Ep. 541 Treatment of Acute Portal Vein Thrombosis with Dr. Ben May
May 6, 2025
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Dr. Ben May, an Interventional Radiologist at Weill Cornell Medicine, specializes in hepatobiliary services and shares his expertise on acute portal vein thrombosis. He discusses the need for effective treatment options beyond anticoagulation, especially for younger patients. Dr. May highlights innovative techniques such as suction thrombectomy and the importance of personalized interventions based on clot characteristics. He also emphasizes collaborative practices in managing complex cases and offers practical tips for successful thrombectomy procedures.
Early diagnosis of acute portal vein thrombosis is crucial to prevent severe complications and ensure timely intervention.
A multidisciplinary approach combining interventional radiologists, hepatologists, and surgical teams enhances the effectiveness of treatment for acute PVT.
Advances in thrombectomy devices have improved intervention success rates, allowing more effective management options for acute portal vein thrombosis.
Deep dives
Understanding Acute Portal Vein Thrombosis
Acute portal vein thrombosis (PVT) is a serious condition that can lead to complications such as bowel ischemia and infarction. This condition arises when an obstruction occurs in the portal vein, disrupting blood flow from the intestines and spleen to the liver. Early diagnosis is crucial as symptoms often present as vague abdominal pain, leading to delayed treatment and increased risks of severe outcomes. It is generally important to intervene within the first month of diagnosis to avoid the transition to chronic PVT, which can result in chronic complications like mesenteric hypertension and varices.
Diagnostic Approaches and Imaging Techniques
The preferred diagnostic approach for acute PVT involves cross-sectional imaging, particularly a contrast-enhanced CT scan, which provides the best visualization of the portal venous system. Ultrasound can be useful but may not offer the same level of detail as CT or MRI, making them less reliable for such assessments. Blood tests play a crucial role in evaluating liver function and determining the urgency of the case, especially with respect to the risk of bowel ischemia. Recognizing the extent of clot involvement and identifying other potential contributing factors, such as underlying hypercoagulable states or recent surgeries, is vital in forming a treatment plan.
Intervention Strategies for Acute PVT
The gold standard for treating acute PVT is anticoagulation, which is critical for preventing further complications. Various interventional strategies include transhepatic access for catheter-directed lysis or thrombectomy, TIPS (transjugular intrahepatic portosystemic shunt) placement, and restoring blood flow through suction thrombectomy using advanced devices. Choosing the appropriate intervention depends on the patient's condition, the extent of the clot, and if there is a sufficient collateral flow. Recent advancements in thrombectomy devices have significantly increased the success rates and reduced the risks associated with these interventions, enabling safer and more efficient management of acute PVT.
Collaboration in Multidisciplinary Care
The management of patients with acute portal vein thrombosis commonly requires a multidisciplinary approach involving interventional radiologists, hepatologists, and surgical teams. Collaborating helps in determining treatment pathways based on collective expertise and fosters a more effective patient care environment. Regular tumor board meetings provide a platform for discussing complex cases and ensuring comprehensive treatment plans. By working closely together, healthcare professionals can optimize patient outcomes and enhance care quality, addressing both immediate needs and long-term health implications.
Post-Procedure Care and Long-Term Monitoring
Post-procedure management of patients who undergo intervention for acute PVT typically includes close monitoring for complications, including bleeding or infection. Anticoagulation therapy should continue to ensure that the blood flow remains patent and to reduce the chance of new clots forming. Routine follow-ups are essential to assess the integrity of interventions, often involving Doppler ultrasounds or CT scans to check the patency of the portal vein. Patients need education about potential long-term issues, including the importance of maintaining regular healthcare checks to monitor for the sequelae of chronic PVT.
To TIPS or not to TIPS? More than ever, younger patients are presenting with acute portal vein thrombosis (PVT) that requires intervention beyond anticoagulation alone. These patients need safe, effective options that offer long-term resolution and a good quality of life after treatment. In this episode of the BackTable Podcast, Dr. Benjamin May, Interventional Radiologist at Weill Cornell Medicine, discusses the evolving treatment landscape for acute PVT. --- SYNPOSIS Dr. May shares insights into the changing interventional approaches, highlights the utility of tools such as suction thrombectomy devices, and explains how his best practices have developed over time. He emphasizes the continued importance of anticoagulation therapy, explores the potential complications and outcomes of various interventions, and discusses how thrombus location and characteristics influence his clinical decisions. With real-world scenarios and a step-by-step walkthrough of his decision-making process, Dr. May offers a comprehensive look at modern strategies for managing acute portal vein thrombosis. --- TIMESTAMPS 00:00 - Introduction 05:46 - Diagnosing Portal Vein Thrombosis 10:52 - Management Options for Acute PVT and What is Safest? 21:09 - Choosing an Intervention Approach 26:19 - Tackling Large Bore Thrombectomy 32:37 - Learnings and Tips for Successful Thrombectomy 39:50 - Impact of Thrombus Location on Intervention Approach 45:01 - Post-Care and Follow-Up 49:46 - Final Thoughts and Encouragement --- RESOURCES “Transjugular Intrahepatic Portosystemic Shunt and Thrombectomy (TIPS-Thrombectomy) for Symptomatic Acute Noncirrhotic Portal Vein Thrombosis” (Shalvoy, 2023) https://www.jvir.org/article/S1051-0443(23)00341-X/abstract
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