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门静脉血栓的诊断和治疗
DOI: 10.12449/JCH260402
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：何雨芩负责撰写论文及表格制作；文良志负责拟定写作思路，指导论文撰写并修改论文。
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摘要: 门静脉血栓（PVT）累及门静脉主干及其属支，急性期可导致肠道缺血坏死，慢性期可引发门静脉海绵样变及门静脉高压相关并发症（如腹水、食管胃静脉曲张破裂出血等）。肝硬化是PVT的首要危险因素。PVT的分型为临床诊断提供了依据，超声为首选筛查手段，增强计算机体层成像是诊断的金标准，磁共振成像/磁共振静脉成像则有助于鉴别血栓的急慢性状态。治疗强调个体化策略：抗凝治疗为急性PVT的一线选择，直接口服抗凝剂展现出良好应用潜力；溶栓治疗适用于急性重症患者，需严格控制出血风险；经颈静脉肝内门体分流术是诊治PVT相关腹水及食管胃静脉曲张破裂出血的重要方式；外科手术则用于药物治疗无效或出现肠坏死等严重并发症的治疗。未来PVT的诊疗应基于多学科协作，并聚焦于个体化方案的优化，在疗效与安全性之间寻求平衡，并依托技术进步持续提升临床实践水平。Abstract: Portal vein thrombosis （PVT） involves the main portal vein and its tributaries， and acute PVT can cause intestinal ischemia and necrosis， while chronic PVT can cause cavernous transformation of the portal vein and portal hypertension-related complications （such as ascites and gastroesophageal variceal bleeding）. Liver cirrhosis is the main risk factor for PVT. the Classification of PVT provides a basis for clinical diagnosis. Ultrasound is the preferred method for screening， and contrast-enhanced computed tomography is the gold standard for diagnosis， while magnetic resonance imaging/magnetic resonance venography can help to identify acute or chronic thrombosis. Treatment emphasizes individualized strategies： anticoagulant therapy is the first-line therapy for acute PVT， and direct oral anticoagulants have shown great potential in clinical practice； thrombolytic therapy is appropriate for severe acute PVT， and it is needed to strictly control the risk of bleeding； transjugular intrahepatic portosystemic shunt is an important method for the diagnosis and treatment of PVT-related ascites and gastroesophageal variceal bleeding； surgical operation can be used for the treatment of patients with no response to pharmacotherapy or those with serious complications such as intestinal necrosis. Future diagnosis and treatment of PVT should be based on multidisciplinary collaboration， focusing on the optimization of individualized regimens， balancing efficacy and safety， and continuously leveraging technological advances to improve clinical practice.
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Key words:
- Portal Vein Thrombosis /
- Diagnosis /
- Therapeutics
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表 1 非肝硬化PVT的病因分类
Table 1. Etiological classification of non-cirrhotic PVT
因素 分类 核心机制及病因 局部疾病因素 腹腔肿瘤（最常见） 肿瘤细胞浸润、分泌促凝物质、压迫血管导致血栓形成［1］ 腹部感染与炎症 如阑尾炎、憩室炎、胰腺炎、胆囊炎和寄生虫感染等，引起局部血管内皮损伤，增加血栓
风险［1］腹部手术/创伤 脾切除术、肝移植术后，PVT发生率较高［9-11］ 罕见结构性病变 如门静脉瘤伴完全血栓形成［12］ 全身疾病因素 骨髓增殖性肿瘤 部分血液系统疾病病因［2］ 遗传性/获得性易栓症 包括凝血因子V Leiden突变、凝血酶原基因突变、抗凝血酶Ⅲ缺乏、蛋白C/S缺乏、高纤维
蛋白原血症、抗磷脂综合征、门静脉血管异常性肝病、先天性肝纤维化等［9］其他系统性疾病 如肾病综合征，偶有PVT报道［13］ 其他因素 激素与生理状态 口服避孕药、妊娠及产褥期［1］ 注：PVT，门静脉血栓。
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表 2 PVT分型简易对比表
Table 2. Simple comparison of PVT classification types
分类 分型标准 优势 Yerdel分型（2000）［18］ 1级：血栓占门静脉比例<50%；
2级：血栓占门静脉比例≥50%，伴或不伴轻度肠系膜静脉血栓
形成；
3级：门静脉或脾静脉完全闭塞；
