Left-sided Portal Hypertension Research Articles

Percutaneous Covered Stenting in Splenic Vein for Left-sided Portal Hypertension Caused by Chronic Splenic Vein Obstruction

Percutaneous Covered Stenting in Splenic Vein for Left-sided Portal Hypertension Caused by Chronic Splenic Vein Obstruction

Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension.

Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions. To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH. A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively. A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates. Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis.

Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies. A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH. All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark). Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06-0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01-0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01-0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20-1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy. This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients. This study has been registered on the PROSPERO database with the registration number CRD42023483764.

Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension: a report of two cases

BackgroundLeft-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection or total pancreatectomy. The usefulness of reconstruction with the splenic vein has been reported in such cases. However, depending on the site of the tumor and other factors, it may be impossible to leave sufficient length of the splenic vein, making anastomosis difficult. We report two patterns of reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension.Case presentationThe first patient was a 79-year-old man who underwent pancreaticoduodenectomy for pancreatic cancer. The root of the splenic vein was infiltrated by the tumor, and we resected this vein at the confluence of the portal vein. Closure of the portal vein was performed without reconstruction of the splenic vein. To prevent left-sided portal hypertension, we anastomosed the right gastroepiploic vein to the middle colic vein. Postoperatively, there was no suggestion of left-sided portal hypertension, such as splenomegaly, varices, and thrombocytosis. The second case was a 63-year-old woman who underwent total pancreatectomy for pancreatic cancer. The splenic vein–superior mesenteric vein confluence was infiltrated by the tumor, and we resected the portal vein, including the confluence. End-to-end anastomosis was performed without reconstruction of the splenic vein. We also divided the left gastric vein, left gastroepiploic vein, right gastroepiploic vein, and right gastric vein, which resulted in a lack of drainage veins from the stomach and severe gastric vein congestion. We anastomosed the right gastroepiploic vein to the left renal vein, which improved the gastric vein congestion. Postoperatively, imaging confirmed short-term patency of the anastomosis site. Although the patient died because of tumor progression 8 months after the surgery, no findings suggested left-sided portal hypertension, such as varices. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy is useful to prevent left-sided portal hypertension.

Two Cases of Gastric Varices with Left-sided Portal Hypertension due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization.

Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.

Safety and efficacy of splenic artery embolization for the treatment of gastric variceal bleeding secondary to left-sided portal hypertension

Safety and efficacy of splenic artery embolization for the treatment of gastric variceal bleeding secondary to left-sided portal hypertension

Pancreatic head cancer with gastrointestinal bleeding as the initial manifestation: a case report and literature review

Gastrointestinal bleeding (GIB) as the initial symptom is rare in patients with pancreatic cancer, which is prone to misdiagnosis and should be paid attention to by clinicians. Here, we present a patient with pancreatic head cancer whose first symptom was only severe upper gastrointestinal bleeding, which initially led to misdiagnosis. However, subsequent imaging revealed a mass in the pancreatic head which was considered a malignant tumor. After surgical resection, the pathology confirmed that the mass in the pancreatic head was pancreatic ductal adenocarcinoma, and the duodenal bulb’s full thickness was infiltrated. A literature review found that pancreatic cancer can present gastrointestinal bleeding by invading the digestive tract and blood vessels, left-sided portal hypertension (LSPH), digestive tract metastasis, and canceration of ectopic pancreatic tissue in the digestive tract. For these cases, clinicians should utilize multidisciplinary diagnosis and treatment based on digestive endoscopy, imaging, interventional therapy, and surgery to control bleeding, identify etiology, and remove tumors.

Percutaneous transsplenic venous embolization of elevated jejunal varices after pancreaticoduodenectomy: A case report

Recent advances in chemotherapy and radiotherapy have led to an increase in the number of long-term survivors of pancreatic cancer. However, this has also increased the number of patients suffering from ectopic varices and bleeding owing to left-sided portal hypertension and thrombocytopenia caused by splenomegaly after pancreaticoduodenectomy combined with resection of the splenic vein. A 65-year-old woman with varices of the elevated jejunum due to left sided portal hypertension after pancreaticoduodenectomy had repeated melena, which started about 1 year before admission. We describe the first reported case of percutaneous transsplenic venous embolization using metallic coils, which successfully achieved hemostasis of refractory bleeding from the elevated jejunal varices after pancreaticoduodenectomy.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection.

