Transjugular Thrombolysis and Stent-Graft Implantation for Acute Portal Vein Aneurysm Thrombosis.

A 68-year-old man presented with a 10-day history of mild abdominal pain. A computed tomography scan revealed acute splanchnic vein thrombosis and a portal vein (PV) aneurysm (Fig. 1) . He was clinically stable and without signs of mesenteric ischemia. Anticoagulant therapy was initiated. Based on the large extent of thrombosis and the objective to avoid chronic portal hypertension, the patient underwent transjugular portal venography, thrombectomy, and lysis 4 days later. The right PV was accessed from the middle hepatic vein under transcutaneous ultrasound (US) guidance using a transjugular intrahepatic portosystemic shunt (TIPS) puncture needle (Optimed Medizinische Instrumente, Ettlingen, Germany). Angiography catheters (4-F Cobra and 5-F Berenstein; Cordis, Miami Lakes, Florida) and guide wires were used to advance through the thrombosed PV aneurysm into the occluded splenic vein (SV) and superior mesenteric vein (SMV). Thrombus within those 2 veins was aspirated through a 10-F introducer sheath (Flexor Check-Flo; Cook Medical, Bloomington, Indiana). A stone basket (20-mm VorticCatchV; Olympus, Tokyo, Japan) was used to fragment the refractory thrombus within the SMV, and balloon angioplasty of the SMV was performed (10-mm Mustang; Boston Scientific, Marlborough, Massachusetts). Next, a balloon-expandable stent-graft (11-mm × 79-mm Viabahn VBX; W. L. Gore, Flagstaff, Arizona) was implanted into the PV, extending from the splenomesenteric venous confluence to the PV bifurcation, completely excluding the aneurysm. The stent-graft was initially deployed to a diameter of 9.5 mm. Thereafter, the caudal third was flared to 16 mm (Atlas Gold; BD, Franklin Lakes, New Jersey). Next, a self-expanding stent-graft (10 mm x 10 cm; Viabahn; W. L. Gore) was deployed in the intraparenchymal tract, with its portal end overlapped with the first stent-graft by 10 mm and its cranial end at the junction of the hepatic vein and the inferior vena cava. The TIPS was created to provide outflow because the intrahepatic PV was completely thrombosed and expected to respond poorly to thrombolysis. The Viabahn stent-graft and cranial two-thirds of the VBX stent-graft were dilated to 10 mm (Mustang). Two US-assisted thrombolysis infusion catheters with 12-cm treatment zones (Ekosonic Endovascular System; Boston Scientific) were placed into the SMV and SV through the jugular 12-F sheath (Check-Flo Performer; Cook Medical). The patient was transferred to an intermediate care unit, and thrombolysis was performed with continuous infusion of alteplase 0.5 mg/h via each of the 2 lysis catheters. The 2 parallel lysis catheters caused leakage of blood through the sheath’s hemostatic valve, requiring a regular exchange of a superabsorbent dressing wrapped around the valve. Anticoagulant therapy was continued using low–molecular weight heparin (enoxaparin 60 mg subcutaneously twice daily). The next day, venography showed almost complete resolution of splanchnic thrombosis and patent stent-grafts. Collateral varices originating from the SV were occluded with embolization coils (Interlock-35 and Vortx; Boston Scientific) to improve hepatopetal blood flow. The lysis catheters and sheath were removed. The hospital course was complicated by nosocomial pneumonia, which was successfully treated with antibiotics. Laboratory tests revealed no evidence of an underlying hematologic disease or coagulation disorder. The following week, a computed tomography scan confirmed patent splanchnic veins and stent-grafts with an excluded aneurysm. Anticoagulant therapy was continued with apixaban (5 mg twice daily). After 8 weeks, the patient was asymptomatic, and US examination with Doppler showed patent stents. This case report did not require institutional review board approval. Acute, noncirrhotic, nonmalignant PV thrombosis is a rare condition, with a prevalence of approximately 0.3% in Western Europe. Risk factors for noncirrhotic PV thrombosis include systemic disorders in 50%–60% of cases, predominantly myeloproliferative neoplasms and JAK2 V617F mutation (1Intagliata N.M. Caldwell S.H. Tripodi A. Diagnosis, development, and treatment of portal vein thrombosis in patients with and without cirrhosis.Gastroenterology. 2019; 156: 1582-1599.e1Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar,2Rössle M. Bettinger D. Trebicka J. et al.A prospective, multicentre study in acute non-cirrhotic, non-malignant portal vein thrombosis: comparison of medical and interventional treatment.Aliment Pharmacol Ther. 2020; 52: 329-339Crossref PubMed Scopus (25) Google Scholar). For extensive thrombosis, routine anticoagulant therapy or systemic lysis is of limited effectiveness, and pharmacomechanical thrombolysis with or without TIPS creation may avert complications of portal hypertension while incurring a low rate of severe adverse events (2Rössle M. Bettinger D. Trebicka J. et al.A prospective, multicentre study in acute non-cirrhotic, non-malignant portal vein thrombosis: comparison of medical and interventional treatment.Aliment Pharmacol Ther. 2020; 52: 329-339Crossref PubMed Scopus (25) Google Scholar,3Kohlbrenner R. Schwertner A.B. Vogel A.R. Conrad M. Lokken R.P. Large thrombosed portomesenteric venous aneurysm treated with pharmacomechanical thrombolysis combined with TIPS placement.CVIR Endovasc. 2022; 5: 11Crossref PubMed Scopus (2) Google Scholar). PV aneurysm is a yet rarer condition, with an incidence of 0.06%. It is defined as a PV diameter of ≥20 mm in patients with liver cirrhosis and a PV diameter of ≥16 mm in patients without cirrhosis (4Laurenzi A. Ettorre G.M. Lionetti R. Meniconi R.L. Colasanti M. Vennarecci G. Portal vein aneurysm: what to know.Dig Liver Dis. 2015; 47: 918-923Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar). PV aneurysms may present with thrombosis, rupture, or obstruction of adjacent structures, including the inferior vena cava or duodenum. It was not evident whether a stenosis or other factors caused the formation of the aneurysm in this patient.