In Reply to: Re: Case 0100_06 -- Management of Acute Liver Failure in a Patient with Portal and Hepatic Vein Thrombosis posted by LARRY RUFER MD on January 04, 19100 at 00:10:41:
I believe that the PV and the HV clot might have caused exascerbation of liver failure. Vis a vis lysis, Iwould have tried it via the TIPS access before placing the shunt; I would have given about 1mg/hr mixed in at least 50cc/hr after mechanically fragmenting it as much as possible, and after having coiled enough varices to make some hepatopetal flow. These maneuvers would assure maximum contact of drug with the thrombus. Keep in mind that once the shunt is in, you are probably delivering very little TPA to the clot; most is leaving via the TIPS.
I would have extracted as much HV clot as possible mechanically before attempting PV access.
The PV thrombus has a chronic feel to it on the angiogram, it might not have lysed anyway.
This case reminds me of my first TIPS; the patient had a ball of PV thrombus extending from the coronary vein after an over-enthusiastic varix sclerosis. I tried lysis (UK, this was in 1991), and outcome was similar to yours.
Interesting problem.