Indiana University Indianapolis, IN, United States
Rawan Aljaras, MD1, Mohsin Mukhtar, MD2, Yi Dong, MD, PhD3 1Indiana University, Indianapolis, IN; 2Indiana University School of Medicine, Indianapolis, IN; 3IU Health Physicians, Indianapolis, IN
Introduction: Portal vein thrombosis (PVT) is an unusual thrombotic condition requiring anticoagulant therapy. Apixaban–a direct Factor Xa inhibitor in the class of direct oral anticoagulants (DOACs)–is used off-label in treating thrombosis at atypical sites, such as PVT. Here we report a middle-aged male who developed cavernous transformation of a PVT despite being treated with Apixaban.
Case Description/Methods: Our subject is a 45-year-old male patient with a past medical history significant for hypogonadism with chronic testosterone use. Patient was found to have polycythemia and acute PVT in 2018, after presenting with abdominal pain to a community hospital. He underwent extensive hematologic investigation of potential causes of polycythemia and hyper-coagulability, including a full genetic work up, ruling out hemochromatosis and other suspected pro-thrombotic disorders. Polycythemia with resultant PVT was thought secondary to testosterone use. Patient has been treated with Apixaban with self-reported adherence for the past three years; he continued to receive testosterone regimen despite recommendation from his hematologist to taper down the dose. He has persistent polycythemia and needs monthly phlebotomy. He was referred to a tertiary medical center due to severe, constant abdominal pain and transaminitis. His liver ultrasound with duplex showed chronic occlusion of portal vein with cavernous transformation. Comprehensive workup including CT abdomen, chronic liver disease panel, liver biopsy, MRCP, and focused hyper-coagulopathy tests were non-revealing. Hematology was consulted, and given no overt etiology, we think that patient may have failed treatment with Apixaban. His anticoagulant therapy was changed to weight-based low molecular weight heparin (LMWH), with gradual improvement of liver function.
Discussion: DOACs are currently approved for stroke prophylaxis in non-valvular atrial fibrillation, venous thromboembolism (VTE) prophylaxis in orthopedic surgery patients, the treatment of VTE involving the extremities and acute pulmonary embolism (PE). Despite this progress, anticoagulation of PVT with DOACs has remained controversial. In light of the current lack of evidence on efficacy and safety of using DOACs in the treatment of PVT, this is a report of an event of failure of Apixaban in the treatment of atypical DVT, i.e. PVT, evidenced by cavernous transformation of the thrombus. Further large-scale clinical trials comparing efficacy of DOACs with vitamin K antagonists and/or LMWH is warranted.
Figure: A- Coronal contrast-enhanced CT showing chronic portal venous thrombosis with cavernous transformation of the portal vein. B- Color doppler US image demonstrating thrombosis of portal vein with the portal vein bed containing numerous serpiginous structures, consistent with cavernous transformation (arrows).
Disclosures: Rawan Aljaras indicated no relevant financial relationships. Mohsin Mukhtar indicated no relevant financial relationships. Yi Dong indicated no relevant financial relationships.
Rawan Aljaras, MD1, Mohsin Mukhtar, MD2, Yi Dong, MD, PhD3. P1878 - Cavernous Transformation of a Portal Vein Thrombus in a Patient Treated With Apixaban: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.