Portal Thrombosis Research Articles

Intrahepatic Rupture of Acute Cholecystitis Complicated by Septic Portal Thrombosis

Intrahepatic Rupture of Acute Cholecystitis Complicated by Septic Portal Thrombosis

Risk Factors and Management of Portal Vein Thrombosis after Hepatectomy: A Single-Center Experience

Objective: This study investigated the risk factors and management of portal vein thrombosis (PVT) after hepatectomy. Background: PVT after hepatectomy can cause liver dysfunction and portal hypertension, and may be fatal. However, it has not been sufficiently investigated. Methods: The study included 1403 consecutive patients who underwent elective hepatectomy at our department from January 2010 to July 2022. The patients were divided into PVT and non-PVT groups based on the presence or absence of PVT, and relevant risk factors were analyzed. The management and prognosis of patients with PVT were investigated. Results: Among the 1403 patients, PVT occurred in 33 cases, giving a frequency of 2.4%. In univariate analyses, female sex (P = 0.03), portal vein reconstruction (P = 0.01), and left lateral sectionectomy (P < 0.001) were significant risk factors for PVT. On multivariate analysis, portal vein reconstruction (P = 0.01) and left lateral segmentectomy (P < 0.001) remained significant risk factors for PVT. The management options for PVT were thrombectomy, antithrombotic therapy, and observation. With antithrombotic therapy, 96.4% of patients achieved PVT resolution. Among patients who underwent hepatectomy with portal vein reconstruction, the PVT site was the main trunk of the portal vein in all 3 cases, and thrombectomy was performed in 2 cases. No perioperative mortality was observed. Conclusions: In the present study, portal vein reconstruction and left lateral sectionectomy were identified as risk factors for PVT after hepatectomy. As PVT can be fatal, early detection and appropriate treatment according to the status of PVT are important.

A Novel Preoperative Classification System for Selecting Suitable Surgeries in Liver Transplant Patients with Portal Vein Cavernous Transformation

Background To evaluate the new preoperative Changgung classification (CC) system of portal vein thrombosis (PVT) in choosing suitable operative procedures to reconstruct portal veins during liver transplantation (LT) in patients with portal vein cavernous transformation (PVCT). Methods This retrospective observational study analyzed data from allograft LTs performed for various liver diseases Results The study included 22 males and 4 females with LT indications comprising cirrhosis (n = 9), hepatocellular carcinoma (n = 12), PVCT (n = 2), liver failure from fulminant hepatitis B (n = 1), dysfunction of transplanted liver (n = 1), and chronic rejection of transplanted liver (n = 1). Patients were classified according to Yerdel (21 Yerdel II and 5 Yerdel III) and CC (C1–C5). In total 16 simple operations were performed on C1–C3 cases and 9 complex operations on C4–C5 cases, with one additional simple operation. The distribution according to the Yerdel classification was 16 simple and 5 complex operations in Yerdel II cases and 1 simple and 4 complex operations in Yerdel III cases. The median follow-up time was 27.5 months with overall one-year and three-year OS rates of 88.1% and 83.9% for the cohort. Specifically, the one-year OS rates for patients classified as C1-3 vs. C4-5 were 93.3% and 80.0%, while the three-year OS rates were 86.7% and 80.0%, respectively (p = 0.526). Conclusion The CC proposed in this study shows comparable potential to the Yerdel classification in preoperatively identifying the need for complex surgical techniques in LT patients with PVCT and may also have predictive power for the survival benefits following LT.

Management of portal vein thrombosis in liver transplant candidates.

Portal vein thrombosis (PVT) is a frequent event among patients with advanced liver disease, with a prevalence reaching up to 26% in those awaiting liver transplantation (LT). Extensive thrombosis affecting the mesenteric vein confluence correlates with increased morbidity and mortality post-LT, particularly when it impedes physiological anastomosis or contraindicates the LT. Current guidelines advocate for routine PVT screening in all potential liver transplant candidates and prompt treatment upon detection. The main objective in LT candidates is to facilitate physiological portal-to-portal anastomosis. Anticoagulation serves as the first-line therapy, achieving recanalization rates between 33 and 75%. Discontinuation of anticoagulation significantly heightens the risk of rethrombosis in a substantial proportion of patients and therefore, it is recommended to continue anticoagulation until LT for those awaiting LT or potential LT candidates. Nevertheless, 30-60% of patients fail to respond to anticoagulation, with PVT progression occurring in up to 14% despite anticoagulation. In such cases, TIPS placement emerges as a viable alternative to maintain portal vein patency. While the feasibility of TIPS placement diminished with the presence of portal cavernoma or chronic portal vein thrombosis, the introduction of novel interventional radiological techniques to recanalize the portal venous axis through transplenic, transmesenteric and/or transhepatic routes is revolutionizing this landscape. These advancements achieve TIPS placement and recanalization in 90-100% of patients, warranting consideration in cirrhotic patients with chronic PVT for whom LT would otherwise be contraindicated or when physiological anastomosis is not feasible.

