What is the management approach for a patient with a dysmorphic liver and extensive Venous Thromboembolism (VTE) involving the portal, splenic, and superior and mesenteric veins, associated with upper abdominal collaterals and gastric varices?

Management of Extensive Portal-Splenic-Mesenteric Vein Thrombosis with Gastric Varices

Urgent anticoagulation is the immediate priority to prevent life-threatening mesenteric ischemia, followed by multidisciplinary evaluation for portal vein recanalization with or without TIPS, while managing gastric varices through endoscopic therapy or BRTO depending on bleeding status and gastrorenal shunt anatomy. 1

Immediate Assessment and Urgent Anticoagulation

Rule Out Intestinal Ischemia First

• Assess for signs of mesenteric ischemia immediately: abdominal pain out of proportion to examination, sepsis, elevated lactate, mesenteric fat stranding on imaging, or dilated bowel loops 1
• If ischemia is present or suspected, initiate urgent anticoagulation immediately—this significantly decreases bowel resection need and improves mortality in the 10-20% of patients who develop this complication 1
• Consider interventional thrombectomy or thrombolysis if no clinical improvement occurs with anticoagulation alone 1

Anticoagulation Decision for Non-Ischemic Presentation

• For recent (<6 months) PVT that is >50% occlusive or involves main portal vein or mesenteric vessels, anticoagulation should be initiated 1
• Your patient has involvement of multiple vascular beds (portal, splenic, superior and mesenteric veins), which strongly favors anticoagulation 1
• Traditional anticoagulants (LMWH/VKA) achieve 71% recanalization versus 42% without treatment, with no increased variceal bleeding risk (11% vs 11%) 1
• Do not anticoagulate if this is chronic (>6 months) PVT with complete occlusion and cavernous transformation, as recanalization is unlikely 1

Multidisciplinary Team Assembly

Assemble a team including gastroenterology/hepatology, interventional radiology, surgery, and hematology immediately 1

• Transfer to a center with these services if not available locally 1

Portal Vein Recanalization Strategy

Determine Chronicity and Extent

• The dysmorphic liver with collaterals suggests chronic changes, but the extent of acute-on-chronic thrombosis must be determined 1
• Portal vein recanalization with stenting is most effective when occlusion is limited to the main and right or left portal vein branches 1
• Success rates: 77% recanalization in noncirrhotic patients with 70% two-year patency when combining angioplasty, stenting, and/or TIPS 1

Recanalization Approach

• If occlusion extends only to main or segmental portal vein branches, attempt direct portal vein recanalization and stenting 1
• If occlusion extends to distal subsegmental branches, TIPS creation is needed to ensure adequate portal flow and patency 1
• TIPS with portal vein recanalization in chronic PVT with variceal bleeding shows 35% success rate with 14% rebleeding in successful cases 1

Gastric Varices Management

If Active Bleeding

• BRTO, endoscopic management, or TIPS are equivalent first-line options for active gastric variceal bleeding 1
• Critical caveat: BRTO is contraindicated in extensive portal vein occlusion because gastric varices may be the sole outflow for the entire splenomesenteric circulation—occlusion can cause splenic infarction and acute mesenteric venous ischemia 1
• Given your patient's extensive thrombosis, BRTO should be avoided unless portal recanalization is first achieved 1

If No Active Bleeding

• Endoscopic variceal obturation achieves 94% acute bleeding control in portal vein obstruction patients, similar to cirrhotic patients 1
• Consider partial splenic embolization to decrease flow into gastric varices, which has shown 100% success in preventing rebleeding in splenic vein occlusion patients 1

Surgical Options

When Interventional Approaches Fail

• Rex-bypass shunt (superior mesenteric vein to left portal vein) relieves esophageal and gastric varices with 86% patency over 6-64 months follow-up 1
• Splenorenal or mesocaval shunt creation decompresses the portal system in portal vein occlusion 1
• Splenectomy removes the source of splenic vein pressurization but should be reserved for refractory cases 1

Critical Pitfalls to Avoid

• Never perform BRTO without first ensuring adequate alternative portal outflow—this can precipitate catastrophic mesenteric ischemia in extensive thrombosis 1
• Do not assume chronic thrombosis means no anticoagulation benefit—if there's any acute component or thrombus progression, anticoagulation improves outcomes 1
• Avoid TIPS alone without portal vein recanalization—lack of continuity between TIPS and splenomesenteric veins prevents variceal decompression and causes inevitable TIPS thrombosis 1
• The presence of collaterals and gastric varices does not eliminate ischemia risk—maintain high suspicion throughout treatment 1

Monitoring and Follow-up

• Serial imaging every 3 months to assess thrombus progression if observation is chosen 1
• Measure portosystemic gradient if interventional evaluation proceeds—gradients >13 mmHg correlate with increased complications 2
• Continue anticoagulation as long as central venous catheters remain in place if present 1