AngioJet Aspiration Thrombectomy Combined with Transcatheter Thrombolysis in Treatment of Acute Portal Venous Systemic Thrombosis

Journal Pre-proof AngioJet Aspiration Thrombectomy Combined with Transcatheter Thrombolysis in Treatment of Acute Portal Venous Systemic Thrombosis Gaopo Cai, Chong Li, Zhaohui Hua, Peng Xu, Zhouyang Jiao, Hui Cao, Shirui Liu, Zhen Li PII:

S0890-5096(20)30034-0

DOI:

https://doi.org/10.1016/j.avsg.2020.01.014

Reference:

AVSG 4869

To appear in:

Annals of Vascular Surgery

Received Date: 23 December 2018 Revised Date:

31 October 2019

Accepted Date: 5 January 2020

Please cite this article as: Cai G, Li C, Hua Z, Xu P, Jiao Z, Cao H, Liu S, Li Z, AngioJet Aspiration Thrombectomy Combined with Transcatheter Thrombolysis in Treatment of Acute Portal Venous Systemic Thrombosis, Annals of Vascular Surgery (2020), doi: https://doi.org/10.1016/ j.avsg.2020.01.014. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.

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AngioJet Aspiration Thrombectomy Combined with Transcatheter Thrombolysis

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in Treatment of Acute Portal Venous Systemic Thrombosis

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Gaopo Cai1, Chong Li2, Zhaohui Hua1, Peng Xu1, Zhouyang Jiao1, Hui Cao1, Shirui

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Liu1, Zhen Li1*

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1 Department of Endovascular Surgery, First Affiliated Hospital of Zhengzhou

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University, Zhengzhou, Henan, China

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2 Division of Vascular Surgery, New York University Langone Health, New York, NY,

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USA

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*Corresponding author: Department of Endovascular Surgery, First Affiliated

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Hospital of Zhengzhou, No. 1 East Jian She Road, Zhengzhou, Henan Province

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450052, China.

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E-mail: [email protected]

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1

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Abstract

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Objective: This study set out to assess the feasibility, effectiveness, and safety of

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percutaneous AngioJet aspiration thrombectomy combined with transcatheter

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thrombolysis for treating acute portal venous systemic thrombosis (APVST).

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Methods: Clinical data of 13 patients with APVST who were treated by AngioJet

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aspiration thrombectomy combined with transcatheter thrombolysis from March 2017

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to July 2018 were analyzed retrospectively. The effect of portal venous recanalization

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was evaluated by intraoperative angiography and postoperative surveillance of

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clinical findings, portal venous ultrasound, or computed tomography.

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Results: Successful puncture of the portal vein was performed in all patients. The

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portal vein was punctured successfully in seven patients via the transjugular

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intrahepatic route, two patients failed to be punctured and then had successful

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percutaneous transhepatic puncture, and four patients underwent percutaneous

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transhepatic portal vein puncture directly. The duration of thrombus aspiration was

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238.46±89.89 seconds (120–360 seconds) and the amount of urokinase in thrombus

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aspiration was 353,000±87,700 IU (20,0000–40,0000 IU). Portal venous thrombosis

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was dissolved by the AngioJet thrombectomy device in all patients. Post-aspiration

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angiography showed that grade III lysis was achieved in eight patients, grade II lysis

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in one patient, and grade I lysis in four patients. The length of transcatheter

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thrombolysis was 3.07±1.75 days (1–7 days) and the total urokinase dose via an

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indwelling catheter was 1,230,000±706,000 IU (20,0000–2,800,000 IU). Four patients

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had a transjugular intrahepatic portosystemic shunt, one patient with stenosis of the 2

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superior mesenteric vein (SMV) achieved balloon angioplasty, and one patient with

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stenosis of the SMV was stented. Operative complications were transient hematuria (4

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patients), palpitation (1 patient) and bowel resection (1 patient). No patients died

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within 30 days. Patients were discharged at 12.00±5.83 days (6–27 days) after

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admission. All patients survived and no recurrence developed during the follow-up of

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9.15±3.18 months (4–15 months).

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Conclusion: Percutaneous AngioJet aspiration thrombectomy combined with

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thrombolytic therapy is feasible and effective for acute portal venous systemic

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thrombosis. This treatment is benefificial for APVST in dissolving thrombus,

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improving SMV flow and relieving symptoms of portal vein hypertension.

