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Power-Pulse Thrombolysis, Thrombectomy, and TIPS Formation for the Accelerated Treatment of Portosplenomesenteric Thrombosis in Budd Chiari Syndrome

2007; Elsevier BV; Volume: 18; Issue: 11 Linguagem: Inglês

10.1016/j.jvir.2007.07.032

1535-7732

Ziv J. Haskal,

Blood Coagulation and Thrombosis Mechanisms

The transjugular intrahepatic portosystemic shunt (TIPS) has proved to be a useful tool in the treatment of Budd-Chiari syndrome and portal system thromboses (1Rossle M. Olschewski M. Siegerstetter V. Berger E. Kurz K. Grandt D. The Budd-Chiari syndrome: outcome after treatment with the transjugular intrahepatic portosystemic shunt.Surgery. 2004; 135: 394-403Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Hernandez-Guerra M. Turnes J. Rubinstein P. et al.PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome.Hepatology. 2004; 40: 1197-1202Crossref PubMed Scopus (124) Google Scholar). Chronic thromboses are typically addressed with mechanical means such as balloon angioplasty and stent placement, whereas more acute thromboses require potentially prolonged catheter-directed infusions of thrombolytic agents (3Bilbao J.I. Elorz M. Vivas I. Martinez-Cuesta A. Bastarrika G. Benito A. Transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of venous symptomatic chronic portal thrombosis in non-cirrhotic patients.Cardiovasc Intervent Radiol. 2004; 27: 474-480Crossref PubMed Scopus (81) Google Scholar, 4Hollingshead M. Burke C.T. Mauro M.A. Weeks S.M. Dixon R.G. Jaques P.F. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis.J Vasc Interv Radiol. 2005; 16: 651-661Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar, 5Kim H.S. Patra A. Khan J. Arepally A. Streiff M.B. Transhepatic catheter-directed thrombectomy and thrombolysis of acute superior mesenteric venous thrombosis.J Vasc Interv Radiol. 2005; 16: 1685-1691Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar, 6Kori I. Bar-Zohar D. Carmiel-Haggai M. et al.Budd-Chiari syndrome and acute portal vein thrombosis: management by a transjugular intrahepatic portosystemic shunt (TIPS) and portal vein interventions via a TIPS.J Gastrointest Surg. 2006; 10: 417-421Crossref PubMed Scopus (14) Google Scholar, 7Stein M. Link D.P. Symptomatic spleno-mesenteric-portal venous thrombosis: recanalization and reconstruction with endovascular stents.J Vasc Interv Radiol. 1999; 10: 363-371Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 8Sehgal M. Haskal Z.J. Use of transjugular intrahepatic portosystemic shunts during lytic therapy of extensive portal splenic and mesenteric venous thrombosis: long-term follow-up.J Vasc Interv Radiol. 2000; 11: 61-65Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar). Herein I report on a patient in whom rapid power-pulse thrombolysis from within the portal, splenic, and mesenteric veins was accomplished twice successfully as part of portal decompression and TIPS formation. A 39-year-old man was referred to the interventional radiology department with a 5-week history of increasing abdominal girth, worsening jaundice, abdominal pain, elevated liver function tests, and portal vein thrombosis. Magnetic resonance images were suggestive of hepatic vein outflow obstruction due to the characteristic patchy liver perfusion, sparing of the caudate lobe, and compression of the inferior vena cava (IVC). Review of findings from liver biopsy performed at an outside institution revealed sinusoidal dilatation, congestion, and hepatocellular dropout and necrosis. At presentation, notable laboratory test results included an aspartate aminotransferase level of 145 U/L (normal, 12–38 U/L), serum ammonia level of 139 μmol/L (normal, 11–35 μmol/L), serum creatinine level of 1.7 mg/dL (150 μmol/L), prothrombin time of 18.8 seconds (normal, 12.7–15.4 seconds), and serum bilirubin level that had more than doubled to 7.8 mg/dL (136 μmol/L) in less than 1 month. One month earlier, his platelet count was 670 × 109/L but had dropped to 53 × 109/L at TIPS placement. At referral, the patient had developed massive ascites. Venography demonstrated smooth compression of the intrahepatic IVC with an 18 mm Hg gradient between the infrahepatic IVC and right atrium. In addition, at wedged hepatic contrast medium injection, a classic pattern of chronic hepatic vein thrombosis and racemose spider web pattern collateral vessels was seen—the confirmatory characteristic of Budd-Chiari syndrome. With use of a transcaval approach and external ultrasonographic (US) guidance, a coaxial 65-cm-long 21-gauge Chiba needle (Cook, Bloomington, Ind) was inserted through a standard TIPS set to access the thrombosed branch of the left portal vein and, ultimately, the occluded superior mesenteric and splenic veins (Figure, part a). The 6-F catheter (AngioJet; Possis Medical, Minneapolis, Minn) was used within the portal, splenic, and superior mesenteric veins in the power-pulse mode (ie, with intentional occlusion of the catheter outflow port) to imbue the thrombus with 20 mg of tissue plasminogen activator (Genentech, South San Francisco, Calif) diluted in 100 