Su1018 The Role of Anticoagulation for Portal Vein Thrombosis Prior to Orthotopic Liver Transplantation

Abstract

Portal vein thrombosis (PVT) is common complication in the setting of end stage liver disease. The presence of PVT in the setting of orthotopic liver transplantation (OLT) can be associated with the need for additional anastomoses and potentially reduced survival. The goal of anticoagulation is to achieve partial recanalization to allow end-to-end portal vein anastomosis. Our AIM was to determine the impact of anticoagulation for PVT when indicated on recanalization of the portal vein at the time of OLT and on post OLT outcomes. Methods : This is a single center retrospective study of all patients who underwent OLT who were previously diagnosed with PVT between March 2011 and July 2014. The study included all patients over age 18 with PVT diagnosed by CT or MRI and who subsequently underwent OLT. Data abstracted included demographic data, anatomic extent of PVT, presence/type of anticoagulation, effect on PVT, complications of anticoagulation, and outcomes after transplant including use of jump graft and survival. PVT was classified as occlusive or non-occlusive involving portal vein with or without extension. The decision to anticoagulate was made by a multidisciplinary team at selection conference. Results: 43/333 (13%) patients were diagnosed with PVT before OLT by axial imaging. Median age was 59 years (IQR= 52-63), 27/43 male, median BMI 28 (IQR= 25.7-33), median MELD score 20 (IQR= 17-25). PVT was diagnosed at median of 338 days prior to OLT. In 30/43 patients anticoagulation was initiated (27 warfarin, 3 enoxaparin) prior to OLT for median duration of 9 months (IQR 5 17). The median time to demonstrated improvement or resolution of PVT was 5 months (IQR 37.2). 19/30(63%) of anticoagulated patients achieved partial to full PVT resolution at time of OLT compared to 8/14 patients (57%) in whom no anticoagulation was initiated. 3 patients with partial or full resolution of PVT had recurrent thrombosis post OLT. 3 patients required jump grafts due to thrombosis. In the entire PVT cohort, there were 5 deaths post OLT (2 no anticoagulation, 1 warfarin, 2 enoxaparin). 1 month survival (no anti-coagulation 86% ;warfarin 100%;enoxaparin 67%), 6 month survival (no anti-coagulation 86% ;warfarin 96%%;enoxaparin 33%)and 1 year survival (no anti-coagulation 85% ;warfarin 94%;enoxaparin 0%) were superior in the warfarin treated group compared to enoxaparin or no anticoagulation (p<0.05). Bleeding complications were rare with no difference noted between the anticoagulated and non-anticoagulated groups. Conclusion: Anticoagulation for PVT prior to OLT is safe, and lead to partial or complete resolution in 19/30 patients. Improved survival was noted in the PVT cohort who received anticoagulation with warfarin prior to OLT. Data collection is ongoing to better refine which PVT patients derive benefit with this strategy.