P1406 - A Rare Case of Symptomatic Acute Superior Mesenteric Vein and Splenic Vein Thromboses Managed With Urgent TIPS and Thrombolysis

Brianna Hamilton, MD, MS, Apaar Dadlani, MBBS, Shayan Amini, MD, Tamneet Basra, MD, Michelle Jones-Pauley, DO, Robert McFadden, MD, David W. Victor, MD, Davood Abdollahian, MD, Sudha Kodali, MD, MSPH
Houston Methodist Hospital, Houston, TX

Introduction: Liver cirrhosis is a risk factor for portal vein thrombosis (PVT) due to the slowed blood flow through the severely scarred liver, increased vascular shear stress secondary to portal venous congestion, and hypercoagulable state. We report a case of PVT treated with transjugular intrahepatic portosystemic shunt (TIPS) procedure and thrombectomy of the SMV and splenic vein.

Case Description/Methods: A 58-year-old female with a past medical history of alcohol-associated cirrhosis, diabetes and hyperlipidemia presented to the Emergency Department with epigastric, left upper quadrant pain, nausea, and non-bloody emesis for 1 day. She had scleral icterus and epigastric/periumbilical abdominal tenderness. Labs were notable for leukocytosis at 20 k/uL, lactic acid 2.3 mmol/L, hemoglobin 18.1 g/dL, alkaline phosphatase 134 U/L, alanine aminotransferase 11 U/L, and aspartate aminotransferase 39 U/L An urgent abdominal CT angiogram revealed mesenteric ischemia, thrombosis of the portal venous confluence with extension into the SMV and its mesenteric branches as well as the splenic vein. A heparin drip was initiated. The patient underwent an urgent TIPS with thrombectomy of the SMV and splenic vein thromboses. Post-procedure she required catheter-directed thrombolysis and repeat thrombectomy of the splenic and SMV vein thrombosis. She felt better post-procedure and eventually was discharged with improved symptoms.

Discussion: Endovascular intervention and TIPS can be used to treat PVT if anticoagulation alone is unsuccessful or contraindicated. These procedures are effective with increased rates of recanalization and sustained patency. TIPS also allows for direct thrombolysis of the affected vessel. Some studies have shown complete resolution and continued patency in 95%-98% of patients upon follow-up. Postoperative thrombolysis is another method to achieve recanalization of the portal vein. Data collected from small studies and case reports show successful PVT lysis when administered systemically and locally using catheterized directed therapy. Direct access into the portal vein via the transjugular or a percutaneous intrahepatic route is preferred to reduce the risk of bleeding, embolization, and thrombolytic-related complications. Percutaneous transhepatic mechanical thrombectomy may also have positive outcomes in acute thrombosis, however, it is associated with vascular trauma and may stimulate re-thrombosis.



Disclosures:


Brianna Hamilton, MD, MS, Apaar Dadlani, MBBS, Shayan Amini, MD, Tamneet Basra, MD, Michelle Jones-Pauley, DO, Robert McFadden, MD, David W. Victor, MD, Davood Abdollahian, MD, Sudha Kodali, MD, MSPH. P1406 - A Rare Case of Symptomatic Acute Superior Mesenteric Vein and Splenic Vein Thromboses Managed With Urgent TIPS and Thrombolysis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.