Correspondence on Letter regarding "Transarterial radioembolization versus tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis".

Correspondence on Letter regarding "Transarterial radioembolization versus tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis".

Portal Cavernoma

Portal cavernoma corresponds to the abnormal development of a venous network whose caliber is initially microscopic, with hepatopetal portal blood flow. It is a consequence of chronic portal thrombosis in a healthy or slightly fibrous liver. The causes are essentially those of portal thrombosis. However, portal thrombosis remains an undetermined cause in 50% of the cases. The clinical manifestations of cavernoma reflect extrahepatic portal hypertension and are exceptionally biliary. The diagnosis of portal cavernoma is radiological. Ultrasound Doppler and CT confirmed the diagnosis. MRI offers a better analysis of biliary impact. The treatment is essentially medically based on anticoagulants. Recording to surgery was reserved for complications.

The Imbalance of Homeostasis in Neutrophil Extracellular Traps is Associated with Portal Vein Thrombosis in Patients with Decompensated Cirrhosis

The Imbalance of Homeostasis in Neutrophil Extracellular Traps is Associated with Portal Vein Thrombosis in Patients with Decompensated Cirrhosis

Management of preoperative recipient portal vein thrombosis in living donor liver transplantation

Management of preoperative recipient portal vein thrombosis in living donor liver transplantation

Septic Thrombophlebitis of the Umbilical Vein Complicating an Intrahepatic Umbilical Venous Catheter in a Premature Newborn

Septic thrombophlebitis of the umbilical vein (SVT) is a serious pathology in neonates, characterized by inflammation of the umbilical vein due to bacterial infection, with 90% of cases linked to the use of central venous catheters (CVCs). This inflammation can lead to thrombus formation as part of the immune system's response. Premature newborn, 33 weeks gestation, delivered vaginally, with history of gestational diabetes, twin pregnancy, macrosomia and premature rupture of membranes (57 hours), initially well adapted to extrauterine life, with a birth weight of 1575 g. The infant was admitted to neonatology for respiratory distress, and an intrahepatic umbilical catheter was inserted. On the 5th day of hospitalization, the infant developed a nosocomial Klebsiella pneumoniae infection, complicated by a fulminant hemorrhagic syndrome with hematemesis and melena. The clinical course was further complicated by multivisceral failure, requiring hepatic Doppler ultrasound, which revealed umbilical vein thrombosis. The newborn was treated with curative doses of Lovenox, while targeted antibiotic therapy was maintained for three weeks after negative blood cultures, resulting in significant clinical and biological improvement. Based on this case, we conclude that it is advisable to think about umbilical vein thrombosis and to perform an abdominal ultrasound in the presence of any digestive hemorrhage in a newborn or an intrahepatic or peripheral umbilical venous catheter, or in subjects at risk (hypotrophy, polycythemia, transfusion on the catheter) in order to screen for possible umbilical or portal vein thrombosis.

Evaluation and management of hepatic dysfunction, portal hypertension and portal/splanchnic vein thrombosis in patients with myelofibrosis undergoing allogeneic haematopoietic cell transplantation: A practice based survey on behalf of the Chronic Malignancies Working Party of the EBMT

