosisManagementManagement

Surgery vs. observationSurgery vs. observation

PVT: Management DilemmaPVT: Management Dilemma

Lack of randomized Lack of randomized controlled datacontrolled dataDetermining acute vs. Determining acute vs. chronic diseasechronic diseaseBetter understanding of Better understanding of etiologyetiologyPerceived risks of Perceived risks of anticoagulationanticoagulation

PVT: EtiologyPVT: Etiology

Common causesCommon causesCirrhosisCirrhosisCoagulation abnormalitiesCoagulation abnormalitiesIntraIntra--abdominal infectionabdominal infectionMalignancyMalignancyUmbilical vein Umbilical vein catheterization (children)catheterization (children)

Uncommon CausesUncommon CausesSchistosomiasisSchistosomiasisPancreatitisPancreatitisPostsurgicalPostsurgical((splenectomysplenectomy, liver , liver txtx))Compression by nodesCompression by nodesDrugs (oral Drugs (oral contraceptives)contraceptives)PregnancyPregnancy

PVT: PresentationPVT: Presentation

Can be asymptomaticCan be asymptomaticIncreased hepatic arterial flowIncreased hepatic arterial flowRapid development of collaterals (Rapid development of collaterals (cavernomatouscavernomatoustransformation)transformation)

Acute PVTAcute PVT<60 days prior to presentation<60 days prior to presentationAbdominal pain, nausea, feverAbdominal pain, nausea, fever symptoms related to extent symptoms related to extent of thrombosis (bowel ischemia)of thrombosis (bowel ischemia)Absence of clinical, Absence of clinical, endoscopicendoscopic or radiological portal HTNor radiological portal HTN

PVT: PresentationPVT: Presentation

Chronic PVTChronic PVTSymptoms of portal HTNSymptoms of portal HTN

VaricealVariceal bleedingbleedingAscitesAscitesSplenomegalySplenomegalyBiliaryBiliary obstruction obstruction ((““cavernomacavernoma””))

Growth retardation in Growth retardation in childrenchildren

PVT: Diagnosis (Ultrasound)PVT: Diagnosis (Ultrasound)

Initial imaging methodInitial imaging methodColor Color dopplerdoppler ultrasound ultrasound has 98% neg. predictive has 98% neg. predictive valuevalue

PVT: Diagnosis (MRA/CT)PVT: Diagnosis (MRA/CT)

MRA as accurate as MRA as accurate as angiography in detecting angiography in detecting PVTPVTCT allows diagnosis of CT allows diagnosis of etiology (malignancy)etiology (malignancy)

PVT: Diagnosis (angiography)PVT: Diagnosis (angiography)

““Gold standardGold standard”” in in diagnosisdiagnosisInvasiveInvasiveUseful when planning Useful when planning shunt surgeryshunt surgery

PVT: ManagementPVT: Management

Goal of management is to reduce associated Goal of management is to reduce associated morbidity and mortalitymorbidity and mortalityTwo broad intentions:Two broad intentions:

Reverse or prevent advancement of thrombosisReverse or prevent advancement of thrombosisTreat complications of established PVT (mainly Treat complications of established PVT (mainly varicealvariceal bleeding)bleeding)

Acute PVT: AnticoagulationAcute PVT: Anticoagulation

ThrombolysisThrombolysis vs. systemic anticoagulation vs. systemic anticoagulation No randomized data comparing the two methodsNo randomized data comparing the two methodsEvidence that early intervention is beneficialEvidence that early intervention is beneficial

MalkowskiMalkowski et alet al (2003) studied 33 cases of acute PVT (2003) studied 33 cases of acute PVT (symptoms 8(symptoms 8--60 days prior to presentation)60 days prior to presentation)

Conservative mgmt. in first 5 ptsConservative mgmt. in first 5 pts all died (all died (varicealvariceal bleeding)bleeding)ThrombolysisThrombolysis in next 28in next 28

RecanalizationRecanalization if symptoms <14 days (n=10)if symptoms <14 days (n=10)Restoration of Restoration of hepatopetalhepatopetal flow in 13/18 remaining pts allowing flow in 13/18 remaining pts allowing normal liver functionnormal liver function

