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Abstract

We thank Mazzarelli and colleagues for their comments on our study and their proposal of transjugular intrahepatic portosystemic shunt (TIPS) as an alternative to anticoagulation for the management of portal vein thrombosis (PVT) in patients with cirrhosis. Plasma hypercoagulability1La Mura V. et al.Liver Int. 2016; 36: 1322-1330Crossref PubMed Scopus (43) Google Scholar, 2Kalambokis G.N. et al.J Hepatol. 2016; 65: 921-928Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar and low portal venous flow3Zocco M.A. et al.J Hepatol. 2009; 51: 682-689Abstract Full Text Full Text PDF PubMed Scopus (346) Google Scholar are the most common driving factors of PVT in cirrhosis and can be treated, respectively, by anticoagulation and TIPS. However, the choice between anticoagulation and TIPS should be based on the benefit/risk ratio resulting from the balance of the advantages, in terms of survival and quality of life, and the disadvantages represented by short- and long-term adverse effects. Several observational studies have shown the efficacy and safety of anticoagulation in patients with cirrhosis and PVT.4Loffredo L. et al.Gastroenterology. 2017; 153: 480-487Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar Our study confirmed these data and, for the first time, showed that treatment with vitamin K antagonists (VKAs) can be associated with amelioration of survival as predicted by the Child-Pugh classification.5La Mura V. et al.Clin Gastroenterol Hepatol. 2018; 16: 1146-1152Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Unfortunately, the intention-to-treat analysis revealed that such survival advantage was only detectable in patients achieving complete portal vein recanalization (VKA-responders, 49% of our series), whereas the hemorrhagic risk posed by anticoagulation seemed to overcome the beneficial effects of treatment in partial/null VKA-responders. These data are in support of PVT as a formal indication for the use of anticoagulation in cirrhosis, but also suggest a cautionary note for long-term treatment with VKAs in partial/null responders. TIPS is the most effective treatment to reduce portal pressure in cirrhosis, thus preventing the life-threatening complications of portal hypertension and, in parallel, promoting recanalization in patients with PVT. However, no clinical data exist on PVT as primary indication for TIPS because the largest series published on this topic have portal hypertension–related bleeding or ascites as primary indications.6Luca A. et al.Gut. 2011; 60: 846-852Crossref PubMed Scopus (203) Google Scholar, 7Wang Z. et al.Radiology. 2016; 279: 943-951Crossref PubMed Scopus (65) Google Scholar In addition, not all patients achieve the same survival advantage by TIPS8Salerno F. et al.Gastroenterology. 2007; 133: 825-834Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar and the occurrence of hepatic encephalopathy, which is the most common, often unpredictable, drawback after this procedure, strongly impacts the quality of life. Finally, not all centers are trained to overcome the technical difficulties related with TIPS insertion in patients with extended/occlusive PVT, thus limiting TIPS implementation for PVT in cirrhosis. Overall, the benefit/risk ratio of TIPS in all cirrhosis patients with PVT is still unclear. All these observations call for specific and validated criteria to select the best candidates for TIPS among patients with cirrhosis and PVT. Criteria proposed by Mazzarelli and colleagues are clinically plausible, but need validation in specifically addressed studies. With our data, we tried to introduce the concept of response to anticoagulation and identified patients with the most advantageous benefit/risk ratio from this pharmacologic treatment. We appreciated the inclusion of such a criterion among those proposed by Mazzarelli and colleagues. It is possible that patients with partial or null response to anticoagulation can benefit the most by TIPS as a second line of therapy for PVT. Harmful and Beneficial Effects of Anticoagulants in Patients With Cirrhosis and Portal Vein ThrombosisClinical Gastroenterology and HepatologyVol. 17Issue 4PreviewWe read with great interest the recent publication by La Mura et al1 that focused on the potential beneficial role of anticoagulants in the treatment of portal vein thrombosis (PVT) in cirrhotic patients. The investigators concluded that vitamin k anticoagulants (VKA) is highly effective in portal recanalization, without any evidence of an increased risk of bleeding, compared with untreated cirrhotic patients. In addition, La Mura et al1 successfully showed that achieving a complete recanalization of portal vein thrombosis (PVT) with VKA is associated with a significant reduction in the long-term risk of portal hypertension-related complication and death and/or need for a liver transplant. Full-Text PDF