Interventional management of acute mesenteric venous thrombosis: a systematic review of current evidence, emerging techniques and future perspectives.

Acute mesenteric venous thrombosis (aMVT) is a rare but life-threatening form of mesenteric ischemia associated with 30-day mortality of 17-76% without timely therapy. Over the past decade, advances in endovascular technology have transformed the therapeutic landscape. This review comprehensively appraises current evidence on innovative interventional techniques in the management of aMVT, including catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT), large-bore aspiration, transjugular intrahepatic portosystemic shunt (TIPS)-guided approaches, and combined endovascular strategies compared with systemic anticoagulation with regard to recanalization rates and complications in cirrhotic and non-cirrhotic patients. A systematic literature search was conducted across PubMed/MEDLINE and CENTRAL (January 2000 - March 2025). A total of 35 primary studies met inclusion criteria, including 34 (97%) retrospective studies and one (3%) randomized controlled trial. Endovascular therapy was associated with higher recanalization rates (53.8-100%) than systemic anticoagulation (39-85%). TIPS-assisted thrombectomy achieved 100% immediate recanalization and 97% one-year primary portal patency in a non-cirrhotic series, with a 1-year mortality of only 3%. Large-bore aspiration demonstrated 95% technical success and no major bleeding, expanding eligibility to patients with thrombolytic contraindications. In optimally managed interventional settings, there was no need for bowel resection, compared with 5.3-21% in systematic anticoagulation-managed cohorts. Current clinical practice guidelines universally assign interventional modalities to Class IIb/Level C recommendations, substantially lagging behind the clinical evidence. Emerging interventional strategies demonstrate promising recanalization rates with an acceptable complication profile in most studies. This may provide advantages over anticoagulation alone in carefully selected patients with aMVT, although available evidence remains heterogeneous and predominantly observational. An institutional decision tree reflecting current interdisciplinary clinical practice is presented as one illustrative approach to patient stratification and escalation. Future prospective and multicenter studies are required to determine the optimal time and type of endovascular interventions to improve future guideline recommendations in carefully defined patients at tertiary centers.