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BackTable / VI / Article
Portal Vein Thrombosis Treatment: Shifting Away from tPA & Thromboytic-Heavy Protocols
Evangeline Adjei-Danquah • Updated Aug 30, 2025 • 38 hits
In acute portal vein thrombosis (PVT), treatment has traditionally included tissue plasminogen activator (tPA) and other lytic-heavy protocols, but these carry a high bleeding risk in patients who require ongoing anticoagulation. Recent advances in large-bore suction thrombectomy devices, combined with intravascular ultrasound (IVUS) guidance, allow effective clot removal without thrombolytics. This approach preserves anticoagulation as the gold standard, minimizes complications, and improves both short-term outcomes and longitudinal portal vein patency. By reducing dependence on thrombolytics, physicians can treat a broader range of patients safely, including younger individuals and those at higher risk for chronic PVT complications such as portal hypertension, varices, and bowel ischemia.
The BackTable Brief
• Thrombolytic-heavy protocols for acute PVT can cause bleeding rates of up to 60%, forcing interruption of anticoagulation and increasing complications.
• Maintaining continuous anticoagulation is critical for safe, effective PVT management, and is standard of treatment.
• Large-bore suction thrombectomy devices and IVUS guidance can allow complete clot removal without using tPA.
• Early trials show high technical success and no major bleeding complications with lytic-free thrombectomy.
• Without the bleeding risks of thrombolytics, more patients including high-risk and younger individuals can be treated promptly.
• IVUS-guided access, working with a second operator, and combining suction with rotational tools improve outcomes.
• Clearing both the SMV and splenic vein helps maintain good portal flow and reduces the risk of recurrent thrombosis.
Table of Contents
(1) Tissue Plasminogen Activator & Thrombolytic-Heavy Protocols Are Falling Into Disuse
(2) Emergence of Lytic-Free Mechanical Thrombectomy
(3) Safe Lytic-Free Portal Vein Thrombectomy
Tissue Plasminogen Activator & Thrombolytic-Heavy Protocols Are Falling Into Disuse
For years, catheter-directed thrombolysis with tPA or other lytic agents was a common interventional option for acute portal vein thrombosis, especially when clot burden was extensive. However, Dr. May discusses accumulating evidence that has shown lytic-heavy protocols to carry significant bleeding risks, with some studies reporting rates as high as 60%. These bleeds are not only dangerous but also force physicians to pause anticoagulation, the gold standard for PVT, compromising treatment effectiveness. Even seemingly small bleeds can require extended hospitalization and increase morbidity. As a result many interventional radiologists are moving away from routine tPA use, reserving it for rare, highly selective cases.
[Dr. Christopher Beck]
Portal venous acute PVT thrombosis, what are the management options? Then once we talk about the management options, we'll walk through each of them and then really dig into the IR part of it.
[Dr. Benjamin May]
Important not to forget the gold standard is anticoagulation. That's established with good data, with consensus statements, et cetera. AC is upfront, is critical, and it's important when we think about other interventions because we don't want to limit what is the gold standard. Beyond that, people have talked about really three different buckets of ways to approach clot in the portal vein.
One is transhepatic access, and then doing some combination of catheter-directed lysis or a thrombectomy. Another is a TIPS approach with or without lysis, but thrombectomy. Then a third is accessing this SMA and dripping tPA into the SMA, which has largely fallen out of favor, associated with a lot of bleeding. It's something I've never tried, but it's usually talked about when you read review articles and whatnot.
[Dr. Christopher Beck]
On dripping tPA into the SMA?
[Dr. Benjamin May]
Yes. There's groups who have left a catheter, transradial or transfemoral, within the SMA and sent the patient to ICU and dripped tPA. A couple papers out of Asia showed 100% success rate with zero complications, and it has not been replicated in other studies, which showed a very large bleeding rate, as high as 60%, and so it's largely fallen out of favor.
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Emergence of Lytic-Free Mechanical Thrombectomy
Recent advances in large-bore suction thrombectomy devices have transformed acute PVT management. Using these systems alongside intravascular ultrasound (IVUS) for precise, safe access, interventionalists can now remove bulky clots without the need for lytics. Dr. Benjamin May shares how this technique preserves continuous anticoagulation, avoids the bleeding risks associated with tPA, and allows for complete or near-complete clearance of the portal and mesenteric venous systems. Early institutional experiences have shown high success rates with no major bleeding complications, even in young, otherwise healthy patients who have extensive clot. The ability to intervene more aggressively yet safely marks a major shift in clinical practice.
