Management of Splenic Vein Thrombosis in Pancreatic Ductal Adenocarcinoma

Diagnostic Evaluation

The American Society of Hematology suggests that splenic vein thrombosis can be acute (symptoms ≤8 weeks, absence of cavernous transformation/collaterals, absence of portal hypertension) or chronic (symptoms >8 weeks, presence of cavernous transformation/collaterals, signs of portal hypertension) 2

The National Comprehensive Cancer Network recommends anticoagulant therapy for patients with pancreatic ductal adenocarcinoma and symptomatic splenic vein thrombosis to reduce morbidity and mortality 1, 2
For acute splenic vein thrombosis, low molecular weight heparin (LMWH) is the preferred initial treatment for venous splenic thrombosis in cancer patients 1, 2
For short-term treatment of venous thromboembolism (3-6 months) in patients with active cancer, direct oral anticoagulants (DOACs) such as apixaban, edoxaban, or rivaroxaban are suggested over LMWH 1
In the absence of randomized trial data, it is common practice to treat splenic vein thrombosis for 6 months 3

The American Society of Hematology 2021 guidelines suggest that both short-term anticoagulant treatment and observation are options for incidentally detected splenic vein thrombosis (conditional recommendation, very low certainty in the evidence of effects) 1, 4
For patients with chronic splenic vein thrombosis and signs of portal hypertension, consideration of beta-blockers, variceal ligation, or sclerotherapy may be necessary 2

In case of intestinal infarction, immediate surgical evaluation is necessary to resect necrotic sections of the intestine 2
For patients with progressive thrombosis that does not respond to anticoagulation, consideration of transjugular intrahepatic portosystemic shunt (TIPS) may be necessary 5