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Portal Vein Thrombosis in Surgical Ward- What to Do: a Technical Review?

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Portal Vein Thrombosis in Surgical Ward- What to Do: a Technical Review? Review Article ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2020.29.004747 Portal Vein Thrombosis in Surgical Ward- What to do: A Technical Review? M Miah*, P Ravi, R Rajebhosale, R Paul, N Husain, M Al Saramigy and P Thomas Department of General Surgery, Queen’s Hospital Burton, UK *Corresponding author: Mohammad Miah, Specialty Doctor, General Surgery, Queen’s Hospital Burton, Burton on Trent, DE13 0RB, UK ARTICLE INFO AbsTRACT Received: July 15, 2020 Splenic and superior mesenteric veins together form the portal vein posterior to Published: July 23, 2020 the pancreas. Portal vein thrombosis (PVT) is a significant clinicopathologic entity that all surgeons should be aware with. It has significant morbidity and mortality Citation: thewith increasing 1% incidence usage in of general numerous population. advanced The imaging lifetime modalities. possibility Sonography, of having CT portal and - vein thrombosis (PVT) is nearly 1%. PVT is being diagnosed more often as a result of M Miah, P Ravi, R Rajebhosale, as. Portal Vein Thrombosis in Surgical conditions of abdomen, trauma, surgery and hypercoagulable states are the most R Paul, N Husain, M Al Saramigy, P Thom . Bi- commonmagnetic resonancerisk factors imaging causing are PVT most in usedsurgical to diagnose patients. PVT. PVT Malignancy, ultimately inflammatory leads to the omed J Sci & Tech Res 29(1)-2020. BJSTR. establishment of many collateral vessels nearby the thrombosed portal vein. First- Ward- What to do: A Technical Review? MS.ID.004747. line treatment for PVT is therapeutic anticoagulation-it helps prevent the spread of the thrombus. Other therapeutic preferences comprise surgery and interventional radiographic procedures. Keywords: Portal vein thrombosis; Risk Factors; Virchow’s triad; Therapeutic Interventions Introduction patients with hepatocellular carcinoma. In addition, PVT is believed Portal vein thrombosis (PVT) is an uncommon event happening with the obstruction or narrowing of the portal vein by a thrombus which is frequently related with the presence of an underlying liver Surgicalto be causative Anatomy in nearly 8% of portal hypertension cases. disease or prothrombotic disorders. Portal vein thrombosis (PVT) The portal vein forms posterior to the neck of the pancreas by the union of the splenic and superior mesenteric veins. It ranges is a significant clinicopathologic entity that all surgeons should be from 5.5 to 8cm in length, and its diameter is approximately 1cm. incidence in general population [1]. It can also follow mesenteric aware with. It has significant morbidity and mortality with 1% It courses toward the porta hepatis in the free edge of the lesser or splenic vein thrombosis. The preponderance of the blood supply omentum and receives the cystic, pyloric, accessory pancreatic, and superior pancreaticoduodenal veins, among other tributaries. risk factors for PVT are predominantly attributed to Virchow’s triad to the liver is portal vein comprising up to 75% of it supplies. The Pathophysiology [2]. PVT occurs with numerous thrombophilic conditions with Patients with PVT are characterized by a hyperdynamic - stasis of blood flow, endothelial injury, and hypercoagulability abdominal pathologies which can be either acute or chronic. PVT circulation syndrome like that seen in cirrhosis. Liver enzymes and is being diagnosed more commonly due to the increasing practice bilirubin are usually normal or only mildly elevated. Quantitative of advanced sonography, computed tomography (CT). The stated tests such as indocyan green clearance demonstrates overall slight lifetime risk of developing PVT in the overall population is roughly functional decrease. Liver biopsy results are typically normal, but hemosiderosis associated with portosystemic shunting has 1%. [3] Nevertheless, the prevalence may be as high as 30% in Copyright@ M Miah | Biomed J Sci & Tech Res | BJSTR. MS.ID.004747. 22136 Volume 29- Issue 1 DOI: 10.26717/BJSTR.2020.29.004747 been described. Cavernous transformation of the portal vein-the or complete. It may have a mixed acute and chronic appearance development of periportal collaterals nearby the recanalizing or as well. Of note, a tumor invading the portal vein may have an blocked main portal vein – happens with chronic PVT. appearance like that of venous thrombosis but is far less common. Tumor invasion of the portal vein is most frequently seen in cases Risk Factors of hepatocellular carcinoma. Risk factors associated with PVT include local or anatomic risk factors and systemic risk factors (Table 1). The presence of risk Management of Portal Vein Thrombosis Most patients with PVT are treated with immediate hepatic