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PWE-092 Systemic tpa for acute splanchnic vein thrombosis
  1. D Patch,
  2. A Marshall,
  3. J O'Beirne,
  4. P Chowdary,
  5. M Sekhar,
  6. R Westbrook,
  7. D Thorburn,
  8. B Davidson,
  9. D Yu
  1. Royal Free Hospital, London, UK


Introduction Acute portal mesenteric vein thrombosis, when extensive, is associated with catastrophic complications of gut infarction, short bowel syndrome, PN dependence and death. The absence of a satisfactory therapeutic regimen has prompted the recommendation for alternative therapies (Hepatology 2010;51:210–218). Based on the safety profile of prolonged low dose tPA in children with extensive deep vein thrombosis, we have developed a ward-based TPA protocol to be used in patients with acute splanchnic vein thrombosis and symptoms/radiological signs of gut ischaemia. This treatment algorithm was approved by RFH DTC.

Method Alteplase is commenced at a dose of 0.05 mg/kg/hr in patients with acute splanchnic vein thrombosis, after informed consent and an MDT decision involving surgery/radiology/hepatology. The standard contraindications to tPA apply. Monitoring involves 12 hrly FBC, clotting, fibrinogen. Thromboelastography/ROTEM were included as exploratory investigations. t-PA may be continued for 72 h. Contrast enhanced CT is performed at 48 h, or earlier if clinically indicated. TIPS is indicated if thrombus/symptoms persist at 72 h.

Results To-date, 6 patients have been treated with this regimen. Aetiology of thrombosis was Chiari malformation (1) previously undiagnosed JAK2+ve MPD (2) local sepsis (1) and unknown (2) (see Table 1). Three patients had complete radiologic normalisation of their splanchnic circulation, 2 of whom also required TIPS due to persistent PVT. Two patients re-permeated their SMV with complete resolution of clinical symptoms and radiological signs of gut ischaemia, but with persistent PV thrombus. One patient did not have a radiological response, although their pain resolved. No patient required surgery for gut ischaemia. All patients survived and were discharged with normal enteric function. Two patients had their infusion interrupted; one for an arterial line puncture site bleed, and one for worsening gut symptoms (infusion re-started).

Abstract PWE-092 Table 1

Conclusion This early experience suggests that systemic tPA in patients with acute PMVT and symptoms/signs of gut ischaemia can be used to achieve resolution of thrombus and symptoms and avoid catastrophic complications of gut infarction. We propose that tPA is of value in a multi-modality approach to the management of acute splanchnic vein thrombosis.

Disclosure of interest None Declared.

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