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Key words: Acute portal venous systemic thrombosis; AngioJet; percutaneous

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mechanical thrombectomy (PMT); transcatheter thrombolysis

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Introduction

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The symptoms of acute portal venous systemic thrombosis (APVST) are difficult to

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detect and it is a potentially lethal visceral disease. APVST accounts for 6%–15% of

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acute mesenteric ischemia 1, 2. Formation of APVST is mainly related to cirrhosis,

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abdominal surgery, abdominal infection, oral contraceptives, malignant tumors, and

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systemic hypercoagulable states3. When compensatory drainage of the portal vein (PV)

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is insufficient in APVST, congestion and edema occur in the jejunum and ileum. This

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eventually progresses to intestinal ischemia and necrosis, necessitating resection.

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Clinically, patients with APVST are treated with systemic anticoagulation, but

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25%–50% of patients still progress to pre-hepatic portal hypertension, and 18% of 3

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these are complicated by transmural intestinal necrosis1, 4. Traditional percutaneous

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transhepatic, catheter-direct thrombolysis (CDT) and indirect thrombolysis through

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the superior mesenteric artery (SMA) are widely used for portal vein thrombosis as

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minimally invasive techniques. These thrombolytic treatment modalities have

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significantly improved portal perfusion compared with anticoagulation only 5.

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In recent years, the AngioJet Ultra thrombectomy system (Boston Scientific,

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Marlborough, MA), which is a percutaneous mechanical thrombectomy (PMT) device,

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has been used. This device can quickly remove the thrombus burden and has a clear

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therapeutic effect on treating portal vein thrombosis6. To date, there are few studies

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that have investigated the effectiveness of AngioJet aspiration thrombectomy

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combined with transcatheter thrombolysis in treatment of APVST. Most studies in

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AngioJet have only been carried out in a small number of patients. This study

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therefore set out to futher explore and evaluate the effect of the new treatment option

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for patients with APVST in our institution.

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Material and Methods

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Patients

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This study was approved by the ethical committee and institutional review board of

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the First Affiliated Hospital of Zhengzhou University. Data from the medical records

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and radiology data were gathered retrospectively between March 2017 and July 2018.

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Thirteen patients were treated by AngioJet aspiration thrombectomy combined with

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thrombolytic therapy. The demographics of the study population, etiology, risk factors,

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presenting symptoms, therapy and response to therapy, duration of hospitalization, 4

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and clinical status at 30 days and at last follow-up results were obtained and analyzed.

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The study population consisted of nine male patients and four female patients with a

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mean age of 48.77±13.95 years (26–73 years). Presenting symptoms included

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abdominal pain (n=12), distention (n=5), peritonitis (n=1), fever (n=1), diarrhea (n=1),

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nausea (n=1), emesis (n=1), hematemesis (n=2), and hematochezia (n=4; Table I). The

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risk factors for APVST of the patients included cirrhosis (n =4), splenectomy (n = 3),

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partial splenic embolization (n = 1), pancreatitis (n = 1), primary thrombocytosis (n =

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1), prothrombotic states (n = 3; Table I).

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The extent and location of thrombus of the PV and SMV were confirmed by

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contrast-enhanced computed tomography (CT) venography before intervention. CT

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imaging showed PV, SMV, and splenic vein (SV) thrombosis in seven patients, PV

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and SMV thrombosis in four patients, SMV thrombosis in one patient, and main

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portal vein thrombosis in one patient (Table I). All patients received systemic

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anticoagulant immediately after diagnosis. Endovascular treatment was performed in

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patients with persisting symptoms, worsening abdominal pain after initiation of

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anticoagulation, or development of signs of peritonitis, complications of portal

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hypertension in cirrhosis (variceal bleeding or worsening ascites), and who are poor

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surgical candidates. The algorithm used is illustrated in Fig. 1. 13 patients were

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treated with endovascular therapies and the clinical data of those patients are

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summarized in Table I.

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Interventional procedures

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Transjugular intrahepatic route: All patients underwent routine indirect portography 5

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via the SMA to visualize the location and extent of thrombosis. Then, an 18 G needle

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(Cordis, Miami, FL) was used to puncture the right internal jugular vein under

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ultrasound guidance, and a 0.035-inch hydrophilic guide wire (Terumo, Japan) and a

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Cobra catheter (Cook) were introduced through a 6-Fr sheath(Terumo) to engage the

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right hepatic vein. The appropriate angle and depth were determined by preoperative

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CT and intraoperative venography. The Rosch-Uchida Transjugular Liver Access set

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(Cook, Bloomington, IN) was then used to access the intrahepatic portal vein. The

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guidewire and catheter cannulated the thrombosed portal vein, and the location and

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extent of the thrombus were assessed again by direct portal venography.

