Patient Report

Yonago Acta medica 2016;59:237–240

Combination Therapy of Interventional Radiology and Surgery for Infarction of theSmall Intestine Caused by Portal Vein and Mesenteric Vein Thrombosis: A PatientReport
Takayoshi Kimura,* Satoru Murata,† Shiro Onozawa,† Takahiko Mine,† Tatsuo Ueda,† Fumie Sugihara,†Daisuke Yasui,† Izumi Miki,† Shinichiro Kumita† and Toshihide Ogawa**Division of Radiology, Department of Pathophysiological and Therapeutic Science, School of Medicine, Tottori University Faculty ofMedicine, Yonago 683-8503, Japan and †Department of Radiology, Nippon Medical School, Tokyo 113-8603, Japan

tions.1–8 However, despite previous reports, a reliable
therapeutic strategy for PVMVT-related with intestinal
infarction is yet to be established.
We report here a case of PVMVT-related intestinal
infarction that was successfully treated with a combination therapy of IR and surgical resection.

ABSTRACTWe report the case of a man in his 70s who sufferedfrom intestinal infarction caused by acute portal vein
and mesenteric vein thrombosis (PVMVT). Combination therapy with percutaneous transcatheter thrombectomy and surgical bowel resection was successfully
performed, and a satisfactory outcome was achieved.
Intestinal infarction caused by PVMVT can be fataland has a high mortality rate even if surgical resection
is performed. The combination therapy of interventional radiology and surgery might be a safe and effective
method for patients with this life-threatening condition.

PATIENT REPORT
A man in his 70s with no significant medical history
was hospitalized in the emergency department becauseof abdominal pain and bloody stool persisting for 4 days.
On physical examination, abdominal rebound tenderness was found. Initial laboratory test results revealed awhite blood cell count of 13100/μL and a C-reactive protein level of 2.41 mg/L. Abdominal enhanced computed
tomography (CT) revealed extensive necrosis of theterminal ileum and continuous thrombus from the ileal
branches via the superior mesenteric vein (SMV) to themain trunk of the portal vein (PV, Fig. 1). The condition
was diagnosed as ileal necrosis due to venous thrombosis, and the combined treatment of IR and surgery wasadministered immediately.
First IR procedure: Under local anesthesia, using
ultrasonographic guidance, percutaneous transhepaticaccess to the left portal vein was established and a 5-Fr
vascular sheath was inserted. Direct portography revealed occlusion with extensive thrombosis from the ileal branches up to the main trunk of the PV. The thrombosed PV and SMV were passed through by a 0.035-inch
guidewire, and catheter-directed thrombolysis was performed after injecting a high dose of urokinase (120000
units, Uronase; Mochida, Tokyo, Japan) via a pulsespray catheter (Fountain; Merit Medical, South Jordan,UT; Figs. 2A and B).
Laparotomy: In the laparotomy performed immediately after the first IR procedure, infarction of the terminal ileum was recognized and approximately 50 cmof the small intestine was resected. Despite the presenceof a large venous thrombus, surgical thrombectomy was
not performed. At the completion of surgery, intravenous
heparin infusion was maintained at the rate of 1000

Key words

interventional radiology; intestinal infarction; portal vein thrombosis; surgical resection
Acute portal vein and mesenteric vein thrombosis(PVMVT) is a rare and insidious disease that is associated with significant mortality and morbidity. Its clinicalmanifestations are often asymptomatic or nonspecific,
such as nausea, anorexia, and abdominal distension.
Thus, the diagnosis of PVMVT is frequently delayed,which can be fatal owing to complications such as mesenteric ischemia and infarction with multiorgan failure.
In patients with PVMVT-related intestinal infarction,
the mortality rate has been reported to be 37–76%.4
Therefore, early accurate diagnosis is very important.
The traditional management of this condition has been
anticoagulation therapy. Surgery is reserved for patients
who have failed anticoagulation therapy or for those who
present with signs of mesenteric ischemia and infarction.
Due to recent advances in catheter-directed treatment,interventional radiology (IR) such as the percutaneoustranshepatic technique has been recognized as an alternative, less invasive option with minimal complicaCorresponding author: Takayoshi Kimura, MD
srkbc189@yahoo.co.jp
Received 2016 May 16
Accepted 2016 June 8
Abbreviations: CT, computed tomography; IR, interventional radiology; PVMVT, portal vein and mesenteric vein thrombosis; SMV,
superior mesenteric vein237