[Dr. Christopher Beck]
Some of these thrombophilic patients can be really young when they present with this. It's not like these are 70-year olds and you're like, oh, we just get them to anticoagulation then they'll be fine. These patients can be really young and like being susceptible to the chronic PVT that can have a lot of morbidity and certainly mortality associated with it.
[Dr. Benjamin May]
Exactly right. We're presenting the last 10 patients we did in this modern era of having suction thrombectomy devices. Our mean age is 39. It's probably a story worth telling. I should even go back. When I started, as I mentioned, not only was liver transplantation really establishing itself at Cornell, but so was bariatric surgery. Portal vein thrombus is a known complication of bariatric surgery. We were seeing every two, three months a patient with acute PVT in the postoperative setting. I was charged with doing a lit search and coming up with a strategy within our institution.
I went through the data, which I reviewed earlier and I said, we should do TIPS approach. I was borrowing a lot from the venous side where in that era, before large-suction thrombectomy, we were doing lysis, dripping tPA, AngioJet, the biggest suction device we had was an 8 French device. We treated about eight patients and it was technical success was high. We're good at doing tips. We're good at getting these devices in, you're trying balloon maceration. It just wasn't great outflow.
Two of them, one had a large subcapsular hematoma, but with just a couple milligrams of tPA, which doesn't sound like a big deal, but now you have to pause AC, which is the gold standard in these cases. That patient was hospitalized for a while. We then restarted AC. I had to reopen the TIPS, I had to reopen everything. She did okay, but with some morbidity. Another patient had an extra capsular puncture as just part of the TIPS, which we get away with all the time, but not when you're dripping tPA and using AC.
I had big intraperitoneal hemorrhage, had to go to the OR and the surgeon confirmed one tiny little, puncture in the capsule was enough to really threaten her life. She ultimately did well also, but we had a, essentially a 25% complication rate. This is early on, and so we paused. We only treated patients at that point for the next five years who were tilting towards bowel ischemia. Everything changed one day when a young guy, 25, healthy, professional, good looking guy was … training for the marathon and just felt like crud the next morning. Came in, got scanned, expansile thrombus, everywhere, small bump in lactate, some ascites, started on AC, getting a little bit better and then got much worse, lactate started to rise. They decided, oh, he has HIT, we'll send off antibodies, we'll start him on argatroban, but stay tuned. I think he'll get better.
Overnight or throughout the course of that day, I should say, just took a turn for the worse. Lactate shot up and started getting into DIC. You know someone's sick when the head of the SICU comes in, because usually it's the surgical resident and then maybe their senior, and then at most the fellow, the surgeon came down himself and said, you need to take this guy right now, which we did, and had a couple of changes. I said, you know what? I don't want to have any extra capsular punctures. I should shout out my colleague, Brian Curry, who was very involved in this case. He was actually following this patient earlier, but both of us work together on a lot of these cases. It's very helpful to have a colleague, all hands on deck for these.
Used intracardiac echo or side-firing IVUS to guide our puncture. Didn't stop argatroban for one second. Didn't use tPA, but got our larger-suction thrombectomy devices, 12 French. In that case, I think we used the 12 French with the cleaner through it. Used the cleaner and the suction thrombectomy and cleared all that clot. I got those beautiful pictures of huge clot. Guy did great. Usually, he infarcted part of his bowels that operated on him, but that was occurred before we intervened. Survived and is back to his life.
That really prompted me just to say, you know what? We have better devices now. We can stay away from tPA. We're getting more facile with IVUS guidance and we should be intervening more. I think I can do this safely. That, I don't know if it was serendipity or what. I sent an email off explaining my rationale. Within that first year, we had 10 patients show up with the same exact presentation. It was very bizarre.
I don't know. My theory is that maybe COVID has something to do with it. I know patients with COVID are more prone to getting clot. I can't tell you why. We just see patient after patient in their 30s and late 20s present often with JAK2 mutations, but no surgery, no other reason. We've been intervening without any bleeding complications. It's been a game changer. I think now with these new devices, new techniques, we can do this safer. Some of those high bleeding risk, this data says, oh, there's a 20% bleeding risk, 30%, 40%. I think with those techniques seems to be, we've had zero. I know Beth Israel in their series had zero. Knock on wood that it will be very low and we can intervene more.
