Mesenteric Vein Access for OPVT-Related Recurrent Variceal Bleeding: An Ambispective Cohort

Condition(s) studied

Investigational drug(s) / intervention(s)

Percutaneous mesenteric vein-assisted interventional treatment: Intervention (stepwise intra-procedural strategy). After MV access is established under ultrasound guidance, operators will follow a predefined escalation algorithm based on anatomy and feasibility: MV-assisted PVR-TIPS (preferred): Using antegrade catheter/guidewire manipulation via MV access, attempt recanalization of the occluded main portal vein trunk. A catheter or balloon may be positioned as a target to complete standard TIPS via the transjugular route. MV-assisted collateral-to-caval shunt (secondary): If main portal vein recanalization is not achievable, catheterize an eligible collateral (e.g., ≥6 mm) and, with target-marker assistance, create a collateral-to-inferior vena cava shunt via the transjugular route. Extrahepatic MV-to-caval shunt (backup): If neither main portal vein recanalization nor a suitable collateral is available, create an extrahepatic MV-to-inferior vena cava shunt tract through MV access as an alternative portal decompression strategy.

Study summary

Occlusive portal vein thrombosis (OPVT) is defined as complete thrombosis of the main portal vein trunk, resulting in total interruption of portal venous inflow and representing the most severe form of portal vein thrombosis. A small proportion of patients may remain asymptomatic for prolonged periods because of sufficient collateral compensation; however, most develop complications of portal hypertension when collateral flow is inadequate, including gastroesophageal variceal bleeding and ascites. Among these, gastroesophageal variceal bleeding is the most life-threatening, and its management is more challenging-with a higher risk of rebleeding-than in patients without portal vein thrombosis.

Occlusive portal vein thrombosis (OPVT) is defined as complete thrombosis of the main portal vein trunk, resulting in total interruption of portal venous inflow and representing the most severe form of portal vein thrombosis. A small proportion of patients may remain asymptomatic for prolonged periods because of sufficient collateral compensation; however, most develop complications of portal hypertension when collateral flow is inadequate, including gastroesophageal variceal bleeding and ascites. Among these, gastroesophageal variceal bleeding is the most life-threatening, and its management is more challenging-with a higher risk of rebleeding-than in patients without portal vein thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective minimally invasive therapy for portal hypertension-related complications; however, in OPVT, technical feasibility largely depends on successful portal vein recanalization. To improve TIPS success in OPVT, our group-together with domestic and international investigators-has explored several adjunctive access routes and technical modifications, including percutaneous transhepatic or transsplenic portal vein recanalization TIPS (PVR-TIPS); transjugular portal cavernous collateral-caval shunt (TCCS); transjugular mesenteric-caval shunt (TMCS); transjugular spleno-caval shunt (TSCS); and surgically assisted hybrid procedures. Although these strategies have improved technical success rates to some extent, their applicability remains limited. In patients with extensive thrombosis involving intrahepatic portal vein branches, in those without a feasible splenic venous puncture route, or in patients with prior splenectomy, percutaneous transhepatic and transsplenic approaches are often not possible. Moreover, in patients with poor hepatic reserve and/or ascites, laparotomy-assisted hybrid procedures substantially increase invasiveness and perioperative risk.

In this context, the present project aims to systematically investigate and evaluate ultrasound-guided percutaneous mesenteric vein (MV) puncture as an adjunctive access strategy for interventional treatment of OPVT. This technique uses ultrasound-guided percutaneous puncture of the MV to establish antegrade portal venous access, thereby facilitating subsequent portal vein recanalization and/or shunt creation.

Eligibility

Primary outcome measure(s)

• Technical success of the index procedure (overall) — During the procedure (index hospitalization)
  Successful creation of a functioning portosystemic shunt using the study strategy (MV-assisted PVR-TIPS, MV-assisted collateral-to-caval shunt, or extrahepatic MV-to-caval shunt), confirmed by completion angiography demonstrating shunt patency/flow and effective portal decompression as assessed intra-procedurally per operator judgment and standard imaging criteria.
• Safety-major procedure-related adverse events — From procedure through 30 days post-procedure.
  Incidence of major adverse events related to MV puncture and/or shunt creation (e.g., clinically significant intraperitoneal hemorrhage, bowel/mesenteric injury, sepsis, procedure-related death, or other events meeting predefined serious adverse event criteria).

Trial sites (1)

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