Management Of Portal Vein Thrombosis Research Articles

The role of transjugular intrahepatic portosystemic shunt in the management of portal vein thrombosis: a systematic review and meta-analysis.

The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal vein thrombosis (PVT) remains controversial. This study aimed to conduct a systematic review and meta-analysis to evaluate the role of TIPS for the management of PVT in adult patients with liver disease. Multiple databases were searched through April 2017. Data were gathered to estimate the rates of technical success, portal vein recanalization, portal patency, hepatic encephalopathy, and mean change in portal pressure gradient in patients with PVT who underwent TIPS. Estimates were pooled across studies using the random effects model. Eighteen studies were included in the analysis. The pooled technical success rate was 86.7% [95% confidence interval (CI)=78.6-92.1%]. Rate of portal vein recanalization was 84.4% (95% CI=78.4-89.0%). The rate of complete recanalization was 73.7% (95% CI=64.3-81.3%). Portal patency was 86.9% (95% CI=79.7-91.8%). Mean change in portal pressure gradient was 14.5 mmHg (95% CI=11.3-17.7 mmHg). Hepatic encephalopathy was 25.3% (95% CI=19.2-32.6%). The number of major adverse events reported across studies was low. The majority of the analyses were not associated with substantial heterogeneity. The use of TIPS in the management of PVT is feasible and effective in achieving a significant and sustainable reduction in clot burden with a low risk of major complications. TIPS should be considered as a viable treatment option in patients with PVT. Given the limited amount of randomized comparative studies reported, additional trials are warranted to assess the safety and efficacy of TIPS as a treatment modality in PVT, in comparison to other treatment options, such as anticoagulation.

Splenectomy as Flow Modulation Strategy and Risk Factors of De Novo Portal Vein Thrombosis in Adult-to-Adult Living Donor Liver Transplantation.

Portal vein thrombosis (PVT) is a severe complication after liver transplantation that can result in increased morbidity and mortality. Few data are available regarding risk factors, classification, and treatment of PVT after living donor liver transplantation (LDLT). Between January 2004 and November 2014, 421 adult-to-adult LDLTs were performed at our institution, and they were included in the analysis. Perioperative characteristics and outcomes from patients with no-PVT (n = 393) were compared with those with de novo PVT (total portal vein thrombosis [t-PVT]; n = 28). Ten patients had early portal vein thrombosis (e-PVT) occurring within 1 month, and 18 patients had late portal vein thrombosis (l-PVT) appearing later than 1 month after LDLT. Analysis of perioperative variables determined that splenectomy was associated with t-PVT (hazard ratio [HR], 3.55; P = 0.01), e-PVT (HR, 4.96; P = 0.04), and l-PVT (HR, 3.84; P = 0.03). In contrast, donor age was only found as a risk factor for l-PVT (HR, 1.05; P = 0.01). Salvage rate for treatment in e-PVT and l-PVT was 100% and 50%, respectively, without having an early event of rethrombosis. Mortality within 30 days did not show a significant difference between groups (no-PVT, 2% versus e-PVT, 10%; P = 0.15). No significant differences were found regarding 1-year (89% versus 92%), 5-year (79% versus 82%), and 10-year (69% versus 79%) graft survival between the t-PVT and no-PVT groups, respectively (P = 0.24). The 1-year (89% versus 96%), 5-year (82% versus 86%), and 10-year (79% versus 83%) patient survival was similar for the patients in the no-PVT and t-PVT groups, respectively (P = 0.70). No cases of graft loss occurred as a direct consequence of PVT. In conclusion, the early diagnosis and management of PVT after LDLT can lead to acceptable early and longterm results without affecting patient and graft survival.

361 - The Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Portal Vein Thrombosis: A Systematic Review and Meta-Analysis

361 - The Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Portal Vein Thrombosis: A Systematic Review and Meta-Analysis

SAT-256 - The role of transjugular intrahepatic portosystemic shunt in the management of portal vein thrombosis: A systematic review and meta-analysis

BackgroundThe role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal vein thrombosis (PVT) remains controversial. This study aimed to conduct a systematic review and meta-analysis to evaluate the role of TIPS for the management of PVT in adult patients with liver di

Portal vein thrombosis in cirrhosis: diagnosis, natural history, and therapeutic challenges.

