The ABCD of portal vein thrombosis: a systematic approach

Portal vein thrombosis refers to complete or partial obstruction of the portal venous system, in the intrahepatic or extrahepatic venous tract or even in the splenic or superior mesenteric veins. This common and potentially fatal condition can develop in various clinical contexts, especially those of liver cirrhosis, hepatocellular carcinoma, and other solid tumors. Certain characteristics, such as the time since the onset of the thrombus (acute or chronic), its biology (hematic or tumoral), the presence of collateral vessels, and the magnetic resonance imaging aspects, are important components of a thorough, careful analysis, as well as informing decisions regarding the appropriate therapeutic strategy. Here, we present a brief review of the anatomy of the portal venous system and a systematic approach to analyzing the condition, using a mnemonic (ABCD, for age, biology, collaterals, and diffusion). We discuss the various imaging methods and illustrate our discussion with images selected from the case files archived at our facility.

Keywords:
Portal vein; Venous thrombosis; Hypertension, portal; Collateral circulation; Magnetic resonance imaging

Authorship

Alexandre Makoto Minoda Correspondence: Dr. Alexandre Makoto Minoda. Rua do Futuro, 514, Graças. Recife, PE, Brazil, 52050-005. Email: alexandreminoda@hotmail.com.

Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil.Instituto de Medicina Integral Professor Fernando Figueira (IMIP)BrazilRecife, PE, BrazilInstituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil.

https://orcid.org/0000-0002-9813-3076

Raissa Brito Fernandes Cadete

https://orcid.org/0000-0002-3007-8402

Sara Reis Teixeira

Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.Universidade de São Paulo (FMRP-USP)BrazilRibeirão Preto, SP, BrazilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0001-5845-058X

Valdair Francisco Muglia

https://orcid.org/0000-0002-4700-0599

Jorge Elias Junior

https://orcid.org/0000-0002-1158-1045

Andréa Farias de Melo-Leite

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

https://orcid.org/0000-0003-0044-7278

Correspondence: Dr. Alexandre Makoto Minoda. Rua do Futuro, 514, Graças. Recife, PE, Brazil, 52050-005. Email: alexandreminoda@hotmail.com.

SCIMAGO INSTITUTIONS RANKINGS

Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.Universidade Federal de Pernambuco (UFPE)BrazilRecife, PE, BrazilUniversidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

Figures

Figures (6)

Thumbnail

Figure 1
Coronal CT reconstruction showing the portal venous system. The main portal vein (black asterisk) is formed by the union of the splenic vein (white arrow) and the superior mesenteric vein (white asterisk). The right and left portal branches divide within the hepatic hilum (black arrowheads). Other tributaries include the inferior mesenteric vein (black arrow) and the gastric veins (white arrowhead).

Thumbnail

Figure 2
Schematic drawing showing the anatomy of the portal venous system. The portal vein (straight arrow), formed by the union of the splenic vein (black asterisk) and superior mesenteric vein (white asterisk), directly receives the right and left gastric veins (arrowheads). The inferior mesenteric vein (curved arrow) drains directly into the splenic vein. (Adapted from Netter⁽¹⁰10 Netter FH. Atlas of human anatomy. 2nd ed. East Hanover, NJ: Novartis; 1997.⁾).