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Varicose veins of the esophagus as a manifestation of left-sided portal hypertension

An autopsy of pancreatic cancer in a woman who died from acute posthemorrhagic anemia due to repeated bleeding from esophageal varices is presented. The mechanism of development of esophageal varices associated with the so-called left-sided portal hypertension, caused by compression of the splenic vein by the tumor and the opening of porto-caval anastomoses, is considered. A brief review discusses other possible causes of left-sided portal hypertension syndrome and its consequences.

Left-sided portal hypertension as a complication of chronic pancreatitis in a young patient. A case report

Left-sided portal hypertension as a complication of chronic pancreatitis in a young patient. A case report

S2942 Bleeding IGV2 from Left-Sided Portal Hypertension in a Decompensated Cirrhotic

S2942 Bleeding IGV2 from Left-Sided Portal Hypertension in a Decompensated Cirrhotic

S2694 An Uncommon Cause of Upper Gastrointestinal Bleeding

Introduction: We present a case of GI bleeding due to a direct communication between a pancreatic fistula and the splenic vein. Case Description/Methods: A 55 year-old female with a history of endometrial cancer, superficial lower extremity thrombus, and alcohol use presented with abdominal pain and dark red blood in her stools requiring blood transfusion. She reported recent ibuprofen use. An upper endoscopy showed small esophageal varices without red wales or stigmata of recent hemorrhage. A CT demonstrated extensive subacute thrombosis of the right and left portal veins, main portal vein (PV), proximal superior mesenteric vein (SMV) and splenic vein (SV). The pancreas appeared atrophic and contained small cysts. There was small ascites. Liver biopsy demonstrated mild steatohepatitis without fibrosis. She underwent placement of a transjugular intrahepatic portosystemic shunt (TIPS) with thrombectomy from the PV, SMV, and SV and was started on anticoagulation. Due to bleeding recurrence, she underwent TIPS revision with tPA injection and additional mechanical thrombectomy. Subsequently on an ultrasound, TIPS thrombosis was again noted and during TIPS revision, a communication was noted between the pancreatic duct and splenic vein, finally identifying the likely source of bleeding. A splenic vein stent was placed. Discussion: This case highlights an uncommon cause of upper GI bleeding and reinforces the importance of keeping a broad differential diagnosis for a patient with portal hypertension. Our patient had a complicated course with 2 TIPS revisions and esophageal varices, but the source of her bleeding was neither variceal nor mucosal. (Figure) Splenic vein thrombus can result as a complication of pancreatitis and subsequently lead to “sinestrial” (left-sided) portal hypertension and the formation of gastric varices which can also present with gastrointestinal bleed (GIB). Our patient did not have the classic finding of sinestral portal hypertension associated with SV thrombosis: gastric varices. Furthermore, during her initial TIPS placement and even her initial thrombectomy, no pancreatic fistula was observed. Although not always visualized due to the intermittent nature of bleeding, hemosuccus pancreaticus in the setting of chronic alcoholic pancreatitis most commonly involves the splenic artery (60-65%) and less commonly involves the gastroduodenal artery. Our patient’s case is unusual because angiogram demonstrated direct communication between a pancreatic fistula and the splenic vein, not the splenic artery.Figure 1.: Large clot burden at superior mesenteric vein.

S678 Treatment of Cardiofundal Gastric Varices From Splenic Vein Occlusion: A Different Phenotype and Framework for Treatment?