Acute PVT: AnticoagulationAcute PVT: Anticoagulation

CondatCondat et al et al (2000): retrospective review of 33 (2000): retrospective review of 33 patients with acute PVT (recent patients with acute PVT (recent abdabd pain, no pain, no evidence of portal HTN, no portal collaterals on evidence of portal HTN, no portal collaterals on imaging)imaging)

27 pts received heparin/27 pts received heparin/coumadincoumadin and had followand had follow--up imagingup imaging 25 showed 25 showed recanalizationrecanalization2 pts received no anticoagulation and showed no 2 pts received no anticoagulation and showed no recanalizationrecanalization on followon follow--up imagingup imaging

Suggests early anticoagulation results in Suggests early anticoagulation results in recanalizationrecanalization

PVT: AnticoagulationPVT: Anticoagulation

Use in pts with chronic PVT varies secondary to Use in pts with chronic PVT varies secondary to presumed increased risk of bleedingpresumed increased risk of bleedingCondatCondat et al et al (2001) retrospectively reviewed 136 pts (2001) retrospectively reviewed 136 pts with PVT, but no cirrhosis or malignancy (84 pts with with PVT, but no cirrhosis or malignancy (84 pts with anticoagulation, 42 without)anticoagulation, 42 without)

No difference in bleeding rate, hemoglobin level on No difference in bleeding rate, hemoglobin level on admission, or subsequent transfusion requirementadmission, or subsequent transfusion requirementAnticoagulation associated with reduction in new Anticoagulation associated with reduction in new thromboticthromboticepisodesepisodes

Unclear whether group without anticoagulation was a Unclear whether group without anticoagulation was a better risk group (fewer better risk group (fewer comorbiditiescomorbidities) at presentation) at presentation

Management of GE Management of GE VariciesVaricies

Several recent prospective randomized studies Several recent prospective randomized studies showing Bshowing B--blockade and/or blockade and/or endoscopicendoscopic therapy therapy decreases rate of first bleed/decreases rate of first bleed/rebleedrebleed

All studies done on cirrhotic pts without mention of All studies done on cirrhotic pts without mention of PVTPVT

Mgmt of Mgmt of VaricesVarices in pts with PVTin pts with PVT

VleggaarVleggaar et al et al prospectively followed 21 pts with prospectively followed 21 pts with varicesvarices secondary to PVT (1982secondary to PVT (1982--1997)1997)

All treated with All treated with sclerotherapysclerotherapy at initial bleedat initial bleedFive pts Five pts rebledrebled and were again treated with and were again treated with sclerotherapysclerotherapy (two had subsequent shunt procedure)(two had subsequent shunt procedure)Pts had 95% survival at five yearsPts had 95% survival at five years

2 pts died from malignancy2 pts died from malignancy0 pts died from 0 pts died from varicealvariceal bleedingbleeding

Conclusion: Conclusion: sclerotherapysclerotherapy should be primary should be primary treatment of bleeding treatment of bleeding varicesvarices in pts with PVTin pts with PVT

Mgmt of Mgmt of VaricesVarices in Pts with PVTin Pts with PVT

ZargarZargar et al et al prospectively randomized 49 children with prospectively randomized 49 children with bleeding bleeding varicesvarices secondary to secondary to extrahepaticextrahepatic portal portal venous obstruction (EHPVO) to venous obstruction (EHPVO) to sclerotherapysclerotherapy vs. band vs. band ligationligation

Both methods equal in arresting bleeding (100%) and Both methods equal in arresting bleeding (100%) and eradiactioneradiaction of of varicesvarices (91.7% vs. 96%)(91.7% vs. 96%)Fewer sessions required in band Fewer sessions required in band ligationligation (3.9(1.1) vs. 6.1(1.7) (3.9(1.1) vs. 6.1(1.7) p<0.0001)p<0.0001)RebleedingRebleeding higher in higher in sclerotherapysclerotherapy group (25% vs. 4% group (25% vs. 4% p=0.49)p=0.49)

Conclusion: VBL safe/rapid means of eradicating Conclusion: VBL safe/rapid means of eradicating varicesvarices associated with EHPVO in childrenassociated with EHPVO in children

Mgmt of Mgmt of VaricesVarices in Pts with PVTin Pts with PVT

Use of BUse of B--blockers for prophylaxis of blockers for prophylaxis of varicealvaricealbleedingbleeding

