Percutaneous transhepatic recanalization and thrombolysis of the superior mesenteric vein.

A 58-year-old woman presented with a 10-month history of progressive epigastric and back pain and recent onset of jaundice and acholic stools. An abdominal CT was performed at another hospital, and a mass was identified in the head of the pancreas. Subsequent percutaneous biopsy revealed pancreatic carcinoma. She was transferred to Duke University Medical Center and underwent a pancreaticoduodenectomy. During this procedure, the superior mesenteric vein was mobilized and freed of adherent tumor, leading to a rent in the vein, which was closed with a 6.0 suture. Her postoperative course was complicated by sepsis, pneumonia, and respiratory distress requiring prolonged intubation. She developed massive ascites and had hypoactive-to-absent bowel sounds. Plain abdominal radiographs suggested the presence of bowel wall edema. A CT scan suggested thrombus in the superior mesenteric vein (Fig. 1A). She was started on total parenteral nutrition. Three weeks later, because her condition had not improved, the patient was referred for mesenteric angiography, which revealed severe peripheral splanchnic vasoconstriction, bowel wall thickening, and occlusion of the proximal superior mesenteric vein (Fig. 1B). Selective splenic arteriography showed patency of the portal vein. Because of the patient’s poor overall physical condition, she was considered a poor candidate for surgical thrombectomy and was referred for percutaneous recanalization of the superior mesenteric vein. Because the splanchnic venous flow was being shunted away from the occlusion by collateral vessels and because an arterial approach would preclude passing a guidewire through the occluded segment to create a channel for the flow of thrombolytic agents, a portal venous approach was chosen. In order to limit the number of needle passes and thus reduce the risk of hemorrhage, sonographic guidance was used to choose an entry point for transhepatic catheterization of the portal vein. With the patient under local anesthesia, a branch of the right portal vein was punctured in a single pass with a 22-gauge Chiba needle (Medi-Tech, Watertown, MA). A 0.01 8-in. (0.046-cm) mandril guidewire was advanced into the portal vein. A coaxial 4/6 French Braun dilator (Cook, Bloomington, IN) was used to dilate the tract with exchange to a 6.5-French Kumpe catheter (Cook). Vigorous hand injection showed a contour bulge at the orifice of the superior mesenteric vein. A 0.038-in. (0.097-cm) straight guidewire was used to probe the orifice and was advanced through the thrombus. The wire was advanced more peripherally into the superior mesentenc vein, and the Kumpe catheter was advanced through the thrombus. As the catheter was slowly withdrawn through most of the length of the thrombus, urokinase was injected by hand at a concentration ofS000 units/mlfor a total of2O,000 units. The catheter was left with its tip embedded in the most central portion of the thrombus, and urokinase was infused at a rate of 4000 units/mm for a total of 4 hr, with periodic hand injections of contrast material to adjust the catheter position more peripherally and to follow the progression of thrombolysis. After demonstration of a narrow but patent lumen, a 0.038-in. (0.097-cm) guidewire was once again advanced into the peripheral superior mesenteric vein, and an 8-mm occlusion balloon was introduced. This was swept repeatedly through the central region of the superior mesenteric vein in order to clear residual thrombus. At the location of previous thrombosis, significant resistance and balloon deformation indicated a structural stenosis. An 8-mm-diameter angioplasty balloon was introduced, and the vein was dilated with three separate 60-sec inflations. Reinjection of the peripheral superior mesenteric vein through the angioplasty balloon lumen showed patency (Fig. i C). The catheter was slowly withdrawn through the portal vein until hand injection of contrast material mdicated that its tip lay in the liver parenchyma. Two tandemly placed 3mm Gianturco coils were deposited within the tract, and a single large