Portal vein thrombosis (PVT) is a frequent complication in cirrhosis and its prevalence increases with disease severity. Several factors are involved in the development and progression of PVT. The challenge for the management of PVT is the precise evaluation of the bleeding risk as opposed to life-threatening extension of thrombosis. Nevertheless, the impact on the progression and outcome of liver disease is unclear. A critical evaluation of the available data discloses that treating PVT in cirrhotics is safe and effective. However, there are open issues, such as which anticoagulant could represent a safer therapeutic option, and when and for how long this treatment should be administered to cirrhotic patients with PVT.

Imaging and minimally invasive endovascular therapy in the management of portal vein thrombosis

Thrombosis of the portal venous system, although rare in the general population, is commonly diagnosed in patients with specific underlying conditions including prothrombotic diseases, cirrhosis, hepatobiliary malignancy, and intraabdominal inflammation. Recent improvements in imaging have played a fundamental role in increased detection of portal vein thrombosis (PVT), frequently reported in asymptomatic patients as an incidental finding. Minimally invasive, endovascular therapy is a medically rational option to achieve recanalization of the portal vein as an adjunct to conservative medical management. This review focuses on the advances in imaging modalities to diagnose, stage and follow-up PVT, and gives a short overview of the available endovascular techniques in this field.

Effects of anticoagulants in patients with cirrhosis-related portal vein thrombosis

Anticoagulation has been recommended for the primary management of portal vein thrombosis (PVT), and the purpose of anticoagulation therapy is to prevent the extension of thrombosis and to improve recanalization (40–80%) (1). Low molecular weight heparin (LMWH) is widely used as a front-line therapy to induce rapid anticoagulation. Different from non-cirrhotics patients, PVT is common in cirrhotic patients despite the clinical manifestation of hypocoagulable state and thrombocytosis (2).

Portal vein thrombosis in patients with cirrhosis.

Portal vein thrombosis (PVT) is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare, but can be life-threatening. However, different aspects of clinical relevance, diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines. In this article, we elaborate on PVT classification, geographical differences in clinical presentation and standards of diagnosis, and briefly on the current pathophysiological understanding and risk factors. This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments. Finally, we review the controversial issue of clinical impact of PVT on prognosis, especially considering liver transplantation and future perspectives.

Living Donor Liver Transplantation for Patients with Pre-existent Portal Vein Thrombosis

Background: Portal vein thrombosis (PVT) in living donor liver transplantation (LDLT) is a surgical challenge with technical difficulty. The aim of this study was to analyze the operative planning for management of PVT in LDLT and the impact of PVT on the outcome in comparison to patients without PVT. Methods: Between July 2003 to August 2016, 213 patients underwent LDLT. The patients were divided into two groups with and without PVT. The preoperative, operative, and postoperative data were analysed. Results: Thirty six patients (16.9%) had different grades of PVT at time of liver transplantation (LT); grades I, II, III and IV were 18 (50%), 14 (38.9%), 3 (8.3%) and 1 patient (2.8%) respectively. The management of PVT was by; thrombectomy in 31 patients (86%), bypass graft in 2 patients (5.6%), portal replacement graft in 1 patient (2.8%), anastomosis with the left renal vein in 1 patient (2.8%) and with large collateral vein in 1 patient (2.8%). Overall postoperative PVT occurred in 10 patients (4.7%), 4 patients of them had preoperative PVT. The perioperative mortality in patients with PVT, and patients without PVT was 33.3%, and 20.3%, respectively (P=0.17). The 1-, 3-, 5-, and 7y survival in patients with PVT was 49.7%, 46.2%, 46.2%, 46.2% respectively and in patients without PVT it was 65%, 53.7%, 50.8%, 49% respectively (P=0.29). Conclusions: Preoperative PVT may not keep a patient from undergoing successful LT with comparable outcome to patients without PVT specially with partial PVT.

New Approach for Portal Vein Thrombosis Management with Endovascular Procedure during Orthotopic Liver Transplantation

New Approach for Portal Vein Thrombosis Management with Endovascular Procedure during Orthotopic Liver Transplantation

Management of portal vein thrombosis in cirrhosis: an update.

Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue. To report an update on the management of PVT. A review was performed on the outcome, prevention, and treatment of PVT. Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival. It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.