cirrhosis, or recent surgery are the most common local risk anticoagulation therapy. This is most often performed through factors can be established in over 85% of cases of PVT, with cancer, factors and various thrombophilias are the most common systemic continuous intravenous heparin infusion (Table 2), but some risk factors. prefers using low-molecular-weight heparin. Chronic treatment Table 1: Risk factors for Portal vein thrombosis. options include warfarin or low-molecular-weight heparin. Category Risk Factors may need to be continued beyond that period depending on the Anticoagulation should be maintained for at least 6 months and Intra-abdominal cause of thrombosis. Other more invasive treatment modalities and so on. Sepsis, Pancreatitis, Cholangitis, Appendicitis Pancreatic malignancy, Hepatocellular Intra-abdominalinflammation carcinoma, Gastric carcinoma, occluded veins, local thrombolytic infusion directly into the area Malignancy used in the setting of PVT include trans jugular catheterization of Cholangiocarcinoma of thrombosis or into the superior mesenteric artery, the creation Prothrombotic Antithrombin III Deficiency, Protein mechanical thrombectomy [4]. The experience with interventional disorder of a trans jugular portosystemic shunt, stent implantation, and mutation,C Deficiency, Disseminated Protein S IntravascularDeficiency, Antiphospholipidcoagulation syndrome, and so Factor on. V Leiden Splenectomy, Cholecystectomy and other techniques in the setting of PVT is still limited, and the benefit Iatrogenic however, an increasing number of case reports that document the abdominal surgery of these procedures remains to be fully defined [5-8]. There are, successful use of interventional radiology for both mechanical Idiopathic, Cirrhosis of liver, Portal Others hypertension. and pharmacologic thrombolysis in the setting of PVT [5-8]. For example, the use of percutaneous transhepatic catheterization with Diagnostic Imaging mechanical and pharmacologic thrombolysis [7]. They recommend Preferred diagnostic examinations in the setting of suspected PVT include Doppler ultrasonography, CT and magnetic resonance local pharmacologic thrombolysis to achieve enhanced dissolution that mechanical thrombectomy be performed first followed by of the thrombus. Surgical interventions such as thrombectomy or suggestive of occlusion. Portal venous thrombus may be partial shunting are certainly more invasive and are associated with their angiography. Non-visualization of the portal vein is strongly own set of complications [8]. Table 2: Risk factors for Portal vein thrombosis. Conservative management Anticoagulation (LMWH/ Thrombectomy and/or with no anticoagulation or Warfarin/DOAC) thrombolysis interventions PVT (post-abdominal infections and Asymptomaticsurgeries) with cases minimal with thrombus provoked • Worsening abdominal pain with burden, and not involving other withAll concomitant symptomatic PVT cases extension with thrombus extension with failed venous segments. into mesenteric or splenic veins. anticoagulation therapy PVT Very high risk of bleeding on Irreversible risk factors or • Impending intestinal necrosis and Acute non-cirrhotic, non-malignant anticoagulation or contraindication persistent hypercoagulable states. infarction from venous thrombosis to active bleeding. seen with multiple splanchnic veins Risk of increase in thrombus thrombus Poor prognosis with other co- burden while not anticoagulated. morbidities. non-obstructive PVT with no • Worsening abdominal pain with •Asymptomaticinvolvement cases of otherwith partial thrombus extension with failed with concomitant PVT extension anticoagulation therapy venous segments and not awaiting All symptomatic cases with PVT in cirrhosis into mesenteric or splenic veins. liver transplantation. • Impending intestinal necrosis and Irreversible risk factors or infarction from venous thrombosis • Very high risk of bleeding on persistent hypercoagulable states. seen with multiple splanchnic veins anticoagulation or contraindication thrombus. to active bleeding Copyright@ M Miah | Biomed J Sci & Tech Res | BJSTR. MS.ID.004746. 22137 Volume 29- Issue 1 DOI: 10.26717/BJSTR.2020.29.004747 • Poor prognosis with other Risk of increase in thrombus • worsening portal hypertension co-morbidities or end-stage liver burden while not anticoagulated and its symptoms – Consider TIPS cirrhosis Awaiting liver transplantation. non-obstructive PVT with no •Asymptomaticinvolvement of cases other with venous partial segments and not awaiting liver • Worsening abdominal pain with transplantation. thrombus extension with failed anticoagulation therapy • Very high risk of bleeding on PVT in malignancy anticoagulation or contraindication • Impending intestinal necrosis and to active bleeding infarction from venous thrombosis • Majority of patients seen with multiple splanchnic veins • Poor
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