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Monday, November 26, 2018

Catheter-Directed Thrombolysis for Portal Vein Thrombosis in Children: A Case Series


Summary


Pediatric portal vein thrombosis (PVT) in children has a high morbidity related to portal hypertension (PH). The current study retrospectively described the experience using catheter-directed thrombolysis (CDT) in the treatment of PVT within 10 consecutive children (mean age 11.9 years) undergoing 13 interventions. PVT confirmed via ultrasound or computed tomography was treated by first obtaining percutaneous transhepatic and/or transjugular intrahepatic portal access followed by placement of a transjugular intrahepatic portosystemic shunt (TIPS) in patients with PH. CDT consisted of intraprocedural tissue plasminogen activator (tPA) administration followed by mechanical thrombectomy, and if indicated, overnight thrombolysis.

Complete thrombolysis and partial thrombolysis was achieved in 7 (53.8%) and 3 (23.1%) cases, respectively. Two major complications occurred including hemoperitoneum requiring blood transfusion and right hemothorax requiring chest tube placement. Six patients (66%) did not have recurrent PVT on mean follow-up of 30.4 months. Regarding the remaining 3 patients; one developed cavernous transformation of the portal vein, one was found to have an occlusion of the left portal vein, and one developed recurrent thrombosis of the portal vein. CDT for PVT can be safely performed in children with similar recanalization rates to those recorded in literature for thrombolysis in PVT in adults.



Figure
Incremental response to CDT in a 15-year-old girl with PVT and superior mesenteric vein involvement. (a) Initial portal venogram from a PTH approach demonstrates extensive thrombus throughout the superior mesenteric vein with extension into the main, right, and left portal veins. (b) Follow-up portal venogram obtained after 36 hours of tPA infusion demonstrating partial lysis of PVT with decreased thrombus burden in the main portal vein but with continued extensive thrombus in the superior mesenteric vein. (c) Final portal venogram obtained after CDT in conjunction with TIPS placement demonstrating complete lysis of previously seen PVT.

Commentary


This case series represents the largest cohort of pediatric patients undergoing CDT for the treatment of PVT and attempts to establish the efficacy and safety of the procedure in this population.

Interestingly, both major complications occurred as a result of percutaneous transhepatic access. It would appear that utilization of the transjugular approach not only reduces the complication profile of the procedure, but also facilitates simultaneous TIPS placement in patients with PH. As access and familiarity with intravascular ultrasound expands, transjugular access for CDT within the portal system should become more efficient and safer.

All patient were discharged on twice-daily enoxaparin for a minimum of 3 months, with 2 patients receiving additional aspirin 81 mg daily. Given this younger population, consideration regarding long-term anticoagulation and the associated risks must be balanced with probability of developing recurrent PVT.

Currently, CDT in PVT in children appears to be a technically safe procedure with promising recanalization rates. Prospective studies with systematic procedural and follow-up imaging protocols are still required to fully understand the safety profile and long-term efficacy of this procedure.

Click here for abstract

Koo KSH, Lamar DL, Shaw DWW, Monroe EJ, Shivaram GM. Catheter-Directed Thrombolysis for Portal Vein Thrombosis in Children: A Case Series. Journal of Vascular and Interventional Radiology. 2018 Nov 1;29(11):1578–83.

Post Author:
Jacob Bundy, MD, MPH
PGY-1
Department of Surgery
University of Michigan Health System
@JBundyRad



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