Cases Of Portal Vein Thrombosis Research Articles

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety.

The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of metabolic and bariatric surgery in patients with compensated advanced chronic liver disease and clinically significant portal hypertension. This is an international, multicentric, retrospective study on 63 individuals affected by obesity with compensated advanced chronic liver disease and clinically significant portal hypertension who underwent metabolic and bariatric surgery in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was post-operative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, we performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score and type of surgery. One patient (1.6%) experienced gastric leakage and mortality. There were 3 (5%) reported cases of portal vein thrombosis, 2 (3%) postoperative acute renal failure, and 1 (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis ((OR: 0.73, 95% CI: 0.55 - 0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication. Metabolic and bariatric surgery is safe in patients with compensated advanced chronic liver disease and clinically significant portal hypertension performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

Diagnostic Prediction of portal vein thrombosis in chronic cirrhosis patients using data-driven precision medicine model.

Portal vein thrombosis (PVT) is a significant issue in cirrhotic patients, necessitating early detection. This study aims to develop a data-driven predictive model for PVT diagnosis in chronic hepatitis liver cirrhosis patients. We employed data from a total of 816 chronic cirrhosis patients with PVT, divided into the Lanzhou cohort (n = 468) for training and the Jilin cohort (n = 348) for validation. This dataset encompassed a wide range of variables, including general characteristics, blood parameters, ultrasonography findings and cirrhosis grading. To build our predictive model, we employed a sophisticated stacking approach, which included Support Vector Machine (SVM), Naïve Bayes and Quadratic Discriminant Analysis (QDA). In the Lanzhou cohort, SVM and Naïve Bayes classifiers effectively classified PVT cases from non-PVT cases, among the top features of which seven were shared: Portal Velocity (PV), Prothrombin Time (PT), Portal Vein Diameter (PVD), Prothrombin Time Activity (PTA), Activated Partial Thromboplastin Time (APTT), age and Child-Pugh score (CPS). The QDA model, trained based on the seven shared features on the Lanzhou cohort and validated on the Jilin cohort, demonstrated significant differentiation between PVT and non-PVT cases (AUROC = 0.73 and AUROC = 0.86, respectively). Subsequently, comparative analysis showed that our QDA model outperformed several other machine learning methods. Our study presents a comprehensive data-driven model for PVT diagnosis in cirrhotic patients, enhancing clinical decision-making. The SVM-Naïve Bayes-QDA model offers a precise approach to managing PVT in this population.

Objective Tumor Response of Hepatocellular Carcinoma Obtained by Transarterial Radioembolization with Iodine-131-Lipiodol Versus Transarterial Chemoembolization for Patients with and without Portal Venous Thrombosis: A Controlled Interventional Trial

Hepatocellular carcinoma (HCC) treatment often requires transarterial chemoembolization (TACE). However, TACE efficacy is controversial in the presence of portal vein thrombosis (PVT). Although transarterial radioembolization (TARE) benefit was previously documented in PVT, neither the objective tumor response (OTR) after TARE with Iodine-131-lipiodol (131I-lipiodol) nor the PVT effect on the results of locoregional therapies was accurately measured in prospective clinical trials. The aim of this study was to compare OTR and survival obtained by TARE with 131I-lipiodol versus TACE in patients with cirrhosis and HCC, as well as between those with and without PVT. 33 patients were included, from whom 38 tumors were assessed. OTR was quantified by a special algorithm to measure hypervascular HCC tissue. 19 tumors received each therapy. Nine subjects (27%) had PVT, most of them in the TARE group (p=0.026). Mean OTR according to the tumor volumes was 24.2%±56% after TARE and 32.8%±48.9% after TACE, with no difference between the treatments (p=0.616). Similar values were also observed between those with and without PVT (p=0.704). Mean survival was 340 days and did not differ between the two treatments (p=0.596), but was 194 days in PVT cases (p=0.007). This is the first study in which OTR obtained by TARE with 131I-lipiodol is accurately measured. Additionally, PVT impact on survival after TARE and TACE was precisely documented. Although the TARE group had more PVT subjects (who had shorter survival), TARE and TACE achieved similar OTR and OS rates.

Natural history of portal vein thrombosis in cirrhosis: A systematic review with meta-analysis.

