The use of transjugular intrahepatic portosystemic shunt should be cautious in patients without cirrhosis with obliterative portal vein thrombosis.

Abstract

Potential conflict of interest: Nothing to report. Financial Support: This work was supported by grants (81570554 & 81501566) from National Natural Science Foundation of China. TO THE EDITOR: Kallini et al. reported 5 patients without cirrhosis with chronic obliterative portal vein thrombosis (PVT) who underwent trans‐splenic intrahepatic portosystemic shunt with portal vein recanalization (PVR‐TIPS) in Hepatology recently.1 We appreciate the novel innovation; however, several issues about the application of TIPS in the current case series may need to be discussed here. Variceal bleeding in patients with noncirrhotic portal vein occlusion is usually well tolerated, and bleeding‐related mortality is much lower than in patients with cirrhosis.2 Endoscopic therapy or beta‐blocker is considered the first‐line treatment for secondary prophylaxis in such patients.2 In the study by Sarin et al., both esophageal variceal ligation and propranolol are effective in the second prevention of variceal bleeding (23.5% vs. 18%), and no death occurred during a median follow‐up period of 23 months.4 Yet, the urgency of TIPS is doubtful in 2 of 5 patients who had no history of bleeding.1 Regular endoscopic screen with the use of band ligation or beta‐blocker may be more reasonable. For the remaining 3 patients, the details of previous band ligation and propranolol administration were not provided. We believe that TIPS would be justified for patients who failed conservative treatments. Previous studies have demonstrated that percutaneous recanalization of obstructed portal vein alone is feasible and effective in patients with or without cirrhosis.5 The application of a decompression procedure like TIPS should be cautious in patients with extrahepatic portal vein occlusion. However, because of lack of detail information of severity and scope of PVT, the actual feasibility and efficacy of portal vein recanalization in these cases are unknown. Finally, the stent (Supporting Fig. S7) was deployed in the splenic vein in the presented case, which is not common practice. We understand that sufficient backflow is important for long‐term patency of the shunt and the adequate decompression of portal venous system. Even so, extending TIPS into the splenic vein may negatively impact the blood flowing of the mesenteric venous system. In conclusion, further studies are required to define the appropriate role of TIPS in patients without cirrhosis with chronic portal vein occlusion and symptomatic portal hypertension.