Heterogeneous approaches exist in regard to the management of disease-related co-morbidities in potential allogeneic haematopoietic cell transplantation (allo-HCT) candidates with myelofibrosis (MF). The EBMT Chronic Malignancies Working Party launched an electronic survey to evaluate how MF-specific comorbidities are approached and whether they ultimately affect the decision to transplant. A total of 41/63 (65%) Centers, all of whom were experienced in the management of MF allo-HCT, responded. Responses were aggregated and reported in a comparative fashion. Screening for portal hypertension (PH) was routinely performed in 54% centers, never in 12% and guided by clinical manifestations in the remaining. Involvement of hepatologists/gastroenterologists was always/very often considered in patients with signs of PH prior to transplant. Centers reported that radiological evidence of PH did not routinely represent a formal contraindication for allo-HCT in most cases (78%). Of note, most centers (61%) did not perform routine screening for gastroesophageal varices; this was systematically considered or guided by clinical manifestations in only 7% and 32% centers, respectively. Presence of gastroesophageal varices was always (15%) or occasionally (19%) considered a formal contraindication to allo-HCT. A prior history of portal vein thrombosis never (78%) or occasionally (15%) represented a formal contraindication. Three Centers would not proceed to transplant in such cases. Less importance was assigned to non-portal splanchnic vein thrombosis (SVT), with all but one centre proceeding to transplant regardless of prior SVT. This survey highlights a considerable heterogeneity across responding centers in approaching MF-related comorbidities prior to transplant, suggesting that harmonisation guidelines are needed to address these issues in this patient population.

The Role of Shear Wave Elastography in Differentiation Between Tumoral and Bland Portal Vein Thrombosis

The Role of Shear Wave Elastography in Differentiation Between Tumoral and Bland Portal Vein Thrombosis

Locoregional Therapies and Interventional Radiology in Managing Hepatocellular Carcinoma: A Comprehensive Approach to Bridging, Downstaging, and Liver Transplantation

AbstractHepatocellular carcinoma (HCC) remains a significant global health challenge, particularly for patients awaiting liver transplants (LTs) due to the scarcity of donor organs. During the waiting period, a multidisciplinary approach becomes crucial to optimize tumor treatment and preserve liver function. In recent years, interventional radiology has emerged as an integral part of treatment strategies. It has played a pivotal role in bridging and downstaging patients on the path to transplantation. Interventional radiologists administer minimally invasive locoregional therapies to HCC patients on LT waiting lists. Additionally, they address complications such as portal hypertension and portal vein thrombosis, which can lead to clinical deterioration and jeopardize transplant candidacy. This article examines the pivotal role of interventional radiology in the management of HCC, highlighting recent studies and advancements within the field. Additionally, it provides a concise review of the eligibility criteria for LT in patients with HCC, alongside a discussion of the surgical techniques employed in LT for these patients.

Biallelic PIGM Coding Variant Causes Intractable Epilepsy and Intellectual Disability Without Thrombotic Events.

During the past two decades, an emerging group of genes coding for proteins involved in glycosylphosphatidylinositol (GPI) anchor biosynthesis are being implicated in early-infantile epileptic encephalopathy. Amongst these, a hypomorphic promoter mutation in the mannosyltransferase-encoding PIGM gene was described in seven patients to date, exhibiting intractable absence epilepsy, portal and cerebral vein thrombosis and intellectual disability (ID). We describe here three siblings exhibiting intractable epilepsy and ID, found to harbor a homozygous c.224G>A p.(Arg75His) missense variant in PIGM, which segregated with the disease in the family. The variant is evolutionary conserved, extremely rare in general population databases and predicted to be deleterious. Structural modeling of the PIGM protein and the p.(Arg75His) variant indicates that it is located in a short luminal region of the protein, predicted to be hydrophilic. Functional prediction suggests that the entire local region is sensitive to mutations, with the p.(Arg75His) variant in particular. This is the first report of a PIGM coding variant, and the second variant altogether to be described affecting this gene. This phenotype differs from that of patients with the shared PIGM promoter mutation by lack of thrombotic events and no decrease in PIGM cDNA levels or CD59 expression on red blood cells.

Spectrum of liver affection in children with sickle cell disease: case series

BackgroundSickle cell hepatopathy (SCH) is a relatively uncommon complication of sickle cell disease (SCD), yet it does not accommodate variations in presentation, outcome, or severity according to age.AimTo present SCH characteristics and assess the effect of implementation of a high-suspicion systematic diagnostic approach and early intervention plan of management.MethodsThis case series presented the characteristics of five children with SCD with variable hepatic manifestation and implemented a diagnostic approach that included testing the transaminases and bilirubin in any patient with any suspicion of liver affection.ResultsThe five patients had a complicated SCD history. They all presented with fever, abdominal pain, and deepening of jaundice. The final diagnosis was reached with a more individualized approach; two had significant coagulopathy and were diagnosed with sickle cell intrahepatic cholestasis, while one had normal synthetic functions of the liver with rising transaminases and bilirubin levels, as well as high titer of Epstein–Barr virus diagnosed as acute viral hepatitis complicated with sickle cell hepatic crisis. One other patient had markedly elevated bilirubin with mild elevation of transaminases, and magnetic resonance cholangiopancreatography showed acute extrahepatic biliary dilatation treated by endoscopic removal of the stone. The fifth patient proved to have portal vein thrombosis by portal duplex causing portal hypertension and decompensated liver. The management plan included early exchange transfusion to keep their hemoglobin S (HbS) below 15% which was performed in three of the patients, in addition to aggressive supportive measures for correction of coagulopathy with full recovery and normalization of their liver functions.ConclusionDespite the diagnostic challenges, the lack of standard diagnostic criteria, and the overlapping clinical presentation of SCH, the management and outcomes improved by following a systematic diagnostic approach.

