Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency

Abstract

Aim: Anticoagulation after pancreaticoduodenectomy with portal vein resection is relevant to maintaining vein patency; however, no uniformly accepted algorithm exists for anticoagulant selection. We evaluated patients undergoing pancreaticoduodenectomy with various degrees of portal venous resection and reconstruction to determine the optimal regimen for anticoagulation therapy. Methods: A retrospective review of 51 patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy with venous resection was performed (2006 through 2016). Venous resections were categorized as tangential, segmental with primary anastomosis, or segmental with vein graft. Type of anticoagulation selected by the surgeon was noted. The primary outcome was vein patency measured through the first year postoperatively. Results: Of 33 patients eligible for study, 7 underwent tangential resection, 16 underwent segmental resection, and 10 underwent vein graft. Vein patency rates at 2, 4, 6, and 11 months were 96.9%, 93.1%, 89.3%, and 62.5%, respectively. All patients with tangential resection showed patency at six months, regardless of the use of anticoagulation or not. For segmental resection, patency was higher with antiplatelet/warfarin (62.5%) compared with no treatment (25%). For segmental resection with vein graft, patency at 10 months was higher with antiplatelet therapy (80%) compared with warfarin (33%). Conclusion: For patients undergoing pancreaticoduodenectomy with portal vein resection, anticoagulation therapy may be guided by the degree of resection and reconstruction required. Although anticoagulation therapy may be unnecessary with tangential vein resection, anticoagulation in the form of antiplatelet therapy may be preferable in patients who have segmental vein resections with primary anastomoses and vein grafts.