Introduction: Cardiofundal gastric varices can result from left-sided portal hypertension due to isolated splenic vein occlusion, either from intraluminal thrombosis or extrinsic compression of the splenic vein. These patients often do not have systemic portal hypertension or cirrhosis. Treatment of non-cirrhosis related cardiofundal varices can be challenging, as conventional gastric variceal therapies such as transjugular intrahepatic portosystemic shunt (TIPS) or balloon occluded retrograde transvenous obliteration (BRTO) are ineffective for left sided portal hypertension. We aimed to describe our center’s experience and approach in treatment of cardiofundal varices in the setting of isolated splenic vein occlusion. Methods: A retrospective review of all patients who presented with concern for bleeding from cardiofundal varices at two tertiary hospitals was performed from Jan 2018 to May 2022. Patients were included if they received treatment for cardiofundal varices from isolated splenic vein occlusion, and excluded if they had been previously diagnosed with cirrhosis or portal vein thrombosis. Results: We found a total of 8 patients who met the study’s inclusion and exclusion criteria. 7/8 (87.5%) were male and the mean age was 58. Etiology of splenic vein occlusion included pancreatic adenocarcinoma (n=4), necrotizing pancreatitis (n=2), and carcinoid/neuroendocrine tumors (n=2); see Table. Maximum variceal cross section diameter ranged from 4-10mm, and were often small in size and diffuse. All patients underwent initial endoscopic therapy, which included EUS guided coil embolization (n=6) and rubber band ligation (n=3), with 1 patient receiving both. Coil embolization was performed as standalone (n=1), with Gelfoam (n=4), or with cyanoacrylate glue (n=1). Technical success and ability to achieve hemostasis on index procedure were both 100%. 4 patients required re-intervention, with 2 refractory to endoscopic therapy requiring splenic artery embolization and splenectomy. Conclusion: Coil embolization and/or band ligation can be effective initial endoscopic therapies for non cirrhotic cardiofundal variceal bleeding. Cardiofundal varices from splenic vein occlusion on EUS often appear much smaller in size as compared to those from cirrhosis, which may preclude coil embolization – in these cases, band ligation may be a more preferable option. For patients who fail initial endoscopic therapy and require significant transfusions, splenic artery embolization and splenectomy can be considered. Table 1. - Individual patient description on etiology of splenic vein thrombosis, treatment on index procedure, and follow up Case Etiology of Splenic Vein Thrombosis Maximum variceal cross section diameter (mm) Treatment on Index Procedure Follow up 1 Pancreatic adenocarcinoma 5 Coil embolization + Gelfoam Repeat EGD with deflation of IGV1 2 Pancreatic adenocarcinoma 4 Band ligation Repeat EGD pending 3 Metastatic carcinoid tumor 5 Coil embolization One additional EUS guided coil embolization in 2 weeks due to bleeding. Bleeding persisted, so referred to IR. BRTO attempted but no shunt, so ultimately underwent splenectomy. 4 Necrotizing pancreatitis 4.5 Coil embolization + Gelfoam No recurrent bleeding 5 Pancreatic adenocarcinoma 4 Band ligation Two additional endoscopic sessions performed for bleeding, first with coil embolization + Gelfoam, second with repeat banding (all within 2-3 months). 6 Pancreatic adenocarcinoma 10 Coil embolization + cyanoacrylate glue Presented with rebleeding from IGV1 within 3 months, received Hemospray followed by splenic artery embolization. 7 Necrotizing pancreatitis 4 Coil embolization + Gelfoam Repeat intervention in 3 weeks with coil embolization + Gelfoam + banding. No recurrent bleeding, IGV1 improved. 8 Pancreatic neuroendocrine tumor 8 Coil embolization + Gelfoam + band ligation Repeat intervention in 2 months with repeat coil embolization + Gelfoam + banding.

Torsion of a Wandering Spleen Involving the Pancreatic Tail and Splenic Flexure and Isolated Left-Sided Portal Hypertension due to Chronic Splenic Vein Thrombosis

Wandering spleen is a rare entity, wherein the spleen is attached only by an elongated vascular pedicle, predisposing it to complications like hilar torsion, infarction, rupture, etc. Pancreatic volvulus is another very rare anomaly, with isolated case reports described in association with wandering spleen. The presentation varies from asymptomatic lump (stimulating a mass) to acute abdomen (due to torsion). We present a case of 26-year-old female patient who complained of pain in abdomen, and was radiologically diagnosed and surgically confirmed to have a torsion of wandering spleen with involvement of pancreatic tail and splenic flexure. Few cases with associated finding of gastric volvulus and sigmoid volvulus have been described previously. Involvement of descending colon in a 9-year-old child has been reported. However, to the authors' knowledge, this is the first case report describing the combination of wandering spleen with splenic flexure and pancreatic tail involvement in an adult.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Usefulness of partial splenic embolization for left-sided portal hypertension in a patient with a pancreatic neuroendocrine neoplasm: a case report and review of the literature

Left-side portal hypertension (LSPH) is caused by isolated obstruction of the splenic vein and is associated with esophagogastric varices that extend from the lower esophagus to the greater curvature of the gastric body. Here, we report on a 74-year-old man with a pancreatic neuroendocrine neoplasm (NEN) in the pancreatic tail with multiple liver metastases. We decided that partial splenic embolization (PSE) was the best course of treatment to prevent rupture of the gastric varices, which were classified as markedly enlarged, nodular, or tumor-shaped and showed erosion of the mucosa. After PSE, the patient had no major complications and was discharged. At 3 and 6 months after the procedure, esophagogastroduodenoscopy and enhanced computerized tomography showed that the gastric varices had improved. This case demonstrates the usefulness of PSE for LSPH in patients with unresected pancreatic NEN.

