Should Interventional Radiology (IR) or Vascular Surgery be consulted for portal vein thrombosis?

Management of Portal Vein Thrombosis: When to Consult Interventional Radiology or Vascular Surgery

Interventional Radiology (IR) should be consulted for portal vein thrombosis, particularly in cases of recent thrombosis (<6 months), evidence of intestinal ischemia, or when the patient is a liver transplant candidate. 1

Assessment and Classification of Portal Vein Thrombosis (PVT)

Portal vein thrombosis requires careful characterization to determine appropriate management:

• Chronicity: Recent (<6 months) vs. chronic (>6 months)
• Extent: Intrahepatic branches, main portal vein, splenic vein, mesenteric veins
• Degree of occlusion: Partial (<50%) vs. significant (>50%) vs. complete
• Presence of complications: Intestinal ischemia, portal hypertension, varices

When to Consult Interventional Radiology

Urgent Consultation (Emergency)

• Intestinal ischemia: Patients with PVT and evidence of intestinal ischemia require urgent intervention to minimize ischemic injury 1
  • Clinical features: Abdominal pain out of proportion to examination, sepsis, elevated lactate
  • Imaging findings: Mesenteric fat stranding, dilated bowel loops

Priority Consultation

1. Recent PVT (<6 months) with >50% occlusion of main portal vein or mesenteric vessels 1
2. Liver transplant candidates with PVT to facilitate technical feasibility of transplantation 1
3. Patients with additional indications for TIPS, such as:
   • Refractory ascites
   • Variceal bleeding
   • Hepatic hydrothorax 1
4. Bleeding gastric varices with gastrorenal shunt present 1

Non-Urgent Consultation

• Recent PVT (<6 months) with <50% occlusion of portal vein, splenic vein, or mesenteric veins 1
• Chronic PVT (>6 months) with cavernous transformation 1

When to Consult Vascular Surgery

Vascular surgery consultation is generally less common for PVT but may be considered in:

1. Failed endovascular therapy with persistent symptoms
2. Surgical thrombectomy candidates with evidence of hemodynamic instability, peritonitis, or bowel infarction 1
3. Patients with splenic vein thrombosis related to non-cirrhotic portal hypertension who may benefit from splenectomy 1

Interventional Treatment Options

IR-Led Interventions

1. Portal Vein Revascularization with TIPS (PVR-TIPS):

   • Creates portosystemic shunt while reestablishing portal flow
   • Particularly useful for transplant candidates 1
   • Post-TIPS venography recommended within 1-2 months to assess for residual thrombus 1

2. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO):

   • Preferred for bleeding gastric varices with gastrorenal shunt 1
   • Less invasive than TIPS
   • Does not worsen encephalopathy but may worsen portal hypertension

3. Catheter-directed thrombolysis:

   • Can be performed via transhepatic or transjugular approach
   • Often combined with mechanical thrombectomy
   • May be considered for acute thrombosis with high clot burden 1

Multidisciplinary Approach

The AGA Clinical Practice Update emphasizes that patients with PVT and intestinal ischemia should be managed by a multidisciplinary team including:

• Gastroenterology/Hepatology
• Interventional Radiology
• Hematology
• Surgery 1

For TIPS management, a multidisciplinary approach involving gastroenterologist/hepatologist and interventional radiologist is recommended for ongoing monitoring and potential revisions 1.

Post-Procedural Management

• Laboratory evaluation to assess for bleeding and hepatic dysfunction
• Cross-sectional imaging within 4-6 weeks after procedures like BRTO
• Surveillance endoscopy to assess and treat esophageal varices that may be exacerbated by procedures 1

Common Pitfalls

• Delayed intervention: Initiating anticoagulation within 6 months (ideally within 2 weeks) of PVT diagnosis correlates with improved recanalization rates 1
• Overlooking intestinal ischemia: This complication requires urgent intervention and is associated with 10-20% mortality 1
• Failing to obtain cross-sectional imaging: Portal venous phase CT or MRI is essential to determine vascular anatomy and presence of portosystemic shunts 1
• Neglecting variceal screening: Patients with PVT require endoscopic variceal screening if not already on non-selective beta-blocker therapy 1

By following this approach, the appropriate specialist consultation can be determined based on the specific characteristics of the portal vein thrombosis and the patient's clinical condition.