Portal Vein Thrombosis

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**Definition and clinical phenotypes**

Portal vein thrombosis (PVT) may be:

- **Acute** (new clot, abdominal pain, fever, ileus; higher risk of extension into SMVthe superior mesenteric vein (SMV) with intestinal ischemia). [@plessier2012]
- **Chronic** (portal hypertension, varices, splenomegaly, cavernous transformation). [@plessier2012]

Also distinguish:

- **Bland vs malignant PVT** (tumor invasion—most commonly hepatocellular carcinoma—changes expectations for recanalization and overall strategy). [@plessier2012]
- **Cirrhotic vs non-cirrhotic PVT** (different bleeding risk profile and competing risks). [@plessier2012]

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**Diagnosis**

- **Doppler ultrasound** is first-line (absent flow, echogenic material, collateralization/cavernoma). [@plessier2012]
- **Contrast CT (portal venous phase)** defines extent (portal confluence, SMV involvement) and evaluates bowel perfusion and alternate diagnoses. [@plessier2012]
- **MR venography** is an alternative when iodinated contrast is unsuitable. [@plessier2012]

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**Treatment goals**

- Prevent extension/recurrence.
- Promote recanalization in selected acute cases.
- Manage portal hypertension sequelae (varices/ascites) in chronic disease. [@plessier2012]

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**Anticoagulation (core therapy for acute bland PVT)**

- Start therapeutic anticoagulation when acute bland PVT is diagnosed and bleeding risk is acceptable, particularly if there is **extension toward the SMV**, symptoms, or a strong prothrombotic driver. [@plessier2012] [@kearon2016]
- Agent selection (LMWH/VKA/DOAC)(low-molecular-weight heparin (LMWH), vitamin K antagonist (VKA), or direct oral anticoagulant (DOAC)) and duration should follow general venous thromboembolism (VTE) principles while considering liver function, drug interactions, and GIgastrointestinal (GI) bleeding risk. [@kearon2016] [@ash2020]
- In patients with cirrhosis, DOACs have demonstrated comparable safety and potentially superior recanalization rates compared to VKAs. [@dai2026]
- Duration is commonly **at least 3–6 months**, with longer therapy considered for persistent risk factors or recurrence. [@kearon2016]

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**Endovascular and portal decompressive options**

- Consider **TIPS**a **transjugular intrahepatic portosystemic shunt (TIPS)** when portal hypertension complications are refractory to standard therapy or when recanalization is needed to facilitate portal inflowinflow, (caseespecially selectionin isliver center-dependent).transplant candidates. [@plessier2012] [@dai2026]
- Catheter-directed thrombolysis/thrombectomy is reserved for highly selected patients with extensive acute thrombosis and threatened bowel, typically in specialized centers. [@plessier2012]

**Surgery**

- If intestinal infarction develops (typically from SMV extension), urgent exploration and bowel resection are required (see [[Acute Mesenteric Ischemia|Mesenteric Ischemia]] principles). [@bala2017] [@clair2016]