Progression of liver disease in cirrhosis is associated with an increased incidence of portal vein thrombosis (PVT) in cirrhosis. However, evidence suggests that spontaneous recanalization of PVT may occur even without anti-thrombotic therapy. Thus, the present meta-analysis was conducted to study the natural history of PVT in cirrhosis, facilitating decisions regarding anticoagulation. Three electronic databases were searched from 2000 to August 2022 for studies reporting the outcome of PVT in cirrhotics without anticoagulation. The pooled proportions with their 95% confidence intervals (CIs) were calculated using a random-effect model. A total of 26 studies (n=1441) were included in the final analysis. Progression of PVT on follow-up was seen in 22.2% (95% CI 16.1-28.4), while 77.7% (95% CI 71.6-83.9) remained non-progressive (improved or stable). The most common outcome was a stable PVT with a pooled event rate of 44.6% (95% CI 34.4-54.7). The pooled rates of regression and complete recanalization of PVT in cirrhotics were 29.3% (95% CI 20.9-37.7) and 10.4% (95% CI 5.0-15.8), respectively. On follow-up after improvement, pooled recurrence rate of PVT was 24.0% (95% CI 14.7-33.4). MELD score, and presence of ascites had a negative association, while a longer follow-up duration had positive association with PVT regression. Approximately 25% of the cases of PVT in cirrhosis are progressive, 30% cases improve, and 45% remain stable. Future studies are needed to analyze the predictors of spontaneous regression.

Outcomes after ABO incompatible pediatric liver transplantation are comparable to ABO identical/compatible transplant.

ABO incompatible (ABOi) liver transplantation (LT) was initially associated with a higher incidence of vascular, biliary, and rejection complications and a lower survival than ABO compatible (ABOc) LT. Various protocols have been proposed to manage anti-isohemagglutinin antibodies and hyperacute rejection. We present our experience with a simplified protocol using only plasmapheresis. A retrospective review of all patients who received an ABOi LT at ourinstitution was performed. Comparisons were made based on era (early: 1997-2008, modern: 2009-2020) and severity of disease (status 1 vs. exception PELD at transplant). A pair-matched comparison was done to patients who received an ABOc LT. p < 0.05 was considered significant. 17 patients received 18 ABOi LT (3 retransplants). Median age at transplant was 7.4 months (1.1-28.9). 66.7% patients were listed as status 1. Hepatic artery thrombosis (HAT) occurred in one patient (5.6%), there were 2 cases of portal vein thrombosis (PVT) (11.1%), and 2 biliary strictures (11.1%). Patient and graft survival improved in the ABOi modern era, although not significantly. In the pair-matched comparison, complications (HAT p = 0.29; PVT p = 0.37; biliary complications p = 0.15) and survival rates were similar. Patient and graft survivals were 100% in the non-status 1 ABOi patients compared to 67% (p = 0.11) and 58% (p = 0.081) respectively for patients who were transplanted as status 1. ABO incompatible liver transplants in infants with a high PELD score have excellent outcomes. Indications for ABO incompatible transplants should be liberalized to prevent deaths on the waiting list or deterioration of children with high PELD scores.

Prevalence of Portal Vein Thrombosis in Budd-Chiari Syndrome Patients

Background and Aim: Thrombosis of the portal vein or obstruction of the hepatic venous outflow tract is the cause of portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS). Patients with PVT may experience a shorter survival rate compared to those without. The present study aimed to determine the portal vein thrombosis occurrence in Budd-Chiari syndrome patients. Patients and Methods: This cross-sectional study was conducted on 46 Budd-Chiari syndrome patients in Gastroenterology department of DHQ Teaching Hospital and Mufti Mahmood Memorial Hospital, Dera Ismail Khan from November 2021 to October 2022. Written informed consent was taken from each individual. Doppler ultrasonography (colored-pulsed) was used to confirm the PVT and BCS cases. Clinical data, laboratory findings, and radiological data were recorded. SPSS version 26 was used for data analysis. Results: The overall mean age of the BCS patients was 28.34±4.6 years. The prevalence of portal vein thrombosis in BCS patients was 12.8% (n=6). Of the total cases, the incidence of chronic and acute BCS presentation was 42 (91.3%) and 4 (8.7%) respectively. The most prevalent symptoms of BCS were abdominal pain and abdominal enlargement in 38 (82.6%) and 41 (89.1%) respectively. Hepatomegaly and ascites were most prevalent clinical signs found in 36 (78.3%) and 37 (80.4%) respectively. The incidence of esophageal varices, gastric extension, and fundal varices were 32 (69.6%), 4 (8.7%), and 2 (4.3%) respectively. About 21 (45.7%) cases had Portal hypertensive gastropathy (PHG). Conclusion: A higher incidence of PVT was observed in the present study than previously reported. Sociodemographic data and underlying etiology of BCS were not significantly different between patients with and without PVT. Those with PVT were more likely to experience hepatic tenderness, increased white blood cells, and increased direct bilirubin. PVT and other patients had similar Doppler ultrasound findings. Keywords: Portal vein thrombosis, Prevalence, Budd-Chiari syndrome