4级：门静脉完全闭塞伴完全闭塞延伸肠系膜上静脉评估肝移植手术者的手术策略
及移植预后；目前使用最广泛的
分类Baveno Ⅶ共识（2021）［19］ 按照门静脉主干阻塞程度分型：
轻度闭塞（<50%）、部分闭塞（>50%）、完全闭塞（100%）、门静脉
海绵样变多用于PVT的发展史或药物治
疗时的临床实践与研究肝硬化管理专家共识（2020）［20］ 附壁性：血栓占据门静脉管腔<50%；
阻塞性：血栓完全或接近完全占据门静脉管腔；
部分性：介于附壁和阻塞性之间；
条索化：血栓长期阻塞门静脉而发生机化，影像学检查无法探明
门静脉管腔（阻塞性和条索化PVT常伴有门静脉海绵样变性）更加简易，与Baveno Ⅶ贴近，且
有助于治疗选择和预后评判，可
能更适用于介入放射学研究注：PVT，门静脉血栓。
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表 3 急、慢性PVT的影像学鉴别要点
Table 3. Key imaging differentiation criteria of acute and chronic PVT
项目 急性PVT 慢性PVT 血栓时间 形成<6个月 形成>6个月 治疗目标 防止血栓蔓延、促进再通；抗凝是基础，若抗凝后血栓进展，需溶栓
治疗预防消化道出血，减少门静脉高压并发症，需
长期抗凝治疗常见并发症 肠穿孔、腹膜炎、感染性休克、多脏器功能衰竭等 食管胃静脉曲张破裂出血、腹水及脾功能亢进 超声检查 门静脉血流速度<15 cm/s，门静脉为低回声或等回声 机化或钙化时出现条索样强回声；海绵样变时
呈蛇纹或蜂窝状混合回声增强CT 急性血栓首选CT检查，平扫期为偏高信号影，门静脉期管腔内的
血栓无造影剂强化；血栓完全性且急性的PVT门静脉管腔有扩张
及双轨征，无侧支循环形成血栓呈低密度，可能伴有钙化，或伴有海绵样
变，或伴有肠系膜静脉血栓或脾静脉血栓，有
侧支循环形成MRI表现 T1WI上多呈等信号或稍高信号，T2WI上呈高信号 慢性血栓因机化、纤维化，T1WI和T2WI多呈混
杂信号，若出现钙化则会表现为低信号门静脉造影 血流少、门静脉增宽 血流丰富、门体侧支形成广泛 注：PVT，门静脉血栓；CT，计算机体层成像；MRI，磁共振成像；T1WI，T1加权成像；T2WI，T2加权成像。
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表 4 PVT抗凝治疗药物的分类和临床应用
Table 4. Classification and clinical applications of PVT anticoagulant therapeutic agents
分类 代表药物 机制 有效性［5，37-38］ 用药方式及安全性 推荐使用 直接口服抗
凝药利伐沙班、依度沙班、
阿哌沙班、达比加群直接抑制凝血
因子Ⅹa、Ⅱa因子有效性优于传统抗凝
药，显著减少PVT体
积；实现更高的完全
再通/溶栓反应率；有
助于PVT长期改善固定剂量口服、无需常规凝
血监测、药物间相互作用
少、饮食限制较少，且有特
异性逆转剂（Andexanet
alfa、Idarucizumab）作为一线推荐 维生素K拮
抗剂华法林 抑制维生素K
依赖性凝血因
子（Ⅱ、Ⅶ、Ⅸ和
Ⅹ）的合成出血率较高（19.2%） 治疗窗窄、需频繁监测INR
调整剂量、受食物（维生素
K）、多种药物影响；维生素
K、凝血酶原复合物浓缩
物、新鲜冰冻血浆等可逆转
维生素K拮抗剂的抗凝
作用传统/二线选择（存
在直接口服抗凝药
禁忌或经济条件有
限时使用）低分子肝素 依诺肝素、达那帕罗
钠等通过抗凝血酶
Ⅲ增强对Ⅹa因
子和Ⅱa因子的
抑制出血率高（21.4%） 皮下注射，不适合长期门诊
治疗主要用于初始/短期
治疗注：INR，国际标准化比值。
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表 5 PVT介入及手术治疗技术对比
Table 5. Comparison of interventional and surgical treatment techniques for PVT
手术方式 血栓类型 技术方法 优劣势 并发症 经皮穿刺介入［43］ 急性PVT 经肝/脾穿刺门静脉溶
栓/取栓直接作用于血栓部位，有效但出
血风险较高出血风险显著（尤其包
膜穿刺）经动脉间接溶栓［43］ 急性PVT 肠系膜上动脉灌注溶栓
药物避免直接门静脉穿刺，溶栓效率
可能较低，通常在直接溶栓无效
时用出血风险 机械血栓清除术［20］ 急性PVT AngioJet流变式血栓清
除；真空抽吸（Indigo/
Inari）；手动抽吸既可快速清除血栓，又可减少溶
栓剂用量，适用于有溶栓禁忌的
患者，但受耗材尺寸限制无出血并发症报道 TIPS［20，44］ 急或慢性PVT 单纯TIPS建立；TIPS+溶
栓/取栓；TIPS联合静脉
曲张栓塞优点：降低出血风险、提供门静
脉流出道、缓解门静脉高压、改
善血栓溶解环境。
急性：1～2年通畅率为63%；慢性：成功率为75%～98%肝性脑病（25%）；TIPS
狭窄/功能障碍（21%～
22%）；支架移位（罕见）外科手术［45］ 慢性PVT+并发症 门静脉重建+分流手术；
肠切除（缺血时）直接处理解剖异常，且移植时端
端吻合可行，但手术创伤大，病
死率较高肝性脑病、血栓再形成、
肠缺血、肠梗阻等注：PVT，门静脉血栓；TIPS，经颈静脉肝内门体分流术。
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[1] CAIANO LM, RIVA N, CARRIER M, et al. Treatment of portal vein thrombosis: An updated narrative review[J]. Minerva Med, 2021, 112( 6): 713- 725. DOI: 10.23736/S0026-4806.21.07526-1. [2] CUSTO S, TABONE E, AQUILINA A, et al. Splanchnic vein thrombosis: The state-of-the-art on anticoagulant treatment[J]. Hamostaseologie, 2024, 44( 4): 242- 254. DOI: 10.1055/a-2232-5480. [3] TONG WL, GADANI S. Chronic portal vein thrombosis: Diagnosis, management, and review of the literature[J]. Tech Vasc Interv Radiol, 2025, 28( 4): 101084. DOI: 10.1016/j.tvir.2025.101084. [4] CHEN HS, TRILOK G, WANG F, et al. A single