Portal Thrombosis in Cirrhotics

The development of thrombotic obstruction in the portal bed of cirrhotic patients presents special problems in diagnosis and treatment. In the cirrhotic population treated for portal hypertension at our Surgical Department during the period 1967-1983 (512 patients), the incidence of thrombosis in the portal bed was 16.6% (85 patients). Bleeding was the main presenting symptom (70/85), with a mean of four episodes prior to treatment. Careful angiographic studies and intraoperative evaluation are fundamental steps to determine the exact anatomical involvement, the presence of recanalized veins or fresh occluding clots, and the applicability of shunt procedures. A massive portosplenomesenteric involvement often associated with poor surgical possibilities was found in 19 patients (22.3%). The presence of partially recanalized veins and fresh occluding clot suitable for disobliterative techniques prior to shunt was found in 16 patients, and out of 73 operated patients a total of 55 shunt procedures could be performed. Fifty-three patients who bled from varices could be followed up to 5 years: 39 underwent a shunt procedure with a 51.2% 5-year survival rate, while only one of 14 nonshunted or nonoperated survived up to 3 years, and a lethal bleeding was the cause of death in all but one. Disobliterative techniques (Fogarty thrombectomy and endovenectomy of intimal fibrotic thickenings) prior to shunting provided a good long-term patency rate with a 50% protection from lethal bleeding recurrences. Nonshunt procedures and the extensive involvement of the portal bed are associated with bad prognosis. Also, endoscopic sclerotherapy, attempted in patients with massive thrombosis, could not prevent recurrences and death from bleeding. Despite a 30% failure rate in our study, shunting surgery should be considered the only therapeutical possibility of preventing further thrombotic recurrences and consequent life threatening bleeding episodes.