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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)
- Venoocclusive disease: Sinusoids and terminal venules
- Associated problems of hepatic venous outflow obstruction
- Cirrhosis, portal hypertension (HTN), hepatic/portal vein thrombosis
- 3 categories based on level of obstruction
- Hepatic vein thrombosis (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
- Primary
- Can lead to portal HTN and related complications
- Usually due to BCS
- Portal vein thrombosis (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
- Local causes
- Clinical presentation
- Acute thrombosis: Spectrum depends on severity
- Right upper quadrant tenderness ± hepatomegaly
- Jaundice, ascites
- Findings of bowel ischemia/infarction with PVT
- Abdominal pain
- Nausea, vomiting, diarrhea
- Fever, sepsis
- Chronic thrombosis: Symptoms related to portal HTN
- Ascites
- Development of varices ± bleeding
- Splenomegaly
- Acute thrombosis: Spectrum depends on severity
- Hepatic venous outflow obstruction
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
OUTCOMES
Complications
Expected Outcomes
Selected References
- Sharma AM et al: Portal vein thrombosis: when to treat and how? Vasc Med. 21(1):61-9, 2016
- 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
- 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
- Ponziani FR et al: Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol. 16(2):143-55, 2010
- Liu FY et al: Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis. World J Gastroenterol. 15(40):5028-34, 2009
- Semiz-Oysu A et al: Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system. Cardiovasc Intervent Radiol. 2007 Jul-Aug;30(4):688-95. Erratum in: Cardiovasc Intervent Radiol. 31(1):232, 2008
- Darcy M: Single-session treatment of portal vein thrombosis using combined pharmacomechanical thrombolysis. Semin Intervent Radiol. 24(3):327-32, 2007
- 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
- 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
- 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
- Kumar S et al: Mesenteric venous thrombosis. N Engl J Med. 345(23):1683-8, 2001
- Miller VE et al: Pulsed Doppler duplex sonography and CT of portal vein thrombosis. AJR Am J Roentgenol. 145(1):73-6, 1985
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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)
- Venoocclusive disease: Sinusoids and terminal venules
- Associated problems of hepatic venous outflow obstruction
- Cirrhosis, portal hypertension (HTN), hepatic/portal vein thrombosis
- 3 categories based on level of obstruction
- Hepatic vein thrombosis (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
- Primary
- Can lead to portal HTN and related complications
- Usually due to BCS
- Portal vein thrombosis (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
- Local causes
- Clinical presentation
- Acute thrombosis: Spectrum depends on severity
- Right upper quadrant tenderness ± hepatomegaly
- Jaundice, ascites
- Findings of bowel ischemia/infarction with PVT
- Abdominal pain
- Nausea, vomiting, diarrhea
- Fever, sepsis
- Chronic thrombosis: Symptoms related to portal HTN
- Ascites
- Development of varices ± bleeding
- Splenomegaly
- Acute thrombosis: Spectrum depends on severity
- Hepatic venous outflow obstruction
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
OUTCOMES
Complications
Expected Outcomes
Selected References
- Sharma AM et al: Portal vein thrombosis: when to treat and how? Vasc Med. 21(1):61-9, 2016
- 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
- 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
- Ponziani FR et al: Portal vein thrombosis: insight into physiopathology, diagnosis, and treatment. World J Gastroenterol. 16(2):143-55, 2010
- Liu FY et al: Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis. World J Gastroenterol. 15(40):5028-34, 2009
- Semiz-Oysu A et al: Interventional radiological management of prehepatic obstruction of [corrected] the splanchnic venous system. Cardiovasc Intervent Radiol. 2007 Jul-Aug;30(4):688-95. Erratum in: Cardiovasc Intervent Radiol. 31(1):232, 2008
- Darcy M: Single-session treatment of portal vein thrombosis using combined pharmacomechanical thrombolysis. Semin Intervent Radiol. 24(3):327-32, 2007
- 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
- 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
- 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
- Kumar S et al: Mesenteric venous thrombosis. N Engl J Med. 345(23):1683-8, 2001
- Miller VE et al: Pulsed Doppler duplex sonography and CT of portal vein thrombosis. AJR Am J Roentgenol. 145(1):73-6, 1985