hospital study on portal vein thrombosis in cirrhotic patients- clinical characteristics& risk factors[J]. Indian J Med Res, 2014, 139( 2): 260- 266. [5] ODRIOZOLA A, PUENTE Á, CUADRADO A, et al. Portal vein thrombosis in the setting of cirrhosis: A comprehensive review[J]. J Clin Med, 2022, 11( 21): 6435. DOI: 10.3390/jcm11216435. [6] HUANG XY, ZHANG YH, YI SY, et al. Potential contribution of the gut microbiota to the development of portal vein thrombosis in liver cirrhosis[J]. Front Microbiol, 2023, 14: 1217338. DOI: 10.3389/fmicb.2023.1217338. [7] SENZOLO M, GARCIA-TSAO G, GARCÍA-PAGÁN JC. Current knowledge and management of portal vein thrombosis in cirrhosis[J]. J Hepatol, 2021, 75( 2): 442- 453. DOI: 10.1016/j.jhep.2021.04.029. [8] ANTON A, CAMPRECIÓS G, PÉREZ-CAMPUZANO V, et al. The pathophysiology of portal vein thrombosis in cirrhosis: Getting deeper into Virchow's triad[J]. J Clin Med, 2022, 11( 3): 800. DOI: 10.3390/jcm11030800. [9] WU JL, DENG XY, LUO JY, et al. Update in the treatment of cirrhotic patients with portal vein thrombosis[J]. Clin Mol Hepatol, 2025, 31( 4): 1139- 1166. DOI: 10.3350/cmh.2025.0411. [10] LIN YK, CAI XR, HONG HJ, et al. Risk factors of portal vein system thrombosis after splenectomy: A meta-analysis[J]. ANZ J Surg, 2023, 93( 12): 2806- 2819. DOI: 10.1111/ans.18633. [11] MANTAKA A, GATSELIS N, TRIANTOS CK, et al. Treatment of portal vein thrombosis in cirrhosis: A multicenter real life cohort study[J]. Minerva Gastroenterol, 2023, 69( 1): 107- 113. DOI: 10.23736/s2724-5985.21.02861-8. [12] de VLOO C, MATTON T, MEERSSEMAN W, et al. Thrombosis of a portal vein aneurysm: A case report with literature review[J]. Acta Clin Belg, 2019, 74( 2): 115- 120. DOI: 10.1080/17843286.2018.1511298. [13] GERA DN, PATEL J, PATEL K, et al. Portal vein thrombosis: A rare complication of nephrotic syndrome[J]. Indian J Nephrol, 2018, 28( 3): 236- 239. DOI: 10.4103/ijn.IJN_25_17. [14] CAO L, WEI K, HAI J, et al. Efficacy and safety of different antithrombotic regimens including direct oral anticoagulants for the prevention of portal vein system thrombosis after splenectomy in patients with liver cirrhosis and portal hypertension: A systematic review and network meta-analysis[J]. Int J Surg, 2025, 111( 12): 9706- 9725. DOI: 10.1097/JS9.0000000000003220. [15] TURON F, DRIEVER EG, BAIGES A, et al. Predicting portal thrombosis in cirrhosis: A prospective study of clinical, ultrasonographic and hemostatic factors[J]. J Hepatol, 2021, 75( 6): 1367- 1376. DOI: 10.1016/j.jhep.2021.07.020. [16] PONZIANI FR, ZOCCO MA, CAMPANALE C, et al. Portal vein thrombosis: Insight into physiopathology, diagnosis, and treatment[J]. World J Gastroenterol, 2010, 16( 2): 143- 155. DOI: 10.3748/wjg.v16.i2.143. [17] UEDA T, SAITO H, SHIRAI S, et al. Endovascular treatment for acute portal vein thrombosis[J]. Interv Radiol, 2024, 10: e20230027. DOI: 10.22575/interventionalradiology.2023-0027. [18] YERDEL MA, GUNSON B, MIRZA D, et al. Portal vein thrombosis in