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Percutaneous transhepatic route: Percutaneous transhepatic portal vein puncture was

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performed in patients in whom the transjugular intrahepatic route was considered to

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be difficult after preoperative assessment, or those who had failed puncture via the

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transjugular approach intraoperatively. A 22 G Chiba needle (Cook)was punctured

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percutaneously into the right branch of portal vein. After confirmation, a 6-Fr sheath

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was exchanged along the guidewire. A 0.035-inch hydrophilic guide wire and a

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multiple side-hole catheter (Cook) were introduced through the sheath to cannulate

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the thrombosed portal vein. Direct portal venography was performed to assess the size

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and extent of the thrombus.

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Thrombus aspiration and endovascular treatment: After portal venography, a 6 Fr

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AngioJet catheter(Boston Scientific) was placed along a stiff guide wire, and

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200,000–400,000 IU of urokinase (Tanjin Biochem Pharmaceutical Co., Ltd., China)

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was infused under the spray mode. After 15 minutes of urokinase injection, the 6

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AngioJet was set to aspiration mode for thrombectomy using 500 ml of normal saline

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with 5000 IU of urokinase, and pulled back from the distal to proximal extent of the

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thrombus at a rate of 1–2 mm/s. Post-thrombectomy venography was performed to

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evaluate resolution and residual thrombus. Balloon dilatation was performed in one

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case of portal vein stenosis and stent placement in one case of SMV thrombosis for

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residual thrombosis. A transjugular intrahepatic portosystemic shunt (TIPS) was

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established after embolization of gastric or esophageal varices with embolization coils

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in four patients who presented with variceal bleeding. Repeated portal venography

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was performed after intervention in all patients to evaluate the effect of thrombectomy.

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The evaluation criteria of thrombus clearance were as follows: grade III indicated

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greater than 90% thrombus clearance; grade II indicated 50%–90% thrombus

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clearance; and grade I was defined as thrombus clearance of less than 50% 7.

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Transcatheter thrombolysis: According to the clearance and residual thrombus

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location, all patients received an indwelling thrombolytic catheter in the SMV or

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SMA. Thrombolysis was started with a continuous infusion of 200,000–600,000

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IU/day of urokinase. Venography was performed every 1–3 days to assess thrombus

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clearance. Termination of thrombolysis was based on improvement in clinical

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symptoms and radiographic findings of thrombus resolution. After removal of the

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transhepatic catheter, the tract was embolized with embolization coils (Cook).

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Perioperative care: The thrombus aspiration time with the AngioJet, the thrombolytic

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time with CDT, the amount of urokinase, and complications were recorded during

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treatment. The coagulation profile and renal function were monitored during 7

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thrombolysis. All patients received subcutaneous injection of 5000 IU low molecular

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weight heparin (Changshan Biochem Pharmaceutical Co., Ltd., Hebei, China) every

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12 hours in the perioperative period. We prescribed warfarin (Qilu Pharmaceutical Co.,

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Ltd., Shandong, China), while maintaining an international normalized ratio of 2–3, or

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rivaroxaban (Bayer Pharma AG, Berlin, Germany) for long-term anticoagulation upon

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discharge. The duration of anticoagulation was 3 months for patients with known

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factors or at least up to 6 months in those with uncertain factors.

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Follow-up: All patients underwent clinical and radiographic follow-up in the first

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month and then every 3–6 months in our hospital. The follow-up included clinical

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symptoms, signs, routine laboratory tests, hepatic and renal function, the coagulation

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profile, and CT or ultrasonography of the portal system.

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Results

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Treatment results: The portal vein was successfully punctured in all 13 patients

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without complications. Seven patients were punctured through the transjugular

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intrahepatic route, two patients failed to be punctured through the transjugular

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intrahepatic route and changed to the percutaneous transhepatic route, and four

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patients were punctured through the percutaneous transhepatic route directly.