Study of related factors to vascular complications after pediatric liver transplantation

Objective: To explore the related factors of vascular complications after liver transplantation in children. Methods: This is a retrospective case-series research. The clinical data of 89 pediatric liver transplant patients admitted to the Organ Transplantation Center, the Affiliated Hospital of Qingdao University from January 2016 to March 2024 were collected retrospectively. This study included 44 males and 45 females,aged from 4 months to 17 years. The ratio of graft to recipient weight was 0.6% to 7.7%. The primary diseases included 48 cases of biliary atresia and 41 cases of non-biliary atresia. The t-test, Wilcoxon rank sum test, χ2 test, and Fisher's exact probability method were used for data analysis. Multivariate Logistic regression was used to analyze the related factors of vascular complications. Results: All 89 children with liver transplantation completed surgery successfully. There were 8 cases of arterial complications after surgery, including 6 cases of hepatic artery thrombosis and 2 cases of hepatic artery stenosis. There were 16 cases of portal vein complications after surgery, including 9 cases of portal vein stenosis and 7 cases of portal vein thrombosis. The results of univariate analysis showed that the age of the recipient ≤1 year was the relevant factor for hepatic arterial complications(χ2=4.772,P=0.029). The age of the recipient ≤1 year, the age of the donor, the hepatic phase, and the time of cold ischemia were the relevant factors for the occurrence of portal vein complications(χ2=7.270,Z=388.500,Z=838.000, Z=594.500;all P<0.05). The results of multivariate analysis showed that age(≤1 year vs. >1 year) and duration of cold ischemia(every additional 1 hour) were independent related factors for portal vein complications after liver transplantation in children(both P<0.05). Conclusion: Children aged ≤1 year and with prolonged cold ischemia are more likely to develop portal vein complications after liver transplantation.

Comparison of the therapeutic effects of transarterial radioembolization and tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis.

Comparison of the therapeutic effects of transarterial radioembolization and tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis.

Current approaches to the management of jejunal variceal bleeding at the site of hepaticojejunostomy after pancreaticoduodenectomy.

Jejunal variceal bleeding at the site of hepaticojejunostomy after pancreaticoduodenectomy due to portal hypertension caused by extrahepatic portal vein obstruction is a life-threatening complication and is very difficult to treat. Pharmacotherapy, endoscopic methods, transcatheter embolization of veins supplying the jejunal afferent loop, portal venous stenting, and surgical procedures can be used for the treatment of jejunal variceal bleeding. Nevertheless, the optimal management strategy has not yet been established, which is due to the lack of randomized controlled trials involving a large cohort of patients necessary for their development.

Disorder of Glucose Metabolism and Therapy: Implications on the Natural History of Advanced Chronic Liver Disease