Optimal Management of Portal Vein Thrombosis in Patients with Liver Cirrhosis: a Review

Portal vein thrombosis (PVT) is a fairly common complication of cirrhosis, especially in patients with advanced liver disease and reduced portal vein flow velocity. Prospective studies have shown that its occurrence parallels rather than causes the progression of liver disease and that spontaneous regression is a frequent finding. PVT occurrence is associated with an increased mortality after liver transplantation. Treatment options include anticoagulation and insertion of a transjugular intrahepatic portosystemic shunt. Anticoagulation with vitamin K antagonists or low-molecular-weight heparins achieves partial or complete portal vein recanalization in most patients. Anticoagulation does not seem to increase the bleeding risk when proper prophylaxis of variceal bleeding is applied. Monitoring of anticoagulation difficulties exist, inherent to the coagulopathy of chronic liver disease. Placement of a transjugular intrahepatic portosystemic shunt is an alternative in selected patients. Trials are underway to evaluate the potential benefit of PVT prophylaxis with low-molecular-weight heparins.

Central neuraxial blockade for splenectomy in myeloproliferative disease: A word of caution

We describe management of portal vein thrombosis (PVT) in a patient with myeloproliferative disease after splenectomy. This case posed a unique therapeutic challenge in maintaining a fine balance between life-saving thrombolysis and the risk of neuraxial complications due to bleeding. The incidence of PVT after splenectomy in patients with myeloproliferative disorders is high (40%). Anaesthesiologists should be aware of this and avoid central neuraxial blockade in such cases. If post-operative emergency thrombolysis is required in a patient having an epidural catheter in situ, it should be done under close monitoring, weighing the risks and benefits. Fibrinogen levels should be monitored to evaluate the presence of residual thrombolytic effects and to time the catheter removal.

Portal Vein Thrombosis in Cirrhotic Patients: Decision to Anticoagulate

The portal vein is formed by the confluence of the splenic and superior mesenteric veins. Portal vein thrombosis (PVT) is caused by the formation of a blood clot within the extra-hepatic portion of the portal vein. Occlusion of the portal vein by thrombus typically occurs in patients with cirrhosis and/or prothrombotic disorders including hepatocellular carcinoma, myeloproliferative disorder, inherited thrombophilia and abdominal trauma [1]. Chronic portal vein thrombosis (PVT) may have a myriad of presentations including worsening clinical symptoms of portal hypertension i.e. ascites, gastroesophageal variceal bleeding or even completely asymptomatic, detected in routine abdominal imaging [1]. The management of portal vein thrombosis (PVT) includes differentiating acute from chronic, cirrhotic from non-cirrhotic causes, considering risk of variceal bleeding from anticoagulation, risk of bowel ischemia from clot extension and possibility of liver transplant [2].

Management of portal vein thrombosis after liver transplantation with a combined open and endovascular approach

Kensinger, Clark D. M.D.*,1; Sexton, Kevin W. M.D.1; Baron, Christopher M. M.D.2; Lipnik, Andrew J. M.D.2; Meranze, Steven G. M.D.2; Gorden, D. Lee M.D.1 Author Information

Management of portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is a fairly common complication of liver cirrhosis. Importantly, occlusive PVT might influence the prognosis of patients with cirrhosis. Evidence from a randomized controlled trial has shown that anticoagulation can prevent the occurrence of PVT in patients with cirrhosis without prior PVT. Evidence from several case series has also demonstrated that anticoagulation can achieve portal vein recanalization in patients with cirrhosis and PVT. Early initiation of anticoagulation therapy and absence of previous portal hypertensive bleeding might be positively associated with a high rate of portal vein recanalization after anticoagulation. However, the possibility of spontaneous resolution of partial PVT questions the necessity of anticoagulation for the treatment of partial PVT. In addition, a relatively low recanalization rate of complete PVT after anticoagulation therapy suggests its limited usefulness in patients with complete PVT. Successful insertion of a transjugular intrahepatic portosystemic shunt (TIPS) not only recanalizes the thrombosed portal vein, but also relieves the symptomatic portal hypertension. However, the technical difficulty of TIPS potentially limits its widespread application, and the risk and benefits should be fully balanced. Notably, current recommendations regarding the management of PVT in liver cirrhosis are insufficient owing to low-quality evidence.