adults undergoing liver transplantation: Risk factors, screening, management, and outcome[J]. Transplantation, 2000, 69( 9): 1873- 1881. DOI: 10.1097/00007890-200005150-00023. [19] de FRANCHIS R, BOSCH J, GARCIA-TSAO G, et al. Baveno VII-Renewing consensus in portal hypertension[J]. J Hepatol, 2022, 76( 4): 959- 974. DOI: 10.1016/j.jhep.2021.12.022. [20] Hepatobiliary Disease Study Group, Chinese Society of Gastroenterology, Chinese Medical Association. Consensus for management of portal vein thrombosis in liver cirrhosis(2020,Shanghai)[J]. J Clin Hepatol, 2020, 36( 12): 2667- 2674. DOI: 10.3969/j.issn.1001-5256.2020.12.007.中华医学会消化病学分会肝胆疾病学组. 肝硬化门静脉血栓管理专家共识(2020年,上海)[J]. 临床肝胆病杂志, 2020, 36( 12): 2667- 2674. DOI: 10.3969/j.issn.1001-5256.2020.12.007. [21] MOLVAR C, AMIN P. Portal vein thrombosis in cirrhosis: Interventional treatment options[J]. Curr Gastroenterol Rep, 2021, 23( 12): 24. DOI: 10.1007/s11894-021-00826-1. [22] GIRARDI L, ZARKA F, PRADIER M, et al. Diagnostic performance of ultrasound, computed tomography and magnetic resonance imaging in portal vein thrombosis: A systematic review with meta-analysis[J]. Thromb Res, 2026, 257: 109560. DOI: 10.1016/j.thromres.2025.109560. [23] JU C, LI X, GADANI S, et al. Portal vein thrombosis: Diagnosis and endovascular management[J]. Rofo, 2022, 194( 2): 169- 180. DOI: 10.1055/a-1642-0990. [24] ZHOU L, HUANG ZC, LIN XH, et al. Case report: CT manifestations of acute portal vein thrombosis: Cases report and literature review[J]. Front Radiol, 2025, 5: 1662089. DOI: 10.3389/fradi.2025.1662089. [25] COPIN P, RONOT M, NUZZO A, et al. Inter-reader agreement of CT features of acute mesenteric ischemia[J]. Eur J Radiol, 2018, 105: 87- 95. DOI: 10.1016/j.ejrad.2018.05.027. [26] PLESSIER A, DARWISH-MURAD S, HERNANDEZ-GUERRA M, et al. Acute portal vein thrombosis unrelated to cirrhosis: A prospective multicenter follow-up study[J]. Hepatology, 2010, 51( 1): 210- 218. DOI: 10.1002/hep.23259. [27] van DAM LF, KLOK FA, TUSHUIZEN ME, et al. Magnetic resonance thrombus imaging to differentiate acute from chronic portal vein thrombosis[J]. TH Open, 2020, 4( 3): e224- e230. DOI: 10.1055/s-0040-1716716. [28] LI CM, HU A, HAACKE M, et al. Direct portal vein thrombosis visualization with t2*-weighted magnetic resonance imaging[J]. Int J Med Sci, 2013, 10( 11): 1570- 1574. DOI: 10.7150/ijms.6681. [29] JOSHI A, KULKARNI S, SHAH A. Role of MRI in evaluation of spectrum of liver lesions in cirrhotic patients[J]. J Assoc Physicians India, 2020, 68( 4): 32- 38. [30] WANG SK, CHENG YF, LIM WX, et al. Applying intraoperative portal venography in liver transplantation vascular surgery[J]. Diagnostics, 2025, 15( 18): 2321. DOI: 10.3390/diagnostics15182321. [31] DEBERNARDI-VENON W, BANDI JC, GARCÍA-PAGÁN JC, et al. CO2 wedged hepatic venography in the evaluation of portal hypertension[J]. Gut, 2000, 46( 6): 856- 860. DOI: 10.1136/gut.46.6.856. [32] YANG L, BETTMANN MA. Identification of the portal vein: Wedge hepatic venography with