No studies on use in PVTNo studies on use in PVTTheory that sluggish blood flow in the portal vein Theory that sluggish blood flow in the portal vein combined with combined with prothromboticprothrombotic state may encourage state may encourage thromboticthrombotic progressionprogression

Argument favors Argument favors endoscopicendoscopic therapy over Btherapy over B--blockadeblockade

Shunting Procedures in PVTShunting Procedures in PVT

General PrinciplesGeneral PrinciplesNo consensus on optimal type of surgery or timing No consensus on optimal type of surgery or timing of surgery of surgery Permanently decompresses the portal systemPermanently decompresses the portal system

Reduction in Reduction in hypersplenismhypersplenism/spleen size/spleen sizeImprovement in growth retardation in childrenImprovement in growth retardation in children

In general associated with low mortality and high In general associated with low mortality and high shunt shunt patencypatency at 5 years (95% at 15 years in one at 5 years (95% at 15 years in one series) series)

Shunting Procedures in PVTShunting Procedures in PVT

SplenorenalSplenorenal or or MesocavalMesocaval shunts used shunts used most frequently to avoid most frequently to avoid use of prosthetic materialuse of prosthetic material

Must have patent Must have patent splenicsplenicvein for vein for splenorenalsplenorenal shuntshuntSplenicSplenic vein >7mm vein >7mm preferred for preferred for patencypatency

Role of TIPS in Mgmt of PVTRole of TIPS in Mgmt of PVT

Useful in managing recurrent Useful in managing recurrent varicealvariceal bleeding in pts with bleeding in pts with cirrhosis and cirrhosis and noncavernousnoncavernousPVTPVTAll series (3) reviewed All series (3) reviewed consisted of 10 or less ptsconsisted of 10 or less ptsThrombosis treated with Thrombosis treated with either balloon angioplasty or either balloon angioplasty or thrombolysisthrombolysis with similar with similar resultsresultsComplications were minimal: Complications were minimal: recurrent bleeding after recurrent bleeding after stentstentthrombosisthrombosis

SVT: EtiologySVT: Etiology

Acute/chronic Acute/chronic pancreatitispancreatitis and pancreatic and pancreatic cancer most common causescancer most common causes

Historically pancreatic cancer more common cause Historically pancreatic cancer more common cause

AdenopathyAdenopathy from from metastaticmetastatic CA/lymphomaCA/lymphomaIatrogenic causes (Iatrogenic causes (splenectomysplenectomy, partial , partial gastrectomygastrectomy, distal , distal splenorenalsplenorenal shunt)shunt)

SVT: SVT: PathophysiologyPathophysiology

SinistralSinistral portal hypertension portal hypertension (left sided)(left sided)

Collaterals most commonly use Collaterals most commonly use short short gastricsgastricsShort Short gastricgastric azygousazygous (distal (distal esophagus)esophagus)Short gastricShort gastric coronary coronary veinvein PVPVGastroepiploicGastroepiploic veinvein SMVSMV

Results in isolated gastric Results in isolated gastric varicesvarices

SVT: Clinical ManifestationsSVT: Clinical Manifestations

Most patients asymptomaticMost patients asymptomaticShould be suspected in following group of pts:Should be suspected in following group of pts:

History of History of pancreatitispancreatitis and newly diagnosed GI and newly diagnosed GI bleedingbleedingSplenomegalySplenomegaly without portal HTN, cirrhosis, or without portal HTN, cirrhosis, or hematologichematologic diseasediseaseIsolated gastric Isolated gastric varicesvarices


VaricealVariceal Bleeding often first manifestation of SVT, but Bleeding often first manifestation of SVT, but studies show risk is lowstudies show risk is low

BernadesBernades et alet al prospectively investigated 266 pts with chronic prospectively investigated 266 pts with chronic pancreatitispancreatitis with US with US

22 pts (8%) had isolated SVT, few had 22 pts (8%) had isolated SVT, few had varicesvaricesOn follow up On follow up endoscopicendoscopic evaluation (up to 36 months), no change in evaluation (up to 36 months), no change in appearance/location of appearance/location of varicesvaricesNo episodes of bleeding during followNo episodes of bleeding during follow--upup