Portal vein thrombosis in liver cirrhosis

Portal vein thrombosis (PVT) is considered to be a frequent complication of liver cirrhosis. However, unlike PVT in patients without cirrhosis, very few data are available on the natural history and management of PVT in cirrhosis, despite its association with potentially life-threatening conditions, such as gastroesophageal bleeding and acute intestinal ischemia. Moreover, no consensus regarding PVT in cirrhosis exists. Suggested causes of PVT in cirrhosis include reduced portal blood flow velocity, multiple congenital or acquired thrombophilic factors, inherited or acquired conditions, and derangement of liver architecture. However, the understanding of PVT in cirrhosis is incomplete. In addition, information on the management of PVT in cirrhosis is inadequate. The aims of this review are to: (1) assemble data on the physiopathological mechanism, clinical findings, diagnosis and management of PVT in cirrhosis; (2) describe the principal factors most frequently involved in PVT development; and (3) summarize the recent knowledge concerning diagnostic and therapeutic procedures.

Management and long-term consequences of portal vein thrombosis after liver transplantation in children

Portal vein thrombosis (PVT) occurs in ≤12% of pediatric recipients of liver transplantation (LT). Known complications of PVT include portal hypertension, allograft loss, and mortality. The management of PVT is varied. A single-center, case-control study of pediatric LT recipients with portal vein (PV) changes after LT was performed. Cases were categorized as early PVT (if PVT was detected within 30 days of transplantation) or late PVT (if PVT was detected more than 30 days after transplantation or if early PVT persisted beyond 30 days). Two non-PVT control patients were matched on the basis of the recipient weight, transplant indication, and allograft type to each patient with PVT. Thirty-two of the 415 LT recipients (7.7%) received 37 allografts and developed PVT. In comparison with control patients, a higher proportion of patients with PVT had PVT present before LT (13.3% versus 0%, P = 0.01). Patients with early PVT usually returned to the operating room, and 9 of 15 patients (60%) had PV flow restored. Patients with late PVT had lower white blood cell (4.9 [1000/μL] versus 6.8 [1000/μL], P < 0.01) and platelet counts (140 [1000/μL] versus 259 [1000/μL], P < 0.01), an elevated international normalized ratio (1.2 versus 1.0, P < 0.001), and more gastrointestinal bleeding (25% versus 8.3%, P = 0.03) compared to controls. Patients with PVT were also less frequently at the expected grade level (52% versus 88%, P < 0.001). The patient survival rates were 84%, 78%, and 78% and 91%, 84%, and 79% for cases and controls at 1, 5, and 10 years, respectively. The allograft survival rates were 90%, 80%, and 80% for cases and 94%, 89%, and 87% for controls at 1, 5, and 10 years, respectively. In conclusion, patients with early and late PVT had preserved allograft function, and there was no impact on mortality. Patients diagnosed with early PVT often underwent operative interventions with successful restoration of flow. Patients diagnosed with late PVT experienced variceal bleeding, and some required portosystemic shunting procedures. Academic delays were also more common. In late PVT, the clinical presentation dictates care because the optimal management algorithm has not yet been determined. Multi-institutional studies are needed to confirm these findings and improve patient outcomes.

A Case of Portal Vein Thrombosis in Acute Necrotizing Pancreatitis Treated with Low-Molecular-Weight Heparin

Portal vein thrombosis can result from the obstruction of blood flow, inflammation, and hypercoagulability of blood. Clinical symptoms include those of bowel ischemia caused by extension of the thrombus, portal hypertension, and gastrointestinal varix bleeding. Cases arising from complications of acute pancreatitis are very rare. The management of portal vein thrombosis varies, but spontaneous resolution of the thrombosis is uncommon. To prevent complications, anticoagulation therapy may be considered. We report a 51-year-old man who was treated successfully with low-molecular-weight heparin for portal vein thrombosis complicating acute necrotizing pancreatitis. (Korean J Med 2013;84:76-80)

PTU-054 Transjugular intrahepatic portosystemic shunts following liver transplantation can be associated with a good prognosis: a single centre experience

IntroductionTransjugular intrahepatic portosystemic shunt (TIPS) is indicated in the management of portal vein thrombosis or stenosis, portal hypertension and for veno-occlusive disease in post-liver transplant (LT) patients. Previous series have...