T. Kimura et al.

units per hour.
Second and third IR procedures: Transcatheter
thrombectomy for the residual thrombus was performedon day 1 and 2 after the operation as the second andthird IR procedure, respectively. Manual aspiration
thrombectomy was performed using a 6-Fr guiding
catheter (Launcher; Medtronic, Minneapolis, MN). Di-

rect thrombolysis was performed using 120000 units ofurokinase. Angioplasty was performed using a balloon
catheter of 8 mm diameter and 4 cm length (Mustang;Boston Scientific, Natick, MA). At the completion ofIR therapy, urokinase administration (5000 units/hour)
was continued for an additional 48 hours via the catheter
placed in the SMV (Fig. 3).

AB

Fig. 1. First dynamic CT. (A) Initial CT shows intraluminal thrombosis in the PV and the mesenteric vein (arrow). (B) Jejunal loop dilatation and diffuse wall thickening with ascites are evident (arrow head). CT, computed tomography; PV, portal vein.

Fig. 2. Percutaneous transhepatic portography shows thrombus in
the portal vein trunk (arrow) extending to the mesenteric vein.
Fig. 3. Direct portography at the second and third IR sessions
reveal residual thrombus in the PV and SMV. Percutaneoustranshepatic thrombectomy, thrombolysis, and angioplasty wereperformed. IR, interventional radiology; PV, portal vein; SMV,superior mesenteric vein.

238

IR and surgery for intestine infarction by PVT

Fig. 5. Follow-up abdominal CT at day 10 after IR and surgery
shows only a small amount of remnant thrombus in the PV andSMV (arrow). CT, computed tomography; IR, interventional radiology; PV, portal vein; SMV, superior mesenteric vein.

Fig. 4. Portography performed 4 days after IR procedure and surgery shows recanalization and antegrade hepatopetal flow in theSMV and PV. IR, interventional radiology; PV, portal vein; SMV,superior mesenteric vein.

management. Acute PVMVT without bowel ischemia has
traditionally been treated using systemic anticoagulation
therapy with heparin and warfarin to prevent propagationof the thrombus and recanalize the occluded vessels. However, for patients with intestinal infarction, perforation,and peritonitis, emergency laparotomy with bowel resection may be essential and warranted for survival. Bowel
resection and anastomosis are the standard procedures
performed with the goal of conserving as much of thebowel as possible. In previous case series of PVMVT-related intestinal infarction, the average length of resectedbowel has been 50–60 cm, which is as same as our base.
Moreover, these series reported high mortality (37–76%)
and high recurrence rates (11–29%).2, 4, 6, 7 Here, we assumed that mortality and recurrence rate were associatedwith the volume of the resected intestine. Moreover, ourpatient had an extensive thrombosis extending from theileal branches up to the main trunk of the PV. Hence,
sufficient surgical thrombectomy was considered hazardous as it comes with a high risk of critical bleeding.
Taking these factors into consideration, we employed an
endovascular approach simultaneously with a surgicalapproach to recanalize the thrombosed vein considerably and reduce the volume of bowel resection.
Endovascular therapy for PVMVT has been recognized as a therapeutic alternative that is minimally invasive and has a relatively low mortality. In a retrospective
study of 20 PVMVT patients with or without intestinal
infarction who were treated with thrombolysis via thetranshepatic route and/or superior mesenteric arteryroute, 75% experienced partial or complete clot reso-

