This protocol addresses patients with acute mesenteric venous thrombosis without peritonitis or peritoneal signs in whom first-line systemic anticoagulation has not achieved adequate mesenteric vein recanalisation, or in whom symptoms persist or worsen after anticoagulation is initiated.
The initial approach is systemic anticoagulation — started promptly with unfractionated heparin or low molecular weight heparin and continued with oral anticoagulation — together with supportive care. The treatment target is mesenteric vein recanalisation, typically demonstrated after a median of six months. When this goal is not reached, or when clinical deterioration occurs during anticoagulant therapy, escalation to the next step is indicated.
An endovascular approach targeting the occluded mesenteric veins may be considered — involving catheter-directed techniques to directly access the veins and address the thrombus.
Full technique selection, procedural sequencing, and clinical decision points are detailed in the structured protocol.
Complete recanalisation of the mesenteric veins, with resolution of thrombus.
DOI: 10.1016/j.ejvs.2025.06.010
Anticoagulation with unfractionated or low molecular weight heparin as first line therapy is recommended for all patients with acute mesenteric vein thrombosis.
Patients with persisting symptoms, worsening abdominal pain after initiation of anticoagulation, or developing signs of peritonitis may be considered for endovascular treatment, if necessary followed by diagnostic laparoscopy or exploratory laparotomy.
Endovascular venous thrombolysis and mechanical thrombectomy may be considered for patients with acute venous mesenteric ischaemia who deteriorate during anticoagulant therapy.
Although technically challenging, both transjugular intrahepatic and percutaneous transhepatic approaches provide resolution of thrombus by direct access to mesenteric veins, after a mean of 40 hours.
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