Successful recanalization of acute extensive portal vein thrombosis by aspiration thrombectomy and thrombolysis via an operatively placed mesenteric catheter: a case report.

Norifumi Kennoki,Jun Otaka,Natsuhiko Shirota,Kiyoshi Koizumi,Koichi Tomita,Koichi Tokuuye,Toru Sano,Naokazu Chiba,Kunihito Suzuki,Shigeyuki Kawachi,Toru Saguchi,Tomohisa Moriya

doi:10.1259/bjrcr.20180022

Abstract

Portal vein thrombosis (PVT) after hepatobiliary surgery is rare but can cause lethal and severe complications. If early diagnosis and recanalization can be achieved, the PVT is expected to be eliminated. A 70-year-old male was diagnosed as having hepatocellular carcinoma occupying the right lobe of the liver. As oligometastatic lung tumors were simultaneously detected on contrast-enhanced CT (CECT), hepatectomy was not indicated. However, the primary tumor was very large, and as large tumor size can be associated with an unfavorable prognosis, and owing to the strong desire of the patient, he underwent right lobe hepatectomy. Jaundice appeared on post-operative Day (POD) 2 and CECT displayed slight intraheptatic bile duct dilation. However, a PVT did not exist at this time. Percutaneous transhepatic biliary drainage was performed and Doppler echo displayed intrahepatic and extrahepatic PVT on post-operative Day 5. Emergent thrombectomy was performed using a Vasplyser PlusTM thrombus aspiration catheter (Johnson & Johnson K.K. Medical Company, Tokyo, Japan) via the ileocolic vein under laparotomy. The mesenteric catheter was placed at the distal point of the residual PVT. Thrombolysis and anticoagulant therapy were performed using heparin and urokinase. In the CECT performed 16 days after the additional operation, the PVT had disappeared and the portal vein was completely recanalized. The mesenteric catheter was removed on the same day and oral anticoagulant therapy was continued. At the time of writing, 14 months have passed with no recurrence of PVT. Early diagnosis of PVT enables treatment with emergent thrombectomy, thrombolysis, and anticoagulant therapy. These treatments result in the improvement of portal vein flow and the complete disappearance of PVT.

Highlights

The standard therapy for portal vein thrombosis (PVT) is systemic anticoagulant therapy
We report a case in which acute PVT was found incidentally after hepatectomy, and successful recanalization was achieved by rapid interventional treatment
Contrastenhanced CT (CECT) 16 days after the additional operation showed that the PVT had completely disappeared (Figure 5c), and the mesenteric catheter was removed on the same day. i.v. heparin administration was stopped and switched to 300 mg day−1 edoxaban orally

Summary

Background

The standard therapy for portal vein thrombosis (PVT) is systemic anticoagulant therapy. In addition to systemic anticoagulation therapy, interventional treatments, such as aspiration thrombectomy and continuous thrombolytic therapy using an indwelling mesenteric catheter have been reported to be useful.[1,2,3,4] Here, we report a case in which acute PVT was found incidentally after hepatectomy, and successful recanalization was achieved by rapid interventional treatment. When an abdominal Doppler echo was performed to puncture the dilated bile duct during percutaneous transhepatic biliary drainage (PTBD) on POD 5, no intrahepatic portal vein was detected. Plain CT was immediately performed and numerous portal vein thrombi were confirmed (Figure 2c). CECT 16 days after the additional operation showed that the PVT had completely disappeared (Figure 5c), and the mesenteric catheter was removed on the same day. At the time of writing, the patient has been alive for 1 year and 2 months after the additional operation, and no further thrombosis nor portal hypertension have occurred

Findings

Discussion

Conclusion