Kareem Abu-Elmagd, Hani Haider, Guilherne Costa, Geoffrey Bond, George Mazariegos, Wallis Marsh, Paulo Fontes, Nikhil Amesur

University of Pittsburgh Medical Center, Pittsburgh, PA, United States

Objective(s): Portomesenteric venous thrombosis (PMVT) is a syndrome associated with life-threatening complications including, short bowel, variceal hemorrhage, and liver failure. With current status of undefined entities and anecdotal treatment strategies, a new classification with algorithmic management is crucial for optimal therapy and successful outcome.

Methods: Two-hundred eighty-nine consecutive patients with symptomatic PMVT were referred for extra-renal abdominal organ transplantation. Thrombosis was confined to portal vein in 178 Child B/C cirrhotics (typeI). Another 37 patients suffered short bowel (typeII) with portal vein patency (IIA) and cavernous transformation (IIB). Remaining 74 had extensive portomesenteric-splenic vein thrombosis (typeIII) with hepatic functions maintained (IIIA) or decompensated (IIIB). Hypercoagulability was diagnosed in 7% of typeI and most of typeIIB&III patients.

Results: With follow-up of 72+64 months, 270 patients (177-typeI, 35-typeII, 58-typeIII) underwent surgical treatment. All typeI were able to receive liver transplant with thrombectomy (n=101) or vein graft (n=76). With typeII, 33 (94%) required intestinal transplantation with liver in 17. Remaining 2 underwent autologous gastrointestinal reconstruction. Despite referral for transplantation, all type IIIA patients (n=37) underwent portal hypertensive surgery for variceal bleeding with non-conventional portosystemic shunt (n=23) and gastric devascularization (n=14). All typeIIIB (n=21) required transplantation with multivisceral graft (n=17) or isolated liver with cavoportal hemitransposition (n=4). With intent to treat, one-year survival was 92% (non-transplant surgery), 80% (liver transplant), and 75% (visceral transplant) with 10-15% lower rates at 5-years. There was no significant difference in survival between the three types of the syndrome.

Conclusions: The proposed classification of PMVT is based upon extent of thrombosis and status of hepatoenteric functions. It is a valid and effective tool to guide and optimize therapy with proper selection of the apt surgical modality including non-transplant surgery for patients with preserved liver functions.