mL of saline. After 30 minutes of dwell time, repeat venography demonstrated substantial lysis of the thrombus (Figure, part b). The AngioJet catheter was used in the thrombectomy mode to evacuate the thrombus. Overlapping Wallstents (Boston Scientific, Natick, Mass) were used to line the 10-mm-diameter transcaval TIPS (Figure, part c) (instead of stent-grafts) because of theoretic graft infection concerns due to the elevated white blood cell count of 16.9 × 109/L. The most cephalic Wallstent was deployed just at the caval exit site so as to minimize the risk of caval occlusion by the cephalic trailing end of the stents. Decompressive flow was seen through the TIPS. The initial portosystemic gradient of 41 mm Hg (measured between the proximally patent peripheral splenic and mesenteric veins and the right atrium) was reduced to 14 mm Hg. Full intravenous heparinization was achieved during the procedure and maintained thereafter. US performed 2 days later demonstrated TIPS thrombosis and rethrombosis of the portal, mesenteric, and splenic veins and no evidence of liver parenchymal injury or disruption. Power-pulse thrombolysis was repeated in an identical 30-minute fashion, resulting in similar single-session rapid thrombolysis. Simultaneous venography of the TIPS and IVC demonstrated the caval end of the TIPS Wallstent to have shortened, now laying approximately 2 mm short of the caval exit site (Figure, part d). A 6-cm-long, 10-mm-diameter stent-graft (Viatorr; WL Gore, Flagstaff, Ariz) was positioned across this length, just entering the IVC (Figure, part e). Overnight infusion of abciximab (Eli Lilly, Indianapolis, Ind) was begun to reduce the risk of rethrombosis. Warfarin therapy was begun. The patient's ascites volume rapidly auto-diuresed during the next several days, his abdominal pain resolved, and liver function improved. Essential thrombocytosis (and possible antithrombin III deficiency) was diagnosed. TIPS venography performed 3 months later demonstrated resolution of the caval compression and accompanying pressure gradient. Transcaval liver biopsy at that time demonstrated near resolution of the sinusoidal congestion and dilatation. Subsequent routine follow-up venography and US performed periodically for up to 22 months demonstrated uninterrupted patency of the splenic and portal veins. At 22-month follow-up, the patient's total bilirubin level has remained stable at 2.2 mg/dL (38 μmol/L), his ascites is absent, and, with the exception of his elevated international normalized ratio (due to anticoagulation) and thrombocytosis, his other laboratory tests remain nearly normal. He is fully active and feels good. This patient illustrates several of the complexities of diagnosis and percutaneous treatment of patients with Budd-Chiari syndrome. In this case, the long-standing diagnosis of hepatic vein outflow was established only when the presumed acute portal venous thromboses developed, prompting the rapid hepatic deterioration and more intensive imaging evaluation. Technical aspects of note include the routine need for higher-risk transcaval access into the portal vein, modified puncture techniques (eg, US guidance and the use of coaxial skinny needles because of the potentially easily disrupted noncirrhotic nature of the liver), stent positioning issues at the caval exit site (because of extrinsic caval compression by the acutely congested liver), and the essential role of polytetrafluoroethylene TIPS stent-grafts in these patients with hypercoagulation (2Hernandez-Guerra M. Turnes J. Rubinstein P. et al.PTFE-covered stents improve TIPS patency in Budd-Chiari syndrome.Hepatology. 2004; 40: 1197-1202Crossref PubMed Scopus (124) Google Scholar). Unique to this case is the demonstrated utility of the power-pulse technique in the unusual application of acute portal venous system thromboses (compared with the typical approach of prolonged thrombolytic infusion). The power-pulse technique is, in effect, a power-assisted version of the original pulsed-spray pharmacomechanical technique, although its description remains limited to case reports or small collected series. The high-pressure pump used to evacuate thrombus is used as a spraying engine to better disperse the lytic agent throughout the thrombus and secondarily fragment and disrupt it. The logic for the use of the power-pulse approach in the presented scenario was the ability to aggressively perform clot fragmentation and lysis without the risk of downstream pulmonary embolization (by virtue of delaying deployment of TIPS stents until after clot dissolution). The successful use of this technique twice in the same patient suggests its potential adjunctive use in the difficult, larger group of patients with acute symptomatic portomesenteric thromboses in hypercoagulable patients with noncirrhotic portal hypertension, acute abdominal pain, and nonsurgical abdomens. These rare patients pose some of the greatest technical and therapeutic interventional challenges, ones in which catheter-directed radiologic therapies at present remain exotic, sparsely available, and, arguably, relatively immature.