Concomitant splenic artery ligation has no preventive effect on left-sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma.

BackgroundLeft‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH.MethodsOne‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed.ResultsThe incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively).ConclusionIn PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.

Left-sided Portal Hypertension and its Outcomes after Pancreaticoduodenectomy According to Resection of the Splenic Vein for Pancreatic Cancer

Background: The study aims to evaluate left-sided portal hypertension development and estimate the effect of long-term outcomes for resected pancreatic cancer patients according to splenic vein (SV) preservation. Methods: 94 patients who underwent pancreaticoduodenectomy (PD) for pancreatic cancer were enrolled in the study. The patients were divided into 2 groups according to SV preserving. (SV ligation group vs. SV preserving group) 47 patients were allocated into SV ligation group and SV preserving group each. Their spleen volume was calculated and compared serially. (preoperation, POM (postoperative month) 6, POM 12 and POM 24) In addition, their survival outcome, including disease-free survival (DFS) and overall survival (OS) were analyzed. Results: There was no significant difference of spleen volume between the 2 groups before PD. (SV ligation vs. SV preserving: 144.1 mL vs. 164.0 mL, p=0.352) However, 1 year after PD, the spleen volume of SV ligation group was significantly larger than that of the SV preserving group. (SV ligation vs. SV preserving: 235.4 mL vs. 163.6 mL, p=0.003) 1 patient who was in SV ligation group experienced gastric variceal bleeding. In the survival analysis, there were no significant differences between the 2 groups. (DFS: SV ligation vs. SV preserving, 11.0 months [8.8-13.2] vs. 12.0 months [11.0-13.0], p-value=0.992; OS: SV ligation vs. SV preserving, 32.0 months [10.4-53.6] vs. 44.0 months [16.3-71.7], p-value=0.659) Conclusion: Although SV ligation during the PD cause left-sided portal hypertension, it did not affect survival outcomes for pancreatic cancer patients.Tabled 1EP02D-105Preop. (mL)p-value6 months (mL)p-value12 months (mL)p-value24 months (mL)p-valueSV ligation144.10.352226.00.087235.40.003248.30.531SV preserving164.0184.3163.6211.2 Open table in a new tab

P-BN09 Management of isolated splenic vein thrombosis: Risks and benefits of Anticoagulation

Abstract Background Isolated splenic vein thrombosis (iSVT) is a common complication of pancreatic disease. Whilst patients remain asymptomatic, there is a risk of sinistral portal hypertension and subsequent bleeding from gastric varices if recanalization does not occur. There is a wide variation of iSVT treatment, even within single centres. We report outcomes of iSVT from tertiary referral hepatobiliary and pancreatic (HPB) units including the impact of anticoagulation on recanalization rates and subsequent variceal bleeding risk. Methods A retrospective cohort study including all patients diagnosed with iSVT on CT scan abdomen and pelvis between 2011 and 2019 from two institutions. Patients with both SVT and portal vein thrombosis at diagnosis, and isolated splenic vein thrombosis secondary to malignancy were excluded. The outcomes of anticoagulation, recanalization rates, risk of bleeding, and progression to portal vein thrombosis were examined. Results Ninety-eight patients with iSVT were included; of which thirty-nine patients received anticoagulation (40%). The most common cause of iSVT was acute pancreatitis n = 88 (90%). The recanalization rate in the anticoagulation group was 46% vs 15% in patients receiving no anticoagulation (p = 0.0008, OR = 4.7, 95% CI 1.775 to 11.72). Upper abdominal vascular collaterals (demonstrated on CT scan angiography) were significantly less among patients who received anticoagulation treatment (p = 0.03, OR = 0.4, 95% CI 0.1736 to 0.9288). The overall rate of upper GI variceal related bleeding was 3% (n = 3/98) and it was independent of anticoagulation treatment. Two of the patients received therapeutic anticoagulation. Conclusions The current data support that therapeutic anticoagulation is associated with a statistically significant increase in recanalization rates of the splenic vein; with a subsequent reduction in radiological left-sided portal hypertension. However, all patients had a very low risk of variceal bleeding regardless of anticoagulation. The findings from this retrospective study should merit further investigation in large-scale randomized clinical trials.