Catheter-directed tissue plasminogen activator infusion and concurrent systemic anticoagulation with heparin to treat portal vein thrombosis post orthoptic liver transplantation.

Portal vein thrombosis (PVT) following orthoptic liver transplantation is a rare complication with an incidence of 1% to 2% (1). We report a case of early PVT post liver transplantation managed with catheter-directed tissue plasminogen activator (TPA) infusion and concurrent anticoagulation with heparin. A 33-year-old man underwent an orthoptic liver transplant for cryptogenic cirrhosis with gastrointestinal hemorrhage, profound thrombocytopenia (platelet count 10) and encephalopathic episodes. His model for end-stage liver disease score was 14 (2). Preoperative imaging showed a small liver, grossly enlarged spleen, and reversed flow in portal vein but no PVT. Laparotomy revealed gross portal hypertension, massive spleen (1400 g), partial PVT, and a small cirrhotic liver. An orthoptic liver transplant with portal vein thrombectomy, end-to-end portal venous anastomosis, infra-renal arterial conduit, and Roux-en-Y biliary reconstruction was carried out. Splenectomy was performed to improve platelet count and to allow abdominal closure. The platelet count was 43 postoperatively and 1128 on discharge. The patient made a good recovery and was discharged on postoperative day 17. Immunosuppression consisted of tacrolimus, mycophenolate mofetil, and prednisolone. Prophylactic enoxaparin (20 mg/day) and 150 mg of aspirin were commenced in the perioperative period. The patient attended 2 weeks later with a 2-day history of fever, rigors, and vomiting but no jaundice. International normalized ratio (INR) was 1.1, and the platelet count was 779. Abdominal ultrasound revealed an echogenic appearance of the portal vein, suspicious of thrombosis. A CT showed complete PVT extending to the top of the superior mesenteric vein and into the remnant splenic vein. Despite this, the liver parenchyma appeared perfused. The hepatic artery, hepatic veins, and inferior vena cava were patent. A sheath and a catheter were inserted into the portal vein by direct transhepatic puncture without any complications. A venogram (Fig. 1a) confirmed the extent of the thrombus. A 5 mg bolus of TPA and 5000 units of heparin were injected into the thrombus, followed by an infusion of Alteplase (1 mg/hr) and intravenous Heparin titrated by APTT (1–1.5). A repeat venogram after 24 hr revealed significant residual clot at the lower end of the portal vein. A 10-mm angioplasty balloon and a pigtail catheter were manipulated into the portal vein to attempt breaking up the remaining clot. Direct TPA infusion and systemic heparinization were continued. A repeat portogram after another 24 hr (Fig. 1b) revealed considerable improvement with reperfusion of the main portal vein and right portal branch but limited filling of left branch. The pigtail catheter was repositioned proximally to perfuse the right and left portal veins. A final venogram on day 3 showed good flow in the right portal vein branches, partial filling of left branches, and no evidence of portal vein stenosis. The catheter and sheath were removed, and the tract was embolised. The patient received 75 mg of aspirin daily and was anticoagulated with warfarin (target INR 2.5–3.5). Systemic heparin was continued for a total of 8 days, until INR was above 2.0. A repeat ultrasound in December 2008 (14 months after intervention) revealed fully patent portal vein, with reestablishment of the left portal vein flow (figure not shown). The patient remains well with normal liver function. PVT is a rare complication of splenectomy (3, 4), and it is conceivable that splenectomy may have predisposed the patient to develop a PVT. Systemic anticoagulation with heparin, transjugular catheterization, local thrombolytic infusion, a transjugular portosystemic shunt, stent implantation, and mechanical thrombectomy have been described for the treatment of PVT (5–7). A transhepatic access seems to be the most direct route to approach a portal vein thrombus (8 –10). In this case, a transhepatic portal approach allowed a targeted thrombolysis for the different stages of the thrombus and comFIGURE 1. Portal venogram showing the initial extent of the thrombus (a) and the result after 72 hr of treatment (b).