Thumbnail

Figure 3
A: Patient in a hypercoagulable state with extensive acute portal vein thrombosis. Longitudinal ultrasound image showing a hypoechoic thrombus (black arrow) in the main portal vein, the caliber of which is increased, with slight peripheral blood flow on color Doppler (white arrow), the flow being related to partial occlusion and not being a flow within the thrombus (which differentiates it from a tumor thrombus). B: Schematic drawing showing the cavernous transformation of the portal vein. Extensive thrombus (asterisk) in the main portal vein, with the formation of multiple collaterals (arrows) around the obstruction. C: Color Doppler ultrasound in a case of chronic portal vein thrombosis, showing serpiginous vessels (arrow) in the periportal region, indicative of cavernous transformation. D: Unenhanced axial CT scan of the abdomen in a case of acute portal vein thrombosis, showing na increase in the caliber of the portal vein (> 13 mm), which contains hyperdense material, best seen in its right branch (arrow). E: Axial T2-weighted MRI scan in a case of acute portal vein thrombosis, showing a hyperintense acute thrombus within the portal vein (white arrow). There is flow artifact (flow void) in the main portal vein, suggesting partial thrombosis (black arrow). F: Magnetic resonance cholangiography in a case of acute portal vein thrombosis. Note the markedly hyperintense signal, suggesting acute portal vein thrombosis. Note also that, at first glance, it can mimic the common bile duct (arrow). However, the diagnosis of acute portal vein thrombosis was confirmed after detailed analysis and three-dimensional reconstructions. G: Contrast-enhanced axial T1-weighted MRI in a case of chronic portal vein thrombosis, showing cavernous transformation of the portal vein (arrow).

Thumbnail

Figure 4
A,B: CT scan showing a tumor thrombus secondary to HCC (asterisk). Axial sections acquired before and after contrast administration (A and B, respectively), showing 20 UH of enhancement in the thrombus (i.e., 37 UH in the pre-contrast phase and 57 UH in the post-contrast phase). In addition, there is expansion of the vessel, also related to the tumor component. C: Axial CT scan of a patient with a vascular thrombus, showing no enhancement of the thrombus in the portal phase (asterisk). D: Contrast-enhanced T1-weighted MRI scan of a patient with a vascular thrombus in the left portal vein branch (black arrow), showing no enhancement.

Thumbnail

Figure 5
A: Gastroesophageal varices. Axial contrast-enhanced CT scan showing dilated vessels at the lesser curvature and at the gastroesophageal junction (arrow). B: Contrast-enhanced MRI showing paraesophageal varices, presenting as dilated vessels around the distal esophageal portion (arrow). C: Contrastenhanced axial T1-weighted MRI scan showing recanalization of the paraumbilical veins, the reopening of the veins occurring in the round/falciform ligament (arrow). D: Contrast-enhanced MRI of a splenorenal shunt. There is communication between the splenic vein and the left renal vein through serpiginous, dilated vessels (arrow). E: Axial contrast-enhanced CT scan showing dilated and tortuous vessels in the gallbladder wall (arrow).

Thumbnail

Figure 6
A: DWI of a patient with chronic liver disease and diffuse HCC, showing restricted diffusion in the right hepatic lobe (white arrow) and in the left portal vein branch (black arrow). B: DWI of another patient with chronic liver disease and diffuse HCC, in which the ADC measured in the thrombus was 1.0 × 10⁻³ mm²/s, a value similar to that found for the tumor.

Figure 1 Coronal CT reconstruction showing the portal venous system. The main portal vein (black asterisk) is formed by the union of the splenic vein (white arrow) and the superior mesenteric vein (white asterisk). The right and left portal branches divide within the hepatic hilum (black arrowheads). Other tributaries include the inferior mesenteric vein (black arrow) and the gastric veins (white arrowhead).

Figure 2 Schematic drawing showing the anatomy of the portal venous system. The portal vein (straight arrow), formed by the union of the splenic vein (black asterisk) and superior mesenteric vein (white asterisk), directly receives the right and left gastric veins (arrowheads). The inferior mesenteric vein (curved arrow) drains directly into the splenic vein. (Adapted from Netter⁽¹⁰10 Netter FH. Atlas of human anatomy. 2nd ed. East Hanover, NJ: Novartis; 1997.⁾).

