Color-flow imaging sonography of portal and hepatic vein flow to monitor fibrinolytic therapy with r-TPA for veno-occlusive disease following myeloablative treatment

Abstract

Veno-occlusive disease (VOD) is a serious complication of myeloablative therapy and stem cell transplantation. We here describe a case of VOD in a patient with acute myeloid leukemia (AML), who received an autologous peripheral blood stem cell graft after busulphan/ cyclophosphamide conditioning in first complete remission and who developed severe VOD at day 17. Color-flow sonography of the portal and hepatic veins revealed hepatofugal blood flow in the portal vein and an absence of flow in the hepatic vein. Treatment with recombinant tissue plasminogen activator (t-PA) was started at a dose of 10 mg/day and increased to 20 mg/day because color-flow sonography indicated no change of blood flow. Daily sonography was continued to monitor the portal and hepatic blood flow in order to assess the need for continuation of t-PA. Once an objective sonographic improvement was observed, t-PA treatment was tapered and stopped. This case demonstrates that color-flow sonography can be used to confirm the clinical diagnosis of VOD. Furthermore this technique provides a way for easily and reliably evaluating the effect in relation to dose of thrombolytic therapy needed. It improves the quality of clinical monitoring which is needed for effective treatment of VOD while minimizing the risk of serious bleeding complications.