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Portal and Hepatic Venous Intervention
Ethan Yiyang Lin, MD; Joshua Kuban, MD; Jennifer R. Buckley, MD, MBA
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Definitions

            • Hepatic venous outflow obstruction
              • 3 categories based on level of obstruction
                • Venoocclusive disease: Sinusoids and terminal venules
                  • Toxin-induced nonthrombotic obstruction
                  • Often occurs after stem cell transplant, chemotherapy, or radiotherapy
                • Budd-Chiari syndrome (BCS)
                  • Pain, ascites, liver enlargement caused by hepatic vein occlusion
                • Congestive hepatopathy
                  • Passive hepatic congestion, usually related to right heart failure (e.g., tricuspid regurgitation, cor pulmonale)
              • Associated problems of hepatic venous outflow obstruction
                • Cirrhosis
                • Portal HTN
                • Hepatic/portal vein thrombosis (HVT/PVT)
            • HVT: Acute or chronic, complete or partial occlusion of hepatic veins ± extension into inferior vena cava (IVC)
              • Usually due to BCS
                • Primary
                  • Intraluminal thrombosis or webs
                  • Atypical myeloproliferative disease present in 50%
                  • Etiologies also include pregnancy, polycythemia vera, Behçet disease, paroxysmal nocturnal hemoglobinuria
                • Secondary
                  • Nonthrombotic
                  • Intraluminal invasion (e.g., tumor) or extraluminal compression
              • Can lead to portal HTN and related complications
            • PVT: Acute or chronic, complete or partial occlusion of portal vein ± extension into mesenteric or splenic veins
              • Local causes
                • Cirrhosis (28%)
                • Abdominal malignancy (27-44%)
                • Inflammatory conditions (10%)
                  • e.g., diverticulitis, pancreatitis, appendicitis, inflammatory bowel disease
                • Intraabdominal infection
                • Portal vein injury
              • Systemic causes
                • Inherited thrombophilia (20%)
                  • e.g., factor V Leiden, prothrombin mutation
                • Acquired thrombophilia
                  • Myelodysplastic syndrome (11%)
                  • Others: Pregnancy, hormone use (including oral contraceptive pills), antiphospholipid syndrome, etc.
              • Mortality rates without treatment; justify risk of endovascular treatment after failed anticoagulation
                • < 10%: Chronic PVT in patient without cirrhosis or malignancy
                • 26%: Chronic PVT in patient with cirrhosis &/or malignancy
                • 20-50%: Acute PVT with evidence of bowel ischemia/infarct
            • Clinical presentation
              • Acute thrombosis: Spectrum depends on severity
                • Right upper quadrant tenderness ± hepatomegaly
                • Jaundice, ascites
                • Findings of bowel ischemia/infarction with PVT/portomesenteric venous stenosis (PMVS)
                  • Abdominal pain
                  • Nausea, vomiting, diarrhea
                  • Fever, sepsis
              • Chronic thrombosis: Symptoms related to portal HTN
                • Ascites
                • Varices ± bleeding
                • Splenomegaly and thrombocytopenia
                • Portal hypertensive gastropathy, enteropathy, and colopathy
            • PMVS
              • Most commonly impacts patients with pancreaticobiliary cancers
              • Etiologies
                • Extrinsic compression from malignant tissue or lymph nodes
                • Direct tumor invasion leading to portal vein tumor thrombus
                • Bland thrombus due to underlying liver cirrhosis or hypercoagulable states from underlying malignancy
                • Postsurgical or radiation periportal fibrosis
              • Symptoms can be multifactorial in cancer patients
              • No guidelines or consensus statements on best practices for when to intervene in patients with PMVS
              • Decision for intervention tailored to patient's goals of care in multidisciplinary discussion

