Moni Stein M.D.
Great Lakes Radiologists, Milwaukee, WI
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Moni Stein M.D. Great Lakes Radiologists, Milwaukee, WI |
Fig. 1. CT of the abdomen through the liver with IV enhancement shows enlarged and thrombosed portal system (arrow). No masses or cirrhosis are seen. |
Fig. 2. Ultrasound of the liver reveals complete thrombosis of the portal vein (see calipers). |
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A 75-year-old man with underlying Alzheimer's dementia presented with abdominal pain, malaise and bloating. He was not febrile and his white count was not elevated. He did not have risk factors for liver malignancy and was not cirrhotic. CT of the abdomen (figure 1) revealed a branching hilar mass, which was later, interpreted as enlarged, thrombosed portal system. There was no evidence of bowel wall thickening to indicate acute mesenteric ischemia. Ultrasound of the abdomen (figure 2) confirmed complete thrombosis of the portal vein both intra- and extrahepatically.
It was determined that this patient likely had subacute mesenteric ischemia with mesenteric congestion and TIPS with thrombectomy was offered as a therapeutic solution. Via the transjugular approach, the portal system was accessed and portal venography confirmed extensive thrombosis of the portal vein to the portal confluence (figure 3). It was decided to try and remove clot using the Amplatz mechanical thrombectomy device, however the success was very limited. Then, a Wallstent was deployed from the mid main portal vein to the hepatic vein to try and improve the outflow. Repeat thrombectomy was attempted with limited results (figure 4). It was decided to not perform thrombolysis, as the family of the patient did not agree to slow infusion in an ICU setting. An additional Wallstent was deployed from the upper SMV to complete the TIPS with establishment of good flow after dilatation to 10 mm and sweeping of the shunt to eliminate residual clot.
The patient did well for a few days with significant improvement of the abdominal pain however, he continued losing weight and lost appetite. It was suspected that he had an underlying malignancy, which explained his general status. The patient died a few weeks after the TIPS creation. Autopsy was never performed.
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Fig. 3. Transjugular portal venography shows portal thrombosis (arrow) from the portal confluence to the intrahepatic branches.
Fig. 4.Following stenting and mechanical thrombectomy with the Amplatz thrombectomy device, portal thrombosis persists.
Fig. 5.TIPS was created from the upper SMV to the right hepatic vein with good flow and elimination of clot.
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| Related Cases:
Case 397_05 -- Portal Vein Thrombosis |
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