Chronic Liver Diseases and COVID-19: Database of General Hospital

Patients with chronic liver diseases (CLD) are at high risk of infection and severe COVID-19 (Corona Virus Disease).Aim: to create a database of patients with CLD, including an analysis of the frequency of detection of SARS-CoV-2 markers, the causes of hospitalization, an assessment of 30-day mortality in the presence of COVID-19 markers and in the absence of infection.Materials and methods. A one-time retrospective observational comparative study was conducted, the result of which was the creation of a database. 693 electronic case hystories of patients with CLD of various etiologies hospitalized in the V.M. Buyanov State Clinical Hospital for the period 01.04.2020–01.10.2021 were analyzed. Th e analysis included the following parameters: gender, age, etiology of the disease, reasons for hospitalization, the presence of ribonucleic acid (RNA) SARS-CoV-2 in a smear of the nasal mucosa and oropharynx, antibodies to SARS-CoV-2 immunoglobulins of classes M, G (IgM, IgG), the outcome of the disease (30-day mortality).Results. Markers of past new coronavirus infection (IgG) were detected in 268 (38,7 %), SARS-CoV-2 RNA was detected in 67 (9,7 %). Th e analysis of the causes of hospitalization revealed the predominance of edematous ascitic syndrome (64,5 %), an increase in hepatic encephalopathy (31,6 %) and an increase in the number of cases of portal vein thrombosis (PVT) (8,9 %). When assessing the 30-day mortality, signifi cant diff erences were found in patients with Alcohol-related liver disease (ARLD), chronic viral hepatitis in the presence of COVID-19 markers and in cases of their absence.Conclusion. SARSCoV-2 markers were found in 335 (48,3 %) of patients with CLD. Th e main reason for hospitalization is the appearance /increase of edematous ascitic syndrome, including due to PVT. 30-day mortality in the postcovid period is signifi cantly higher (р = 0,0246) in ARLD compared with patients without COVID-19 (218 (34,9 %) и 300 (25,3 %), respectively, р = 0,0246).

Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis

Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p= 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p= 0.001). Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.

Tromboembolismo venoso em Idade Pediátrica: Um olhar de 20 anos numa Unidade de Cuidados Intensivos Pediátricos

Objective: Clinical characterization and approach of patients with thromboembolism (VTE). Methods: Retrospective, descriptive study of patients aged &lt;18 years with VTE in a pediatric intensive care unit in a tertiary care hospital over 20 years [2002-2021]. Results: Identified 51 patients: deep vein thrombosis (DVT) (n=30), cerebral vein thrombosis (CVT) (n=21), pulmonary thromboembolism (PTE) (n=4), portal vein thrombosis (PVT) (n=2) and renal vein thrombosis (RVT) (n=1). In 5 patients CVT and DVT coexisted (n=1); PTE and DVT (n=3); and RVT and DVT (n=1). Mean 2.6 cases/year. 52.3% male, median 6 years [1M;17Y]. The presence of a central venous catheter was the main risk factor (72%) in DVT associated with edema in the region; Doppler ultrasound was the exam of choice. All with PTE were adolescents; 75% had chest complaints confirmed by angio-CT; identified =2 risk factors in each patient. The case of RVT was a 2-year-old child with renal neoplasm. The cases of PVT were adolescents with symptoms of portal hypertension. The main symptom in CVT was headache (63.6); 52.4% secondary to upper respiratory infection; thrombophilia study positive in 42.9%. Analytically, all had elevated D-dimers. Most started anticoagulation with enoxaparin (86.3%), which they maintained for 3 to 6 months after discharge. Mean hospital stay was 17.6 days. There was 1 episode of recurrence and 1 death unrelated to VTE.

