Primary Catheter-Directed Thrombolysis For Porto-Mesenteric Venous Thrombosis (PMVT) In Non-Cirrhotic Patients.

Purpose: To report our technique, treatment strategy and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients.Methods: 16 non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004-2020. 8 patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000-30,000 IU/hour concomitant with heparin 300-400 IU/hour), catheter aspiration and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/hour) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in 8 patients. A total of up to 20.4 million IU urokinase was infused for 1-30 days’ treatment duration. TIPS was created in 3 patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall 1- and 2-year primary and secondary patency were both 74.0% and 84.6% respectively. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT . TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails.

Congenital protein C deficiency causing major arterial thrombosis in a neonate

A 9-day-old female baby presented with complaints of progressively worsening respiratory distress and lethargy. The parents were first cousins with history of multiple fetal losses in previous pregnancies. On examination, the baby was noted to be tachypnoeic, tachycardic with poor peripheral perfusion of the lower extremities. Femoral pulses on both sides were barely palpable. Echocardiography was normal. But cardiac catheterisation revealed the presence of an intraluminal obstruction of the distal aorta by a large thrombus. An attempt to dissolve the thrombus with urokinase infusion was unsuccessful. The affected vessels were then surgically explored and a large thrombus from the common iliac artery and distal abdominal aorta was removed. Following this, the child recovered uneventfully with return of lower limb pulsation. A thrombotic profile revealed the underlying diagnosis of congenital protein C deficiency responsible for the arterial thrombosis. This is an extremely unusual presentation, hardly ever been reported before.