Introduction: Hepatogenous diabetes (HD) is a disorder of glucose metabolism (DGM) that develops as a complication of advanced chronic liver disease (ACLD) with an estimated prevalence of 20–70%. It appears to be associated with a larger number of decompensations, but its impact on the natural history of the disease is unclear. The treatment of DGM is hampered by the fact that some therapeutic agents are associated with a risk of complications in ACLD. The aim of this work was to study DGM in a population of patients with ACLD: prevalence, liver disease decompensation episodes, mortality analysis and study of the impact of antidiabetic therapies in patients with ACLD who developed DGM. Materials and Methods: A cohort of consecutive patients with ACLD without previous DGM, who attended a Hepatology clinic in the period of January to June 2015 was selected. Follow-up was carried out for 5 years. Data on age, gender, date of diagnosis and etiology of ACLD, Child-Pugh and MELD-Na classifications at enrollment, development of DGM, and antidiabetic therapy were collected. Logistic regression models for hospitalizations due to decompensated ACLD, ascites, hepatic encephalopathy (HE), upper gastrointestinal bleeding (UGB), hepatocellular carcinoma (HCC), portal vein thrombosis (PVT), infectious complications, acute-on-chronic liver failure (ACLF), and death were built. A survival analysis for patients with and without DGM was also performed. Treatment effectiveness for patients with DGM was assessed. Results: Initially, 221 patients were included, 154 (69.7%) of whom developed DGM after the diagnosis of ACLD. DGM patients presented a significantly higher number of hospitalizations. Odds ratio (OR) for death was not significantly related with DGM. At 5 years of follow-up, 68.9% of patients with DGM were alive, against 81.8% without DGM (p = 0.087). From the 154 patients who were diagnosed with DGM, 42.9% were not receiving pharmacological treatment for DGM. Treated patients were prescribed with either biguanides (34.8%), a SGLT2 inhibitor (8.6%), or insulin (7.7%). Only 1 patient was treated with a GLP-1 analogue. A tendency of OR favoring treatment was observed for biguanides and SGLT2 inhibitors in all outcomes except ascites. In the univariable analysis, the use of biguanides was associated with lower risk of death (OR: 0.84 [95% CI: 0.73–0.96]) and HE (OR: 0.85 [95% CI: 0.73–0.98]). Conclusion: DGM occurs with high prevalence in patients with ACLD and it seems to be related to more hospitalizations, which highlights the importance of its early identification and appropriate therapeutic approach. In the absence of contraindications, biguanides should be considered for treatment of patients with ACLD and DGM as they appear to be associated with a tendency to better outcomes and may present some advantage in terms of survival.

Predictive value of hepatic venous pressure gradient in cirrhotic portal vein thrombosis development

Background & AimsThere are lots of risk factors reported for cirrhotic portal vein thrombosis (PVT) development, however, the relationship between hepatic venous pressure gradient (HVPG) and PVT development remains unclear. MethodsThe clinical outcomes of cirrhotic patients who had no PVT and underwent HVPG measurement at baseline between March 2018 and March 2022 were analyzed retrospectively. Screening for non-tumoral PVT development was implemented by contrast-enhanced computed tomography and/or magnetic resonance imaging every 6-12 months. ResultsEighty-two cirrhotic patients were evaluated over a follow-up period. Of these, 12 patients (14.6%) experienced the development of PVT. The occurrence of non-tumoral PVT at one, two, and three years were 6.6%, 11.7%, and 22.2% respectively. HVPG (p=0.038;HR 1.07;95%CI 1.00-1.14) and alcohol liver disease (ALD) (p=0.019;HR 4.20;95%CI 1.27-13.89) were independently associated with a high PVT risk. The cutoff value of HVPG was 17.52 mmHg. The cumulative incidence of PVT differed significantly among groups stratified by HVPG thresholds of 16mmHg (P=0.011). The sensitivity and specificity of HVPG≥16mmHg in predicting PVT development were 100.0% and 35.7%. ConclusionsIn patients with liver cirrhosis, the value of HVPG was the independent predictive factor of PVT development. Screening for PVT was recommended during follow-up in patients with HVPG≥16 mmHg.

Role of sonography in detection and evaluation of post liver transplant complications.

To evaluate the role of sonography in revealing and characterizing liver transplant complications based on gray scale and color Doppler, describe the normal Doppler findings, and discuss the significance of distinguishing normal transient changes in the spectral waveform from findings that may suggests ominous complications. We carried out a retrospective cross-sectional study at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. The medical records and imaging studies of a total of 122 candidates who underwent transplantation between January 2016 to February 2022 were reviewed. Our results showed that most patients were males with the most frequent age group being those between 54-71 years. Hepatitis B virus and hepatic cellular carcinoma were the most common indications for transplants. A total of 95 patients received a graft from a living related donor. Regarding complications, biliary issues (including leaks and ducts dilation) were the second most frequent complication after collections. Vascular complications represented 7.4% of all complications and was the leading cause of death in 4.8% of cases. Among all vascular issues encountered during liver transplant, portal vein thrombosis was the most predominant. In respect to Doppler findings, portal vein velocities and resistive index of hepatic artery had re-averaged within 7-10 post-operative days in most patients. Ultrasound plays crucial role in the post-operative management of compilations, facilitating early detection, which is substantial for the graft survival.