P1020: SCREENING FOR PORTAL HYPERTENSION IN PATIENTS WITH PHILADELPHIA NEGATIVE MYELOPROLIFERATIVE NEOPLASMS

Background: Portal hypertension (PH) is a well-recognized complication of BCR-ABL negative myeloproliferative neoplasms (MPNs) and is associated with significant morbidity and mortality. However, the prevalence of PH and its associated risk factors have not been studied systematically in this patient population. Screening by esophagogastroduodenoscopy (EGD) can facilitate early diagnosis of PH and opportunity for intervention to prevent complications. Aims: To investigate the prevalence of PH and its patient and disease-related risk factors. Methods: From May 2013 to March 2019, MPN patients ≥ 18 years old with spleen >5 cm below the costal margin in myelofibrosis (MF) or any size in Polycythemia Vera (PV) or Essential Thrombocythemia (ET) were enrolled prospectively (NCT01816256). Patients with a known history of portal or hepatic vein thrombosis, liver cirrhosis, and esophageal varices were excluded. Screening for PH was done by EGD to evaluate for esophageal varices (EV) or gastric varices (GV), and portal hypertensive gastropathy (PHG). Abdominal Doppler ultrasonography (USG) was performed to evaluate for portal vein thrombosis and spleen size. PH severity was based on the size of varices or severity of PHG. For sample-size calculation, a precision approach was used, considering scenarios where PH prevalence ranged from 5 to 10% and an upper limit for sample size of 100. At a prevalence estimate of 8%, the 90% confidence interval (CI) was 4-14%, with an acceptable lower limit for moving forward with a screening program. Prevalence of PH was calculated as a proportion and CI are exact using Clopper-Pearson method. Results: Among 102 enrolled patients, EGD and USG were completed in 85 and 84, respectively. Primary and Post-PV/ET MF comprised the majority of the study population (93% [79/85]). Evidence of PH was found in 32 patients (38%, [90% CI 29-47]) of whom 12 (14% [90% CI 9-22]) had moderate to severe PH. EV, GV, and PHG were found in 81% (26/32), 13% (4/32), and 31% (10/32) of patients, respectively. The prevalence of PH among MF and PV/ET patients was 35% (28/79) and 67% (4/6), respectively. In MF patients, PH was moderate-to-severe in 13% (90% CI 8-20). No cases of portal vein thrombosis were identified on USG. Apart from a palpable liver observed more frequently in non-PH patients, there were no other significant differences in baseline characteristics among patients with and without PH. The frequency of JAK2, MPL and CALR mutations among PH patients was 78% (25/32),13% (4/32), and 6% (2/32). There was a trend towards more JAK2 mutations in PH patients (78% [25/32] vs 64% [34/53], p=0.23), but no difference in DIPSS risk or frequency of high molecular-risk mutations. Overall survival was similar in both groups. PH-directed interventions were initiated in 59% (19/32); 28% (9/32) were started on beta blocker (BB) prophylaxis, 16% (5/32) were treated with BB and variceal banding, and 16% (5/32) continued on surveillance EGDs alone. Three patients with moderate PH at baseline developed variceal bleeding (2) and ascites (1). All 3 patients were on BB prophylaxis, and 1 had prior prophylactic banding. There were no adverse events related to study procedures EGD or USG. Image:Summary/Conclusion: Given the study population, our results are generalizable to MF patients. Our study shows that clinically significant PH is common in MF patients, and led to additional clinical interventions in significant number of patients. These data support the inclusion of asymptomatic PH screening in the work up of MF patients.

Physiological reno-portal bypass in liver transplantation with non-tumorous portal vein thrombosis.