CO2 or iodinated contrast medium[J]. Acad Radiol, 1999, 6( 2): 89- 93. DOI: 10.1016/S1076-6332(99)80487-5. [33] CAPOROSSI JM, VIDAL V, JACQUIER A, et al. Balloon occlusion versus wedged hepatic venography using iodinated contrast for targeting the portal vein during TIPS[J]. Diagn Interv Imaging, 2015, 96( 4): 357- 363. DOI: 10.1016/j.diii.2014.11.011. [34] de FRANCHIS R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension[J]. J Hepatol, 2015, 63( 3): 743- 752. DOI: 10.1016/j.jhep.2015.05.022. [35] DELGADO MG, SEIJO S, YEPES I, et al. Efficacy and safety of anticoagulation on patients with cirrhosis and portal vein thrombosis[J]. Clin Gastroenterol Hepatol, 2012, 10( 7): 776- 783. DOI: 10.1016/j.cgh.2012.01.012. [36] European Association for the Study of the Liver. EASL clinical practice guidelines on vascular diseases of the liver[J]. J Hepatol, 2026, 84( 2): 399- 456. DOI: 10.1016/j.jhep.2025.08.001. [37] TSOCHATZIS EA, SENZOLO M, GERMANI G, et al. Systematic review: Portal vein thrombosis in cirrhosis[J]. Aliment Pharmacol Ther, 2010, 31( 3): 366- 374. DOI: 10.1111/j.1365-2036.2009.04182.x. [38] XIAO XL, ZHU WG, DAI QX. Direct oral anticoagulants versus traditional anticoagulation in cirrhotic patients with portal vein thrombosis: Updated systematic review[J]. Clin Appl Thromb Hemost, 2024, 30: 10760296241303758. DOI: 10.1177/10760296241303758. [39] ELKRIEF L, HERNANDEZ-GEA V, SENZOLO M, et al. Portal vein thrombosis: Diagnosis, management, and endpoints for future clinical studies[J]. Lancet Gastroenterol Hepatol, 2024, 9( 9): 859- 883. DOI: 10.1016/S2468-1253(24)00155-9. [40] KUMARI D. Acute mesenteric and portal vein thrombosis: Etiology, diagnosis, and interventional management[J]. Tech Vasc Interv Radiol, 2025, 28( 3): 101058. DOI: 10.1016/j.tvir.2025.101058. [41] PRIMIGNANI M, TOSETTI G, IERARDI AM. Approach to different thrombolysis techniques and timing of thrombolysis in the management of portal vein thrombosis in cirrhotic patients[J]. J Transl Int Med, 2023, 11( 3): 198- 202. DOI: 10.2478/jtim-2023-0113. [42] HOLLINGSHEAD M, BURKE CT, MAURO MA, et al. Transcatheter thrombolytic therapy for acute mesenteric and portal vein thrombosis[J]. J Vasc Interv Radiol, 2005, 16( 5): 651- 661. DOI: 10.1097/01.RVI.0000156265.79960.86. [43] LIU FY, WANG MQ, DUAN F, et al. Interventional therapy for symptomatic-benign portal vein occlusion[J]. Hepatogastroenterology, 2010, 57( 104): 1367- 1374. [44] ALANI M, ROWLEY M, KANG P, et al. Utility of transjugular intrahepatic portosystemic shunt placement for maintaining portal vein patency in candidates on wait lists who develop thrombus[J]. Exp Clin Transplant, 2020, 18( 7): 808- 813. DOI: 10.6002/ect.2019.0153. [45] RAVAIOLI M, ZANELLO M, GRAZI GL, et al. Portal vein thrombosis and liver transplantation: Evolution during 10 years of experience at the University of Bologna[J]. Ann Surg, 2011, 253( 2): 378- 384. DOI: 10.1097/SLA.0b013e318206818b. -
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