O5 24-month clinical outcomes of a therapeutic stepwise approach involving low-dose systemic thrombolysis for managing acute portomesenteric thrombosis

<h3>Background</h3> Acute non-malignant portomesenteric venous thrombosis (PMVT) is associated with high morbidity and mortality in a young patient population. Chronically it can result in portal hypertension (PHT), pain and poor nutrition. We report 24-month outcomes of a series of patients presenting with this condition who acutely received a stepwise therapeutic protocol consisting of systemic thrombolysis with low-dose tissue plasminogen activator (L-tPa) +/- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) with thrombectomy and catheter-directed thrombolysis if indicated. <h3>Method</h3> We conducted a retrospective analysis of clinical records of patients with acute PMVT who were transferred to a tertiary centre for stepwise management between 2014–2024 and thereafter followed up at 3 months (3M), 6 months (6M), 12 months (12M) and 24 months (24M) post-discharge. <h3>Results</h3> 99 patients were included, 65 (65.7%) were male. Mean age was 47 years (SD=15). All patients had thrombosis of the superior mesenteric vein (SMV) on cross-sectional imaging and had persistent abdominal pain despite standard anticoagulation prior to the initiation of L-tPa. 8/99 (8.1%) patients had underlying chronic liver disease. Median time to initiation was 12 (IQR=13) days of symptoms. Follow-up post-discharge at 3M (n=63), 6M (n=49), 12M (n=50) and 24M (n=30) of these patients were reviewed. Findings are summarised in table 1. The majority of patients (see table) received warfarin as long-term anticoagulation. 92.9% were pain-free at discharge which was maintained in 72% of the patients followed up at 12 months. 93.3% of patients at 24M were maintaining adequate nutrition. Further surgical or vascular intervention was not required in 93.3% of patients at 24M. 16.3% required readmission to hospital at 6M, 26% at 12M and 20% at 24M. 86% and 83.3% of patients followed-up at 12M and 24M respectively did not develop any clinical features of PHT. TIPSS was inserted in 48 patients of which 41 (85.4%) remained patent on discharge; 16/21 (76.2%) and 9/11 (81.8%) were still patent at 12M and 24M respectively. <h3>Conclusion</h3> Our stepwise protocol achieved good recanalization and patency rates. Most patients had sustained symptom control over a 24M period. Few patients developed features of PHT (&lt;17% at 24 months). This contrasts with recently presented data in patients with recent thrombosis and no intervention which showed 39% of patients developed PHT (and over half of these patients had milder presentation with incomplete portal vein thrombosis and no SMV thrombosis)¹. Readmission and further intervention were avoided in the majority. <h3>Reference</h3> GS-004 Development of portal hypertension after non-cirrhotic non-tumoral recent portal vein thrombosis (RPVT). A long-term follow-up study. Alabau B,<i> et al. Journal of Hepatology</i>. May 2025;82:S3–S4.