Indications

• Symptomatic PV or HV thrombosis PLUS

  • • Failed anticoagulation

    • Concern for bowel ischemia / infarct

    • Concomitant need for TIPS

Contraindications

• Absolute (for tPA use):

  • • Active hemorrhage or potential for bleeding

    • Surgery in previous 10 days

    • Neurosurgery in previous 3 weeks

    • Intracranial process (e.g. recent CVA, neoplasm)

    • Recent trauma

    • Extensive bowel infarct or septic shock (reperfusion may exacerbate)

• Relative:

  • • Ascites (perform para before transhepatic access)

    • Standard concerns with angiography (allergy, renal failure, coags)

Imaging Review

• CT / MR / US:

  • • Extent of thrombosis. Occlusion of SMV and splenic vein = poor prognosis

    • Underlying etiology? Malignancy, infection, etc.

    • Findings of Budd-Chiari with HV thrombosis

    • Presence and extent of bowel ischemia. Bowel perf à OR

    • Ascites

Tips for Workup

• If patient is not a candidate for tPA or systemic anticoagulation, rethrombosis rates are high, so few will attempt perc thrombectomy.

• Transhepatic access (or new TIPS access) will receive abx ppx

• PV thrombolysis much higher complication rate (9-60%) than HV thrombolysis (5-10%)

• Pt will need ICU bed for 24hr lysis monitoring

• Consent:

  • • Hemorrhage: Intraperitoneal, subcapsular, access site

    • Other: technical failure, rethrombosis, abdominal pain, nausea, transaminitis, infection, contrast nephropathy.