The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK.
Department of Radiology, Royal Free London NHS Trust, London, UK.
Aliment Pharmacol Ther. 2019 Nov;50(9):1049-1058. doi: 10.1111/apt.15479. Epub 2019 Sep 5.
Anticoagulation alone in acute, extensive portomesenteric vein thrombosis (PVT) does not always result in spontaneous clot lysis, and leaves the patient at risk of complications including intestinal infarction and portal hypertension.
To develop a new standard of care for patients with acute PVT and evidence of intestinal ischaemia.
We present a case series of patients with acute PVT and evidence of intestinal ischaemia plus ongoing symptoms despite initial systemic anticoagulation, who were treated with a thrombolysis protocol between 2014 and 2019. This stepwise protocol initially uses low-dose systemic alteplase, and in patients with ongoing abdominal pain, and no evidence of radiological improvement, is followed by local clot dissolution therapy (CDT) through a TIPSS. Outcomes and safety were assessed.
Twenty-two patients were included. The mean age was 44.6 (standard deviation [SD] 16.0) years, and 64% had an identifiable prothrombotic risk factor. All patients had intestinal wall oedema and 77% had complete occlusion of all portomesenteric veins. Systemic thrombolysis was started 18.7 (SD 11.2) days after the onset of symptoms. 55% of patients underwent TIPSS insertion for CDT. At the end of treatment, symptoms resolved in 91% of patients and recanalisation in 86%. Only one patient required resection for intestinal ischaemia, and there were no deaths. Major complications occurred in two patients (9%).
Our stepwise protocol is effective, resulting in good recanalisation rates. It can be commenced early while organising transfer to a centre capable of performing local CDT.
急性、广泛门腔静脉血栓形成（PVT）患者单独抗凝治疗并不总能导致血栓自发溶解，且使患者面临包括肠梗死和门静脉高压在内的并发症风险。
为急性 PVT 合并肠缺血证据的患者制定新的治疗标准。
我们报告了一组急性 PVT 合并肠缺血证据且尽管初始全身抗凝仍持续存在症状的患者，他们在 2014 年至 2019 年期间接受了溶栓方案治疗。该逐步方案最初使用低剂量全身性阿替普酶，如果患者持续腹痛且影像学无改善，则通过 TIPSS 进行局部血栓溶解治疗（CDT）。评估了结局和安全性。
共纳入 22 例患者。患者的平均年龄为 44.6（标准差 [SD] 16.0）岁，64%有可识别的血栓形成风险因素。所有患者均有肠壁水肿，77%的患者所有门腔静脉均完全闭塞。全身溶栓治疗在症状出现后 18.7（SD 11.2）天开始。55%的患者因 CDT 而行 TIPSS 插入术。治疗结束时，91%的患者症状缓解，86%的患者再通。仅 1 例患者因肠缺血而行切除术，无死亡病例。2 例患者（9%）发生严重并发症。
我们的逐步方案有效，再通率高。它可以在早期开始，同时安排转至能够进行局部 CDT 的中心。