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Thrombosis of the portal vein and SMV was treated with PMT. The mean thrombus

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aspiration time was 238.46±89.89 seconds (120–360 seconds). The mean total amount

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of urokinase used during thrombus aspiration was 353,000±87,700 IU

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(200,000–400,000 IU). Grade III lysis was achieved in eight patients, grade II lysis in

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one patient, and grade I lysis in four patients. The mean duration time of CDT after 8

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PMT was 3.07±1.75 days (1–7 days), and the mean dose of urokinase during CDT

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was 1,230,000±706,000 IU (200,000–2,800,000 IU). Re-evaluation of thrombose

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clearance after termination of CDT showed 11 patients with grade III thrombolysis

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and two patients with grade II thrombolysis. Balloon dilatation with the EV3 (6×60

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mm; Medtronic, Minneapolis, MN) was performed in one patient with stenosis of the

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main portal vein and SMV. Stent placement with the E-LUMINEXX Biliary Stent

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(12×60 mm; Bard, New Providence, NJ) was performed in one patient with SMV

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thrombosis that was refractory to PMT and CDT. In four of 13 patients, a TIPS was

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established (Fig. 2). Four patients had hematuria after intervention, and the urine color

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returned to normal in 1–2 days. No deterioration of creatinine clearance or oliguria

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occurred. Peritonitis persisted in one patient after resolution of APVST, and

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laparotomy was performed 1 day later. Intraoperatively, 20 cm distal to the ligament

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of Treitz, there was approximately 60 cm of gangrenous small bowel. Partial small

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bowel resection and ileostomy were performed. The patient was treated with early

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nutritional support and was discharged 27 days later. Palpitation occurred in one

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patient during PMT and the symptom was relieved after cessation of aspiration

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thrombectomy. The 13 patients were discharged 12.00±5.83 days (6–27 days) after

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admission (Table II).

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Follow-up: The mean length of time of follow-up was 9.15±3.18 months (4–15

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months). Four of 13 patients were follow-up for one year at least. All 13 survivors had

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no recurrence of their initial clinical symptoms or showed signs of APVST. An SMV

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stent was patent in the patient who received it. The TIPS was patent and shunt 9

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stenosis and hepatic encephalopathy were not observed in the four patients during

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follow-up.

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Discussion

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APVST is a serious disease that is not uncommon and can be life-threatening. The

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morbidity and mortality rate of APVST is as high as 50%1, 8. Timely diagnosis and

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treatment are essential for preventing complications, such as intestinal necrosis and

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portal hypertension9. Currently, anticoagulant therapy with low molecular weight

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heparin is still the primary treatment of APVST. Previous studies have shown that

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systemic anticoagulant therapy is effective and can achieve a certain degree of

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recanalization in the SMV and PV 4, 10-12. However, Sheth et al.13 reported that the

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incidence of persistent obstruction and portal hypertension is still high in those who

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receive anticoagulant therapy alone. Recent European guidelines recommend that

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patients with mesenteric venous thrombosis should undergo endovascular treatment in

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the absence of standard anticoagulant therapy14. Data from those studies suggest that

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that portal venous blood flow be promptly restored for symptomatic patients receiving

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anticoagulation therapy. This should be achieved to quickly alleviate mesenteric

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congestion, reduce the incidence of intestinal necrosis, and prevent complications of

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portal hypertension and cavernous transformation of the portal vein.

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Transcatheter thrombolysis is the most commonly used interventional modality

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for endovascular treatment of portal vein thrombosis. However, bleeding might occur

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in as many as 60% of patients who are treated with local thrombolytic therapy 15, 16.

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The AngioJet Ultra thrombectomy system is a pharmaco-mechanical thrombectomy 10

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device that macerates the thrombus and clears it through a rheolytic effect (Bernoulli

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principle)17. Successful application of this device in portal vein thrombosis has been

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reported 4, 6, 18, 19, The AngioJet has the advantage of rapidly removing portal vein

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thrombosis, rapidly improving intestinal congestion, and reducing the length of

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hospital stay and thrombolysis-related complications compared with catheter-directed

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thrombolysis. Patients with a contraindication of thrombolysis can also be treated with

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this device. Our findings showed that 61.5% (8/13) of patients achieved complete

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recanalization (grade III) of PV, and the complete recanalization rate are higher than

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anticoagulation therapy which have been described in 33%-45% of recently reports20.

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The five patients with a partial recanalization(less than III) of PV might have had

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partial organization of the thrombus or thrombosis of small branches of the SMV or

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PV that PMT could not reach 21. Patients in our group were treated with AngioJet

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aspiration thrombectomy combined with infusion of a low dose of urokinase through

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the thrombolytic catheter. Transcatheter thrombolysis was initiated through the SMV

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or SMA after PMT, latter of which was important for removing residual thrombus in

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small branches. At completion of thrombolysis treatment, grade III lysis occurred in

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four patients and grade II lysis occurred in one of the five patients with thrombus

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clearance less than 50%. This combination treatment is effective for thrombus

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clearance, especially for patients with residual thrombosis after PMT.