Figure 3 A: Patient in a hypercoagulable state with extensive acute portal vein thrombosis. Longitudinal ultrasound image showing a hypoechoic thrombus (black arrow) in the main portal vein, the caliber of which is increased, with slight peripheral blood flow on color Doppler (white arrow), the flow being related to partial occlusion and not being a flow within the thrombus (which differentiates it from a tumor thrombus). B: Schematic drawing showing the cavernous transformation of the portal vein. Extensive thrombus (asterisk) in the main portal vein, with the formation of multiple collaterals (arrows) around the obstruction. C: Color Doppler ultrasound in a case of chronic portal vein thrombosis, showing serpiginous vessels (arrow) in the periportal region, indicative of cavernous transformation. D: Unenhanced axial CT scan of the abdomen in a case of acute portal vein thrombosis, showing na increase in the caliber of the portal vein (> 13 mm), which contains hyperdense material, best seen in its right branch (arrow). E: Axial T2-weighted MRI scan in a case of acute portal vein thrombosis, showing a hyperintense acute thrombus within the portal vein (white arrow). There is flow artifact (flow void) in the main portal vein, suggesting partial thrombosis (black arrow). F: Magnetic resonance cholangiography in a case of acute portal vein thrombosis. Note the markedly hyperintense signal, suggesting acute portal vein thrombosis. Note also that, at first glance, it can mimic the common bile duct (arrow). However, the diagnosis of acute portal vein thrombosis was confirmed after detailed analysis and three-dimensional reconstructions. G: Contrast-enhanced axial T1-weighted MRI in a case of chronic portal vein thrombosis, showing cavernous transformation of the portal vein (arrow).

Figure 4 A,B: CT scan showing a tumor thrombus secondary to HCC (asterisk). Axial sections acquired before and after contrast administration (A and B, respectively), showing 20 UH of enhancement in the thrombus (i.e., 37 UH in the pre-contrast phase and 57 UH in the post-contrast phase). In addition, there is expansion of the vessel, also related to the tumor component. C: Axial CT scan of a patient with a vascular thrombus, showing no enhancement of the thrombus in the portal phase (asterisk). D: Contrast-enhanced T1-weighted MRI scan of a patient with a vascular thrombus in the left portal vein branch (black arrow), showing no enhancement.

Figure 5 A: Gastroesophageal varices. Axial contrast-enhanced CT scan showing dilated vessels at the lesser curvature and at the gastroesophageal junction (arrow). B: Contrast-enhanced MRI showing paraesophageal varices, presenting as dilated vessels around the distal esophageal portion (arrow). C: Contrastenhanced axial T1-weighted MRI scan showing recanalization of the paraumbilical veins, the reopening of the veins occurring in the round/falciform ligament (arrow). D: Contrast-enhanced MRI of a splenorenal shunt. There is communication between the splenic vein and the left renal vein through serpiginous, dilated vessels (arrow). E: Axial contrast-enhanced CT scan showing dilated and tortuous vessels in the gallbladder wall (arrow).

Figure 6 A: DWI of a patient with chronic liver disease and diffuse HCC, showing restricted diffusion in the right hepatic lobe (white arrow) and in the left portal vein branch (black arrow). B: DWI of another patient with chronic liver disease and diffuse HCC, in which the ADC measured in the thrombus was 1.0 × 10⁻³ mm²/s, a value similar to that found for the tumor.

How to cite

copy

Publicação do Colégio Brasileiro de Radiologia e Diagnóstico por Imagem Av. Paulista, 37 - 7º andar - conjunto 71, 01311-902 - São Paulo - SP, Tel.: +55 11 3372-4541, Fax: 3285-1690, Fax: +55 11 3285-1690 - São Paulo - SP - Brazil
E-mail: radiologiabrasileira@cbr.org.br

Acompanhe os números deste periódico no seu leitor de RSS

Versão para download de PDF

PDF

Inglês
Português

Versões e tradução automática

Versão original do texto

English
Português

Tradução automática

Google Translator
Microsoft Translator

Como citar

RIS

BIBTEX

Outros formatos de citação e exportação:

SciELO - Scientific Electronic Library Online
Rua Dr. Diogo de Faria, 1087 – 9º andar – Vila Clementino 04037-003 São Paulo/SP - Brasil
E-mail: scielo@scielo.org

Leia a Declaração de Acesso Aberto

Métricas

The ABCD of portal vein thrombosis: a systematic approach

PlumX

Mensagem

[1] Correspondence: Dr. Alexandre Makoto Minoda. Rua do Futuro, 514, Graças. Recife, PE, Brazil, 52050-005. Email: alexandreminoda@hotmail.com.