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Fig. 1. Oblique US of the main portal vein demonstrating the thrombus as an intraluminal filling defect. |
Fig. 2. Enhanced CT of the liver confirms the intraluminal filling defect of the extrahepatic portal vein. |
Case Reference No. CC-397-05 A 63-year-old woman presented with a 6-week history of vague abdominal pain. Physical examination was unremarkable. An ultrasound of the abdomen was performed which showed portal vein thrombosis with periportal soft tissue fullness (Fig. 1). This was confirmed by computed tomography (Fig. 2, 3). Due to concern of malignancy the periportal soft tissue was sampled under CT guidance and showed no evidence of malignancy. An ERCP was performed and was unremarkable. Routine hematology and clotting profile including protein C, protein S, antithrombin III and fibrinogen was normal. Her working clinical diagnosis was idiopathic portal vein thrombosis. Catheter directed thrombolysis of the portal vein was discussed with the referring physician. The referring physician decided to treat conservatively with systemic anticoagulation. Later a repeat CT scan (Fig. 4) showed complete occlusion of the portal vein with cavernous transformation. The patient has continued on anticoagulants, but continues to have mild to moderate abdominal pain. There has been no evidence of malignancy. The patient has had no episodes of variceal hemorrhage. The patient is 6-months post initial diagnosis. |
Fig. 3. Enhanced CT of the liver confirms the intraluminal filling defect of the extrahepatic portal vein.
Fig. 4. Complete thrombosis of the portal vein with cavernous transformation and hypoperfusion of the central portion of the liver. |
There are many causes of portal vein thrombosis, yet in up to 50% of cases, no etiology can be identified. We, as interventional radiologists, were interested in catheter directed thrombolysis of the portal vein thrombus when identified on the initial CT and US exams. Questions 1) Would catheter directed thrombolysis of the portal vein have been an appropriate initial therapy? 2) If catheter directed thrombolysis was initiated, what is the probability of rethrombosis? References 1. Miyazaki Y, Shinomur Y, et al. Portal vein thrombosis associated with active ulcerative colitis: percutaneous transhepatic recanalization. Am J Gastroenterol 90: 1533-4, 1995. 2. Webb LJ, Sherlock S: The etiology, presentation and natural history of extra-hepatic portal venous occlusion. QJ Med 192: 627-639, 1979. Related cases: |
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