In Reply to: Case 1001-08 -- Acute Portal Vein Thrombosis With Subacute Mesenteric Ischemia posted by Editor on October 04, 2001 at 11:53:55:
Moni:
It looks like you had your hands tied on this one. It is likely that this patient has a tumor, where? I don't know. The portal vein thrombus appears acute, but the lack of response to the ATD suggests it is at least 8-10 days old. I think TIPS was justified in this case. Considering the information that you gave us, this was probably the patient's best shot. We did a very similar case about a year ago in an old lady who, funny enough, was also demented. The thrombus in the portal vein looked very similar to the one you present us here. In that case, we did a TIPS, we tried pulse-spray thrombolysis as we did not have a mechanical thrombectomy device available in that particular hospital and we ended up placing the stent into the mesenteric vein, just as in your case. She survived for 2 weeks and died in multiorgan failure.
I think the prognosis depends on the cause of the thrombosis. We have managed acute portal vein thrombosis in one young alcoholic patient with associated pancreatitis and this patient did much better.
Thrombolysis would have been a potentially good option. Access from the SMA with infusion of tPA via SMA has been reported to work, but this option was not available to you anyway.
If TIPS is performed on an emergency basis, we always use the APACHE II score to evaluate our patients. If the APACHE II score is greater than 18, we consider the patient not to be a suitable candidate for TIPS and recommend against it. In this population group (Emergency TIPS + APACHE II score > 18, our 30 day mortality rate is 100%). Rubin and Haskal wrote a paper (Am J Gastroenterol 1995;90:556) and our findings reproduce their findings. I think their mortality rate in this population was 98%.