Bradley Bradley et alet al prospectively followed 11 pts with SVTprospectively followed 11 pts with SVTGastric or gastroGastric or gastro--esophageal esophageal varicesvarices found in 6 pts (angiography)found in 6 pts (angiography)At mean followAt mean follow--up of 6.5 years, 2 pts developed bleeding up of 6.5 years, 2 pts developed bleeding

SVT: Incidence of SVT: Incidence of VaricesVaricesAuthorAuthor nn Esophageal Esophageal

VaricesVaricesGastric Gastric VaricesVarices

Combined Combined VaricesVarices

GI bleeding GI bleeding due to due to varicesvarices

WarshawWarshaw et alet al(1987)(1987)

88 -- -- 88 22

Bradley (1987)Bradley (1987) 1111 -- 66 22

Evans Evans et alet al(1990)(1990)

1212 -- 1010 -- 1010

BernadesBernades et alet al(1992)(1992)

2222 -- -- 22 11


Other signs/symptoms:Other signs/symptoms:SplenomegalySplenomegaly with rare with rare leukopenialeukopenia, , thrombocytopenia, or thrombocytopenia, or splenicsplenic painpainAbdominal painAbdominal pain

Chronic Chronic pancreatitispancreatitis, , pseudocystpseudocyst, carcinoma, carcinoma

SVT: DiagnosisSVT: Diagnosis

UltrasonographyUltrasonography initial testinitial testAccuracy may be limited by Accuracy may be limited by size/location of veinsize/location of veinIf patent, normalIf patent, normal--appearing appearing splenicsplenic vein seen, SVT unlikelyvein seen, SVT unlikely

Venous phase angiographyVenous phase angiographyGold standard confirmatory Gold standard confirmatory testtestLocalizes obstruction and Localizes obstruction and routes of collateralizationroutes of collateralization

SVT: ManagementSVT: Management

SclerotherapySclerotherapy::Gastric Gastric varicesvarices controlled in approx. 2/3 of active controlled in approx. 2/3 of active bleedsbleeds

Gastric banding:Gastric banding:One prospective trial of 8 pts showed successful One prospective trial of 8 pts showed successful eradication of eradication of varicesvarices in 85% (7/8)in 85% (7/8)

Only one pt had isolated gastric Only one pt had isolated gastric varicesvarices, none evaluated , none evaluated for SVTfor SVT


SplenectomySplenectomy: : Treatment of choice for Treatment of choice for bleeding bleeding varicesvaricesassociated with isolated associated with isolated SVTSVTEliminates venous Eliminates venous collateral outflow, collateral outflow, decompresses decompresses surrounding surrounding varicesvaricesAbility to treat pancreatic Ability to treat pancreatic pathology pathology

SVT: SVT: ManagmentManagment

Pts with asymptomatic Pts with asymptomatic varicesvarices::Role of Role of splenectomysplenectomy is is contraversialcontraversialDue to relatively low risk of bleeding, observation is Due to relatively low risk of bleeding, observation is appropriateappropriateIf pt undergoing If pt undergoing laparotomylaparotomy for other reason, for other reason, splenectomysplenectomy is advisedis advised


SplenicSplenic arterial arterial embolizationembolization::Rarely studiedRarely studiedAssociated with Associated with splenicsplenic abscess (25%)abscess (25%)Pts with high operative riskPts with high operative riskPts with diffuse Pts with diffuse metastaticmetastatic diseasedisease

