The Role of TIPS in Acute Portal Vein Thrombosis: Indications, Technique & Outcomes

[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…

If imminent bowel ischemia is a no-brainer, we start on AC and we're going to intervene. In the absence of that, things are changing. All of those techniques, interventions I talked about that are all written up, they're really were before an era of having large suction thrombectomy devices. I think things are changing. They're certainly changing in our group. I know Beth Israel just published a nice series in JVIR a year ago on 32 consecutive patients with TIPS and oftentimes mechanical thrombectomy, which I'd like to dive into later. Before that, we were using TPA more. We didn't have large-suction thrombectomy devices, and we were having more bleeds. I can get into that and tell some of those stories. That started an era, at least our institution, of putting people on AC and seeing if they–

When I say trial for a week, seeing if their symptoms got better, making sure the lactate went down. If you re-image them, really you didn't see much change in terms of the clot. If they were feeling better and they weren't making lactate and it seemed like their bowel wasn't threatened, a lot of those patients were just getting treated with AC alone, which is fine. You're going to get most patients. There's a great study out of Europe that I'll go through. Most patients will do just fine in the short term or medium term with AC alone.
I say that because the study I'm referencing followed 102 patients prospectively in multi-centers throughout Europe, non-cirrhotic portal vein thrombus, AC alone. 2 out of 100 had bowel ischemia, 9 had subsequent bleeding within the first year, GI bleeding. The rest didn't. However, only 35% actually cleared clot from their main portal. They ended up with chronic PVT and all the sequelae of chronic PVT. AC alone, you have a 65% chance, of our best data, of not clearing portal thrombus.

Then you're left with cavernous transformation, which causes portal biliopathy, so compression of the biliary tree. You have patients with just feeding intolerance, pain after eating, ascites, encephalopathy, and small bowel varices. It's a very difficult group to treat because on one hand, you want to treat them with AC, many of them have hypercoagulable states, JAK2 mutations, et cetera. They also have varices. Now they're prone to bleeding and prone to clotting.

If you have a small bowel, we've had patients die in our hospital with small bowel varices because the GI docs couldn't get to it, we couldn't get to it, chronic PVT, there's no great access point, and they're really hard patients to manage. It's a decision that, yes, we want to treat these patients with acute clot, and Yes, most of them will do fine with AC alone, but with a high chance of really chronic life debilitating and potentially deadly repercussions years down the road.

[Dr. Christopher Beck]
Post-care for these patients. Let's say it's a patient who you've treated with thrombectomy, got a good result, laid down the TIPS, just talking about immediate post-op care. I'm assuming all these are, I assume, but I haven't asked, these are under anesthesia.

[Dr. Benjamin May]
Yes, we use general anesthesia. If I hold a heparin, it's for a couple of hours, we turn it right back on once we establish access. Continue AC throughout. I'm not a believer in holding AC, even for 12 hours or something, if we don't have to. It's incredible. I love these cases. They're fun. You get instant gratification to see a large clot out on the flow and et cetera. Patients, they feel great the next morning. Of course, sometimes people have pain, et cetera. I'm not saying I'm trying to oversell it, but they were pretty miserable. They were not able to eat well.

They just know something's not right. The next morning, you see this big food trailer eating pancakes. Yes, they have a bandage on their neck and they go, oh yes, it's a little sore here, but they're so thankful. Even just the color on their face. It's pretty incredible, honestly, how much of a turnaround a lot of these patients experience. That's another super rewarding part of this procedure in particular. We're keeping a close eye on them for a day or two, make sure they don't have bleeding. They're going to get established care with our hepatology group.

We don't routinely put them on HE prophylaxis, lactulose or whatnot, but it's obviously want to keep a close eye and make sure they're not having any of the symptoms so we can get ahead of it. We're getting an ultrasound in a week. It's standard TIPS care. Then seeing them every three months just to make sure that TIPS is open. There are cases I mentioned that we got out a lot of clot, but we want to do a little more work. It was just getting late or whatever. Maybe we scan them and see clot or maybe we just do another venogram. I think in some of these papers, they're routinely doing a TIPS venogram on every one of these patients.

I don't find that to be necessary. A few of them, we've gone back. As I mentioned, if you put the TIPS stent in first, it will gel off some clot and it's always just sitting there. You'll see our ultrasound, just sitting there at the edge. Sometimes you want to go back and balloon that and work on that a little bit. Those are the things we've done. So far, I think we're up to 12 now since we started with the large suction devices with 100% technical success rate and no bleeding complications. We've had to go in, I don't want to quote the-- I have to look at the data again, but we've had to go in and maybe a quarter of them to just touch things up, maybe extend the stent, maybe do a little more a thrombectomy. Really good outcomes.