Safe Lytic-Free Portal Vein Thrombectomy
Successful lytic-free thrombectomy for acute PVT takes good planning, careful technique, and the right equipment. Many doctors recommend using IVUS guidance to avoid puncturing outside the liver, keeping anticoagulation going during the case when possible, and working with another experienced operator to help optimize instrument management and control. Large-bore suction devices, combined with rotational tools that help loosen clot from the vessel wall, can break up and remove clot more effectively than a thrombolytic alone. “Swallowing” balloons can make it easier to get devices through tight curves. When possible, clearing both the superior mesenteric and splenic veins can help improve perfusion and lower recurrent thrombus risk.
[Dr. Christopher Beck]
Let's say in the patient, either you're going to make it a game time decision. You're not ready to put the TIPS down, but you're going to clear it out first. Will you just walk us through the blocking and tackling of-- if you're going to use one of these large-bore thrombectomy techniques about how you're getting your devices down and then just how you're, how you're activating them. Also if you're comfortable, you can talk about devices, specifics.
[Dr. Benjamin May]
Let's say we're going to do suction thrombectomy upfront and not leave a TIPS, but it does matter because it's harder to get these devices, believe it or not, through a TIPS stent, that uncovered portion, just your device catches on that uncovered portion and there's a curve there. Swallowing a balloon is quite helpful. I'm just constantly putting up a millimeter balloon and pushing hard and pulling back, and swallowing to get our devices in place.
We started using the 12 French and then quickly started using either the 16 Lightning, which is Penumbra's device, or Argon now has a CLEANER Vac 18 French, which is also nice. I think both are great. I do another, again, not to hear the plug devices, but the rotational cleaner that is used, I think probably designed for dialysis work is also quite helpful. The portal vein is big, it's expansile, and it's hard to get your wall-to-wall suction. These are stiff devices. Putting the rotational cleaner through either of those suction devices, either the CLEANER Vac or the Lightning is quite helpful in mobilizing clot off the wall and just getting everything sucked through.
Device-wise, that's what I go to. It sounds scary to put an 18 French sheath through the liver. I certainly was nervous about it. I swallow a balloon to do it, but it goes really smoothly. I've been using the GORE DrySeal, but there's others as well. It's 30 centimeters. For most patients, it gets you just in. If you're nervous, you can leave a safety wire through. There's options there. Those are the device I'm using.
Not going into nuts and bolts. There's a lot of turns in the portal system and these devices are big, so they work best. The reps will tell you that they work best without a wire through them. What I usually do is for first pass, I'll get a wire out the splenic. That'll draw the device off to one wall of the portal. I'll advance the suction devices far into the spine because I need to or can. If I need to swallow a balloon, I will, and then make one pass just pulling back over the wire. Oftentimes. If not, maybe I'll pull the wire and then reintroduce it because you don't want to lose access.
Then do the same thing down the SMV because that will get you on the opposite wall. Then once, assuming flow is starting to get better, I'll pull the wire and do it again. That's usually what I do. It's also, I'll add, super helpful to have the reps in the room with you. Both of those companies, certainly New York City, have excellent-- they're just so helpful, not only with their devices, but these little tricks and tips that they've seen. I'm a big believer in having them in the room with you, because it just can, it can really make the difference.
[Dr. Christopher Beck]
As far as the actual procedure, so you're going to go in, make a couple passes with the thrombectomy. If you are going to use the cleaner, you use it as troubleshooting afterwards and you just run it through with like, you got some residual clot or something.
[Dr. Benjamin May]
I should have mentioned, no, I'm nesting. The cleaner will go right through both of those devices and you can run them simultaneous. That's actually what our presentation at SIR is going to be about, simultaneous rotational and suction thrombectomy for portal vein thrombus, a newer technique, but they work so great together. You don't have to. You can run one and then switch it out. The rotational cleaner is long, it goes right through, it's whipping up that clot and you can be sucking at the same time and just clears out a lot of clot. It is really great.
Podcast Contributors
Dr. Benjamin May
Dr. Benjamin May is an interventional radiologist at Weill Cornell Medicine in New York City, New York.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2025, May 6). Ep. 541 – Treatment of Acute Portal Vein Thrombosis [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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