Reno-portal anastomosis (RPA) in presence of spleno-renal shunts (SRS) is a physiological option to restore blood flow in liver transplantation with portal vein thrombosis (PVT). Diffuse splanchnic venous system thrombosis (complex PVT) is its main indication but RPA proved to be useful in selected cases of less extensive thrombosis (non-complex PVT). Up until now only two monocentric and one multicentric case series has been published on this topic in addition to few anecdotal reports. After 2014, we introduced RPA in our institution to manage some cases of complex PVT in presence of SRS. Here, we present the evolution of indication to RPA. From 2014 to 2020, we performed ten RPA: nine patients presented non-complex and one complex PVT. Overall early and late complication rates were 66.6% and 50%, respectively. Two patients developed RPA stenosis, treated by interventional radiology. Self-resolving acute kidney injury (AKI) was observed in three cases. No re-transplantation was necessary. RPA was patent in all patients, with a mean follow-up of 41.9months. The overall patient survival was 70% at 1year and 60% at 3 and 5years. Four patients died at 1, 2, 3 and 20months from LT. Causes of deaths were, respectively, stroke, cerebral infection, sepsis (MOF) and sudden variceal bleeding in sinusoidal obstruction syndrome. The relative simplicity and effectiveness of RPA in presence of SRS allowed us to rely more and more often on this technique in liver transplantation with challenging non-complex PVT.

Four Cases of Portal Vein Thrombosis Associated with Diverticulitis of the Colon

Four Cases of Portal Vein Thrombosis Associated with Diverticulitis of the Colon

Portal Vein Thrombosis: A Saga of two Nebulous Etiologies

Portal Vein Thrombosis (PVT) is the most prevalent cause of extrahepatic portal vein obstruction. Cirrhosis, inherited procoagulant conditions (such as Factor V Leiden, Antithrombin III deficiency, etc.), myeloproliferative neoplasms, hepatocellular carcinoma and operative manipulation of the portal vein are all common causes of portal vein thrombosis. Even though a diagnosis is usually made, more than 25% of patients have no clear explanation for their PVT. The authors describe two cases of portal vein thrombosis in an atypical setting-one in a middle-aged female with type 2 diabetes mellitus with pyoperitoneum and the other is in a young male coinfected with human immunodeficiency virus and hepatitis E virus. Both cases had very different outcomes and thus emphasized the notion that PVT is a potentially fatal condition demanding a thorough diagnostic workup and evaluation.

Acute Portal Vein, Superior Mesenteric Vein and Splenic Vein Thrombosis Secondary to JAK2 V617 Mutation- A Case Report

Portal vein thrombosis (PVT) is a rare finding which usually occurs in association with local factors such as cirrhosis, malignancy, pancreatitis, intraabdominal infections or systemic hypercoagulable states. It may present acutely as abdominal pain, ascites, fever or exist in a chronic state which is generally asymptomatic and an incidental finding. With advancement in Imaging and laboratory studies, PVT cases are diagnosed more frequently along with its predisposing factors. The invention of JAK2 mutation and it’s addition to the WHO criteria for Myeloproliferative neoplasm (MPN) diagnosis, has increased the number of MPN cases which were previously labelled idiopathic. We present a case of 54 year old female diagnosed with unprovoked PVT with bowel ischemia and JAK 2 mutation positive, managed surgically and with long term anticoagulation.

Portal Vein Thrombosis: Diagnosis and Endovascular Management.

Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking. The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted. Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization. Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus. · This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience.. · Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2022; 194: 169 - 180.

S2907 Portal Vein Thrombosis in the COVID-19 Era: A Rare Presentation

Introduction: An increased incidence of venous thromboembolism (VTE) has been reported with SARS-COV2 (severe acute respiratory syndrome coronavirus 2) infections. VTE in unusual sites like the portal vein is limited to case reports. This report adds to the growing body of literature about thrombotic complications with SARS-COV2 infections. Case Description/Methods: A female aged 39 with a medical history of diabetes, hypertension and cholecystectomy presented with three days of right upper quadrant (RUQ) pain. She denied substance use, cirrhosis, autoimmune disease or previous VTE. On presentation, vitals were stable. She had RUQ tenderness. Blood work revealed elevated alkaline phosphatase and transaminases. White cell count, bilirubin and coagulation were normal. Imaging revealed occlusive thrombus of the right portal vein proximal to the bifurcation with peripheral extension (images 1 and 2). Extensive hypercoagulable and infectious workup was negative. She was immediately started on enoxaparin. A chest x ray was suggestive of SARS-COV2 infection and confirmatory testing was positive. Her symptoms improved and lab abnormalities resolved. She was discharged home with oral anticoagulants and instructions to self-isolate. Discussion: Most reported cases of Portal vein thrombosis (PVT) with SARS-COV2 are incidental. Our patient presented with RUQ abdominal pain, highlighting an unusual presentation. PVT is rare and occurs with cirrhosis, connective tissue disease, malignancies, pancreatitis and thrombophilia. These were absent in our patient and other causes of hypercoagulability such as antiphospholipid syndrome, proteins C, S and antithrombin deficiencies, Factor V mutations were ruled out. SARS-COV2 infected patients experience a hypercoagulable state with the incidence of thrombotic complications as high as 31%. Some have suggested that systemic inflammation leads to endothelial dysfunction, causing Von-Willebrand Factor and toll-like receptor activation, leading to platelet aggregation and coagulation cascade initiation. Others have speculated that inflammatory cytokines bind to endothelial surface angiotensin converting enzyme receptor leading to lymphocytic endotheliitis and prothrombotic gene overexpression. Anticoagulation should be used in PVT to reduce complications of intestinal infarction and portal hypertension. Recanalization occurs in 60% of cases with anticoagulation in the first week. We used therapeutic enoxaparin and switched to an oral anticoagulant for a 6-month course.Figure 1.: Image 1 a and b: CT scan showing right portal vein thrombosis, just at its bifurcation (blue arrows) c: chest x ray showing bilateral patchy opacities.