          PREPROCEDURE

          • Indications

            • Contraindications

              • Disease Stratification and Treatment of PMVS

                • Preprocedure Imaging

                  • Getting Started

                    PROCEDURE

                    • Patient Position/Location

                      • Procedure Steps

                        • Alternative Procedures/Therapies

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Sare A et al: Safety and efficacy of endovascular treatment of portal vein stenosis in liver transplant recipients: a systematic review. Vasc Endovascular Surg. 55(5):452-60, 2021
                              2. Park JH et al: Portal vein stent for symptomatic malignant portal vein stenosis: a single-center experience. Curr Probl Cancer. 44(2):100476, 2020
                              3. Thompson SM et al: Portomesenteric venous complications after pancreatic surgery with venous reconstruction: imaging and intervention. Radiographics. 40(2):531-44, 2020
                              4. Sheth RA et al: Portomesenteric venous stenting for palliation of ascites and variceal bleeding caused by prehepatic portal hypertension. Oncologist. 23(6):712-18, 2018
                              5. Sharma AM et al: Portal vein thrombosis: when to treat and how? Vasc Med. 21(1):61-9, 2016
                              6. Nery F et al: Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology. 61(2):660-7, 2015
                              7. Abdel-Aal AK et al: Endovascular treatment of acute portal vein thrombosis using ultrasound-accelerated catheter-directed thrombolysis. Vasc Endovascular Surg. 48(7-8):460-5, 2014
                              8. Wang MQ et al: Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route. Abdom Imaging. 36(4):390-8, 2011
                              9. Ponziani FR et al: Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol. 16(2):143-55, 2010
                              10. Liu FY et al: Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis. World J Gastroenterol. 15(40):5028-34, 2009
                              11. Novellas S et al: Palliative portal vein stent placement in malignant and symptomatic extrinsic portal vein stenosis or occlusion. Cardiovasc Intervent Radiol. 32(3):462-70, 2009
                              12. Darcy M: Single-session treatment of portal vein thrombosis using combined pharmacomechanical thrombolysis. Semin Intervent Radiol. 24(3):327-32, 2007
                              13. Ferro C et al: Transjugular intrahepatic portosystemic shunt, mechanical aspiration thrombectomy, and direct thrombolysis in the treatment of acute portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol. 30(5):1070-4, 2007
                              14. Semiz-Oysu A et al: Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system. Cardiovasc Intervent Radiol. 30(4):688-95, 2007
                              15. Kim HS et al: Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J Vasc Interv Radiol. 16(12):1685-91, 2005
                              16. Bilbao JI et al: Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol. 27(5):474-80, 2004
                              17. Kumar S et al: Mesenteric venous thrombosis. N Engl J Med. 345(23):1683-8, 2001
                              18. Miller VE et al: Pulsed Doppler duplex sonography and CT of portal vein thrombosis. AJR Am J Roentgenol. 145(1):73-6, 1985
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      TERMINOLOGY

                                      • Definitions

                                        • Hepatic venous outflow obstruction
                                          • 3 categories based on level of obstruction
                                            • Venoocclusive disease: Sinusoids and terminal venules
                                              • Toxin-induced nonthrombotic obstruction
                                              • Often occurs after stem cell transplant, chemotherapy, or radiotherapy
                                            • Budd-Chiari syndrome (BCS)
                                              • Pain, ascites, liver enlargement caused by hepatic vein occlusion
                                            • Congestive hepatopathy
                                              • Passive hepatic congestion, usually related to right heart failure (e.g., tricuspid regurgitation, cor pulmonale)
                                          • Associated problems of hepatic venous outflow obstruction
                                            • Cirrhosis
                                            • Portal HTN
                                            • Hepatic/portal vein thrombosis (HVT/PVT)
                                        • HVT: Acute or chronic, complete or partial occlusion of hepatic veins ± extension into inferior vena cava (IVC)
                                          • Usually due to BCS
                                            • Primary
                                              • Intraluminal thrombosis or webs
                                              • Atypical myeloproliferative disease present in 50%
                                              • Etiologies also include pregnancy, polycythemia vera, Behçet disease, paroxysmal nocturnal hemoglobinuria
                                            • Secondary
                                              • Nonthrombotic
                                              • Intraluminal invasion (e.g., tumor) or extraluminal compression
                                          • Can lead to portal HTN and related complications
                                        • PVT: Acute or chronic, complete or partial occlusion of portal vein ± extension into mesenteric or splenic veins
                                          • Local causes
                                            • Cirrhosis (28%)
                                            • Abdominal malignancy (27-44%)
                                            • Inflammatory conditions (10%)
                                              • e.g., diverticulitis, pancreatitis, appendicitis, inflammatory bowel disease
                                            • Intraabdominal infection
                                            • Portal vein injury
                                          • Systemic causes
                                            • Inherited thrombophilia (20%)
                                              • e.g., factor V Leiden, prothrombin mutation
                                            • Acquired thrombophilia
                                              • Myelodysplastic syndrome (11%)
                                              • Others: Pregnancy, hormone use (including oral contraceptive pills), antiphospholipid syndrome, etc.
                                          • Mortality rates without treatment; justify risk of endovascular treatment after failed anticoagulation
                                            • < 10%: Chronic PVT in patient without cirrhosis or malignancy
                                            • 26%: Chronic PVT in patient with cirrhosis &/or malignancy
                                            • 20-50%: Acute PVT with evidence of bowel ischemia/infarct
                                        • Clinical presentation
                                          • Acute thrombosis: Spectrum depends on severity
                                            • Right upper quadrant tenderness ± hepatomegaly
                                            • Jaundice, ascites
                                            • Findings of bowel ischemia/infarction with PVT/portomesenteric venous stenosis (PMVS)
                                              • Abdominal pain
                                              • Nausea, vomiting, diarrhea
                                              • Fever, sepsis
                                          • Chronic thrombosis: Symptoms related to portal HTN
                                            • Ascites
                                            • Varices ± bleeding
                                            • Splenomegaly and thrombocytopenia
                                            • Portal hypertensive gastropathy, enteropathy, and colopathy
                                        • PMVS
                                          • Most commonly impacts patients with pancreaticobiliary cancers
                                          • Etiologies
                                            • Extrinsic compression from malignant tissue or lymph nodes
                                            • Direct tumor invasion leading to portal vein tumor thrombus
                                            • Bland thrombus due to underlying liver cirrhosis or hypercoagulable states from underlying malignancy
                                            • Postsurgical or radiation periportal fibrosis
                                          • Symptoms can be multifactorial in cancer patients
                                          • No guidelines or consensus statements on best practices for when to intervene in patients with PMVS
                                          • Decision for intervention tailored to patient's goals of care in multidisciplinary discussion