ReferencesReferencesBernadesBernades P. et al. P. et al. SplenicSplenic and Portal venous obstruction in chronic and Portal venous obstruction in chronic pancreatitispancreatitis. . Dig. Dis. Dig. Dis. SciSci.. 1992;37:3401992;37:340--346.346.Blum, U. et al. Blum, U. et al. NoncavernomatousNoncavernomatous PVT in Hepatic Cirrhosis: Treatment with TIPS and local PVT in Hepatic Cirrhosis: Treatment with TIPS and local thrombolysisthrombolysis. . RadiologyRadiology 1995; 1995; 195:153195:153--157.157.Bradley EL. The natural history of Bradley EL. The natural history of splenicsplenic vein thrombosis due to chronic vein thrombosis due to chronic pancreatitispancreatitis: indications for surgery. : indications for surgery. Int. J. Int. J. PancreatolPancreatol. . 1987;2:871987;2:87--92.92.CondatCondat, B. et al. Current Outcome of Portal Vein Thrombosis in adults:, B. et al. Current Outcome of Portal Vein Thrombosis in adults: Risks and benefits of anticoagulant therapy. Risks and benefits of anticoagulant therapy. CondatCondat, B. et al. Recent portal or mesenteric thrombosis: increased re, B. et al. Recent portal or mesenteric thrombosis: increased recognition and frequent cognition and frequent recanalizationrecanalization on anticoagulant on anticoagulant therapy. therapy. HepatologyHepatology. 2000;32:466. 2000;32:466--470.470.Evans GRD, et al. Evans GRD, et al. SinistralSinistral portal hypertension. portal hypertension. Am. Am. SurgSurg. 1990;56:758. 1990;56:758--763.763.Ganger, D. et al. TIPS for BuddGanger, D. et al. TIPS for Budd--ChiariChiari Syndrome or PVT. Syndrome or PVT. Am. J. Am. J. GastroenterolGastroenterol. 1999;94:603. 1999;94:603--608.608.HidajatHidajat, N. Imaging and radiological interventions of portal vein throm, N. Imaging and radiological interventions of portal vein thrombosis. bosis. ActaActa. . RadiolRadiol. 2005;4:336. 2005;4:336--343. 343. SakorafasSakorafas, GH. , GH. SplenicSplenic Vein Thrombosis Complicating Chronic Vein Thrombosis Complicating Chronic PancreatitisPancreatitis. . Scand J Scand J GastroenterolGastroenterol. 1999; 12:1171. 1999; 12:1171--1177.1177.Sharon et al. Sharon et al. SplenicSplenic Vein Thrombosis and GI Bleeding in Chronic Vein Thrombosis and GI Bleeding in Chronic PancreatitisPancreatitis. . World J. World J. SurgSurg. 27, 1271. 27, 1271--1274, 2003.1274, 2003.Simpson, W. et al. Simpson, W. et al. SplenicSplenic Vein Thrombosis. South. Med. J. 1990;83:417Vein Thrombosis. South. Med. J. 1990;83:417--421.421.VleggarVleggar, FP. et al. , FP. et al. EndoscopicEndoscopic SclerotherapySclerotherapy for bleeding for bleeding esophagelesophagel varicesvarices secondary to secondary to extrahepaticextrahepatic portal vein obstruction in an portal vein obstruction in an adult adult caucasiancaucasian population. population. EurEur. J. . J. GastroenterolGastroenterol. . HepatolHepatol. 1998;10:81. 1998;10:81--85.85.Wang, Wang, JingJing--Tong. Portal Vein Thrombosis. Tong. Portal Vein Thrombosis. HepatHepat. . PancPanc. Dis. Int. . Dis. Int. 2005;4:5152005;4:515--518.518.WarshawWarshaw AL, et al. Recognition and clinical implications of mesenteric AL, et al. Recognition and clinical implications of mesenteric and portal vein obstruction in chronic and portal vein obstruction in chronic pancreatitispancreatitis. . Arch. Arch. SurgSurg. 1987; 122:410. 1987; 122:410--415.415.Webster, G. et al. Portal Vein ThrombosisWebster, G. et al. Portal Vein Thrombosis——new insights into etiology and management. new insights into etiology and management. Aliment. Aliment. PharmacolPharmacol. . TherTher. 2005;21:1. 2005;21:1--9.9.Wolff, M. Current state of Wolff, M. Current state of portosystemicportosystemic shunt surgery. shunt surgery. Lang. Arch. Lang. Arch. SurgSurg. . 2003;388:1412003;388:141--149.149.ZargarZargar, SA et al. , SA et al. EndoscopicEndoscopic ligationligation compared with compared with sclerotherapysclerotherapy for bleeding esophageal for bleeding esophageal varicesvarices in children with in children with extrahepaticextrahepaticportal venous obstruction. portal venous obstruction. HepatologyHepatology. 2002;36:666. 2002;36:666--672.672.

optimal management of splenic/portal vein thrombosis

Documents