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In our series, no patients died at 30 days and a mean of 9.15±3.18 months of

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follow-up. In a review of the literature, Morasch et al22 concluded that the lower of

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30-day mortality rate associated with better long-term outcomes in patients with acute 11

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SMV thrombosis. Our results are similar to those reports. Rapid thrombus removal or

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dissolution through early endovascular treatment may have contributed to the lower

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mortality rates than previously studies. There were no complications, such as bleeding

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at the puncture site, cerebral hemorrhage, or intra-abdominal hemorrhage. Four

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patients with transient postoperative hematuria did not experience renal dysfunction

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or a decline in creatinine clearance. The mean time of PMT was 238.46±89.89

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seconds. Minimizing the time of PMT and reducing the dosage of thrombolytics are

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methods of decreasing hemorrhagic complications. Adequate hydration pre- and

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post-operation can decrease renal insults from hemoglobinuria and contrast.

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Standardized and skilled puncture through the transjugular approach to the portal

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vein for PMT has a low risk of access-related complications. In contrast to femoral

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vein access, internal jugular vein access allows patients to ambulate immediately

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postoperation. Patency of the portal vein outflow tract is essential for preventing

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recurrence of thrombosis. Establishment of an intrahepatic portosystemic shunt should

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be based on age, the etiology of APVST, liver function, and the risk of variceal

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rebleeding. A theoretical risk of PMT through a TIPS is pulmonary embolism, but this

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did not occur in this series. We postulate that the reason for this finding was due to

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sufficient anticoagulation, use of urokinase, and a reduction in the volume of

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thrombus because of washing away blood from AngioJet aspiration. Based on these

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factors, we believe that PMT after establishment of an intrahepatic portosystemic

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shunt is safe.

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Exploratory laparotomy was performed for one patient who had unresolved 12

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peritonitis 1 day after recanalization of the portal vein. An ineffective anticoagulant

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reaction and residual SMV distal branch thrombus after thrombolysis may have been

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the reasons for intestinal progression from blood stasis and edema to transmural

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intestinal necrosis. For this patient, PMT before delayed localized bowel resection

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was implemented. This treatment modality can effectively shorten the length of a

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congested bowel. Emergency laparotomy has a high risk of thrombus recurrence,

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leading to additional strikes for patients with severe bowel ischemia16, 23. Wu et

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al.24suggested that endovascular treatment before laparotomy is beneficial for patients

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with portal venous thrombosis. In summary, early initiation of endovascular treatment

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can reduce intestinal congestion caused by APVST and avoid the risk of short bowel

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syndrome caused by an extensive intestinal resection 25.

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Limitations

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Limitations of this study include its retrospective nature and outcome that was based

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on short- to medium-term follow-up. Because of low incidence as well as the

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short-term use of AngioJet device in our institution, it is hard to conduct a large-scale,

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randomized, controlled trial. Therefore, no convincing statistically significant results

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were obtained. Our department is actively following these patients and recording any

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long-term complications of this treatment. Meanwhile, a long-term controlled study of

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larger sample size has been undertaken in our center. Finally, all patients in this study

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are Mandarin Chinese, but this should only minimally affect the response to PMT or

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thrombolysis.

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Conclusions 13

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Our study suggests that pharmaco-mechanical thrombectomy with the AngioJet

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combined with catheter-directed thrombolysis is safe and effective for treating APVST.

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This treatment strategy has the advantage of immediately achieving portal

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recanalization with high patency, rapidly improving symptoms, reducing the

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incidence of hemorrhagic complications, and preserving bowel length. Further studies

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are required for determine long-term efficacy and safety of this procedure.

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Declarations of interests: none

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14

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damage control surgery for treatment of acute mesenteric venous thrombosis

357

associated with bowel necrosis: a retrospective study. World J Emerg Surg.

358

2015;10:50.

359

18

360

Figure Legend

361

Figure 1. Flow chart of treatment algorithm for patients with acute portal venous

362

systemic thrombosis (APVST). TI=transjugular intrahepatic route, PT= percutaneous

363

transhepatic route.