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Disease Stratification and Treatment of PMVS

                                            • Preprocedure Imaging

                                              • Getting Started

                                                PROCEDURE

                                                • Patient Position/Location

                                                  • Procedure Steps

                                                    • Alternative Procedures/Therapies

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Sare A et al: Safety and efficacy of endovascular treatment of portal vein stenosis in liver transplant recipients: a systematic review. Vasc Endovascular Surg. 55(5):452-60, 2021
                                                          2. Park JH et al: Portal vein stent for symptomatic malignant portal vein stenosis: a single-center experience. Curr Probl Cancer. 44(2):100476, 2020
                                                          3. Thompson SM et al: Portomesenteric venous complications after pancreatic surgery with venous reconstruction: imaging and intervention. Radiographics. 40(2):531-44, 2020
                                                          4. Sheth RA et al: Portomesenteric venous stenting for palliation of ascites and variceal bleeding caused by prehepatic portal hypertension. Oncologist. 23(6):712-18, 2018
                                                          5. Sharma AM et al: Portal vein thrombosis: when to treat and how? Vasc Med. 21(1):61-9, 2016
                                                          6. Nery F et al: Causes and consequences of portal vein thrombosis in 1,243 patients with cirrhosis: results of a longitudinal study. Hepatology. 61(2):660-7, 2015
                                                          7. Abdel-Aal AK et al: Endovascular treatment of acute portal vein thrombosis using ultrasound-accelerated catheter-directed thrombolysis. Vasc Endovascular Surg. 48(7-8):460-5, 2014
                                                          8. Wang MQ et al: Acute symptomatic mesenteric venous thrombosis: treatment by catheter-directed thrombolysis with transjugular intrahepatic route. Abdom Imaging. 36(4):390-8, 2011
                                                          9. Ponziani FR et al: Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol. 16(2):143-55, 2010
                                                          10. Liu FY et al: Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis. World J Gastroenterol. 15(40):5028-34, 2009
                                                          11. Novellas S et al: Palliative portal vein stent placement in malignant and symptomatic extrinsic portal vein stenosis or occlusion. Cardiovasc Intervent Radiol. 32(3):462-70, 2009
                                                          12. Darcy M: Single-session treatment of portal vein thrombosis using combined pharmacomechanical thrombolysis. Semin Intervent Radiol. 24(3):327-32, 2007
                                                          13. Ferro C et al: Transjugular intrahepatic portosystemic shunt, mechanical aspiration thrombectomy, and direct thrombolysis in the treatment of acute portal and superior mesenteric vein thrombosis. Cardiovasc Intervent Radiol. 30(5):1070-4, 2007
                                                          14. Semiz-Oysu A et al: Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system. Cardiovasc Intervent Radiol. 30(4):688-95, 2007
                                                          15. Kim HS et al: Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis. J Vasc Interv Radiol. 16(12):1685-91, 2005
                                                          16. Bilbao JI et al: Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients. Cardiovasc Intervent Radiol. 27(5):474-80, 2004
                                                          17. Kumar S et al: Mesenteric venous thrombosis. N Engl J Med. 345(23):1683-8, 2001
                                                          18. Miller VE et al: Pulsed Doppler duplex sonography and CT of portal vein thrombosis. AJR Am J Roentgenol. 145(1):73-6, 1985