Follow-up: Four days after the operation, sufficient
blood flow and recanalization of the SMV and PV wereconfirmed by portography (Fig. 4). Follow-up CT performed 9 days after the first IR procedure revealed onlya small amount of remnant thrombus in the SMV andPV (Fig. 5). No adverse event or complication occurred,
and the patient was discharged on day 24 of hospitalization. He was followed up in the outpatient department
with performing anticoagulant therapy using warfarin,
and no complication was noted.
DISCUSSIONPVMVT is a relatively rare disease with an incidenceof approximately 5–15% among mesenteric ischemic
events.1, 2 Myeloproliferative disease, intraabdominal infections or inflammations, septicemia, cirrhosis, intraabdominal surgery, trauma, hypercoagulable states (insufficiency of antithrombin III, protein C, protein S, etc.),
oral contraceptives use, and liver tumors are the mostcommon causes for PVMVT.3 However, our patient hadnone of these risk factors and the cause of thrombosis
was not identified despite elaborate examinations.
The main goals of therapy for acute PVMVT are
preventing extension of the thrombus, recanalization of
the vessels in the short term, and preventing recurrence inthe long term. Anticoagulation is the initial approach in239

T. Kimura et al.

lution and 85% experienced resolution of symptoms.8
The ratio of a bleeding complication is not so high as
0.06–15% in the previous reports.9–12 In the present case,
we performed percutaneous transhepatic thrombolysis,
thrombectomy, and angioplasty, which permits access tothe PV and SMV system and thus allows for infusion ofthrombolytic agents directly into the occluded vein witha limited amount of lytic agents and for longer durations.2, 3 Using this method, recanalization from the ileal
branch up to the PV was achieved safely, and adequate
blood circulation was maintained without any adverse
events. Moreover, the length of the resected intestine
was limited to 50 cm, and thrombosis or bowel ischemia
did not recur.
To the best of our knowledge, till date, no report hasindicated the efficacy of combination therapy of IR andsurgical resection for PVMVT-related intestinal infarction. Percutaneous transhepatic thrombolysis, thrombectomy, and angioplasty with surgical resection are valid
strategies for recanalization, and they may be effective
in reducing the mortality rate of patients with PVMVT-related intestinal infarction.
In conclusion, acute PVMVT-related intestinal infarction is a rare disease with high mortality; hence, early diagnosis and treatment are essential. We successfully
saved this life-threatening case with the combination
therapy of IR and surgical resection.

ic thrombolysis of mesenteric venous thrombosis. Vascular.
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3 Ozkan U, Oguzkurt L, Tercan F, Tokmak N. Percutaneoustranshepatic thrombolysis in the treatment of acute portal venous thrombosis. Diagn Interv Radiol. 2006;12:105-7. PMID:16752359.
4 Jun KW, Kim MH, Park KM, Chun HJ, Hong KC, Jeon YS,Cho SG, Kim JY. Mechanical thrombectomy-assisted thrombolysis for acute symptomatic portal and superior mesentericvenous thrombosis. Ann Surg Treat Res. 2014;86:334-41.
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2007;30:1222-6. PMID: 17573552.
6 Ludwig DJ, Hauptmann E, Rosoff L Jr, Neuzil D. Mesentericand portal vein thrombosis in a young patient with protein S
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PMID: 24949327.
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Radiol. 2005;16:651-61. PMID: 15872320.
9 Ouriel K, Gray B, Clair DG, Olin J. Complications associatedwith the use of urokinase and recombinant tissue plasminogenactivator for catheter-directed peripheral arterial and venousthrombolysis. J Vasc Interv Radiol 2000;11:295-8. PMID:10735422.
10 Schäfer C, Zundler J, Bode JC. Thrombolytic therapy in patients with portal vein thrombosis: case report and review ofthe literature. Eur J Gastroenterol Hepatol 2000;12:1141-5.
PMID: 11057461.
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The authors declare no conflict of interest

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