364 365

Figure 2. Portal venography through a TIPS showing acute extensive portomesenteric

366

vein thrombosis in a 51-year-old man(A). Transjugular intrahepatic thrombectomy

367

with AngioJet catheter was performed throughout the thrombosed segment of the

368

SMV and PV (B). Post- thrombectomy portal venography demonstrating restored

369

perfusion, reduced collateral filling and residual proximal thrombus in SMV (C).

370

Angiography 1 day after CDT showing excellent antegrade flow and a patent lumen

371

in the SMV and PV (D). Portal venography and CT scan show no remaining

372

thrombosis in the SMV and PV at 12 months (E and F). 19

373

20

Table I Clinical data of patients Patient

Age(y

no.

)/Sex

1

26/M

Etiologies and risk factors

None

Main symptoms and signs

Abdominal pain, distention,

Location of

Puncture

Symptoms to

In-hospital

thrombosis

route

intervention(da

time

ys)

(days)

PV+SMV+SV

TI

5

27

local peritonitis, fever 2

63/M

Cirrhosis, hepatitis B

Abdominal pain, hematochezia

SMV

TI

4

10

3

54/M

None

Abdominal pain, distention

PV+SMV+SV

TI

12

6

4

42/M

Cirrhosis, hepatitis B,

Distention, abdominal

MPV

TI

18

8

splenectomy

pain ,hematochezia

5

65/F

Primary thrombocytosis

Abdominal pain,

PV+SMV+SV

TI

15

12

6

51/F

Cirrhosis, hepatitis B,

Abdominal pain, hematemesis,

PV+SMV

TI

6

9

splenectomy

hematochezia

Cirrhosis, hepatitis B,

Abdominal pain, hematemesis,

PV+SMV

TI

20

14

PV+SMV

TI changed

9

11

7

73/F

hematochezia 8

43/M

Splenectomy and pancreatitis

Abdominal pain, distention,

9

27/M

None

Abdominal pain

PV+SMV+SV

PT

7

16

10

45/M

PSE

Abdominal pain, distention

PV+SMV+SV

PT

16

7

11

55/M

thrombophilia

Abdominal pain

PV+SMV+SV

PT

8

18

12

52/F

Protein S deficiency

Distention

PV+SMV+SV

PT

12

6

13

38/M

Anti-thrombin III deficiency

Abdominal pain, nausea,

PV+SMV

TI changed

4

12

nausea, emesis

emesis

to PT

to PT

TI=transjugular intrahepatic route, PT= percutaneous transhepatic route, PSE= partial splenic embolization

Table II Treatment and follow-up results Patient

Thrombus

Dose of

Thrombus

Endovascular

Route of

Thrombolytic

Dose of

no.

aspiration

PMT

lysis after

treatment

thrombolysis

time (days)

time (S)

(IU)

PMT

360

40,0000

Grade III

1

None

SMA

1

Follow-up

Follow-up

thrombolysis

duration

results

(IU)

(mo.)

200,000

Complications

Intestinal

4

No recurrence

necrosis 2

240

40,0000

Grade III

TIPS

SMA

3

1,200,000

Hematuria

12

No recurrence

3

320

40,0000

Grade I

None

TI

7

2,800,000

None

8

No recurrence

4

210

40,0000

Grade I

TIPS

TI

5

2,000,000

None

6

No recurrence

5

130

40,0000

Grade III

PTA

SMA

1

600,000

Transient

12

No recurrence

palpitation 6

120

20,0000

Grade III

TIPS

TI

3

120,000

None

6

No recurrence

7

260

40,0000

Grade III

TIPS

TI

3

1,200,000

None

8

No recurrence

8

160

20,0000

Grade III

None

SMA

2

800,000

None

7

No recurrence

9

200

40,0000

Grade III

None

SMA

1

400,000

Hematuria

8

No recurrence

10

360

40,0000

Grade II

None

PT

4

1,600,000

Hematuria

10

No recurrence

11

280

40,0000

Grade I

None

PT

4

1,600,000

Hematuria

15

No recurrence

12

120

20,0000

Grade III

None

SMA

2

800,000

None

10

No recurrence

13

340

40,0000

Grade I

SP

SMA

4

1,600,000

None

13

No recurrence

TIPS=transjugular intrahepatic portosystemic shunt, PTA=percutaneous balloon dilatation, SP=stent placement, SMA=superior

mesenteric arterial route, TI=transjugular intrahepatic route, PT= percutaneous transhepatic route