Profile of Thrombosis Distribution Following Haploidentical and Identical-Sibling Transplantation: A 15-Year Experience at a Single Center in China

AbstractIntroduction:Thrombotic episodes are a serious cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) patients. There have been many studies on the incidence and risk factors of thrombosis after HSCT, but no systematic and comprehensive summary of the distribution, frequency and occurrence time of thrombosis in allogeneic HSCT recipients is available. Given that the complications after HSCT correlate with the transplant type, the incidence of thrombosis may also differ in different transplant protocals. Our center has explored and carried out haploidentical HSCT for a long time, and this study aimed to compare the thrombosis characteristics between haploidentical HSCT and identical-sibling HSCT.Methods:A retrospective study of allogeneic HSCT recipients at the Peking University Institute of Hematology was conducted from 2003, the initiation of haploidentical HSCT, to 2017. All haploidentical HSCT donors were treated with G-CSF, and the HSCT recipients received a modified busulfan (BU) / cyclophosphamide (CY) + antihuman thymocyte immunoglobulin (ATG) regimen for myeloablative conditioning and a cyclosporine A (CsA) + mycophenolate mofetil (MMF) + short-term methotrexate (MTX) regimen for GVHD prophylaxis. Thrombotic episodes in our study were classified into groups including deep-vein thrombosis (DVT), pulmonary embolism (PE), catheter-induced thrombosis (CIT), stroke, portal vein thrombosis (PVT) and others. DVT and PE belonged to venous thromboembolic events (VTE). Univariate and multivariable Cox models were used to explore the risk factors, including hematopoietic cell transplant comorbidity index (HCT-CI), for the development of thrombotic events.Results:We identified 2392 haploidentical HSCT recipients and 727 identical-sibling HSCT recipients, and a total of 219 (7.02%) thromboembolic events were registered. Among them, 166 thromboembolic events developed after haploidentical HSCT, including 51 cases (2.13%) of DVT, 3 cases (0.13%) of PE, 63 cases (2.63%) of CIT, 40 cases (1.67%) of stroke, 4 cases (0.17%) of PVT and 5 cases (0.21%) of other thrombotic episodes. Additionally, 42 thromboembolic events developed after identical-sibling HSCT, including 14 cases (1.93%) of DVT, 0 cases of PE, 17 cases (2.34%) of CIT, 10 cases (1.38%) of stroke, and 1 case (0.14%) of PVT. The incidence of thrombosis in haploidentical and identical-sibling HSCT recipients was not significantly different (P>0.05 ).CIT appeared on day 26 of BMT (median value; range, 15 to 48), VTE (PE, DVT) on day 215 (range, 20 to 732), stroke on day 47 (range, 22 to 268), and PVT on day 55 (range, 40 to 274). The overall survivals (OSs) of these thrombosis groups were 92.1%, 90.7% , 37.5% and 25%. Patients with VTE and CIT have a significantly longer OS than those with PVT and stroke (P<0.05).Based on our nested-control study, HCT-CI ≥ 3 (P<0.05) and GVHD (P<0.05)were significant risk factors for thrombosis occurrence in HSCT recipients in multivariable Cox models.Conclusion:The incidence of thrombosis in haploidentical and identical-sibling HSCT recipients was not significantly different. CIT was the most common thromboembolic event in HSCT recipients at our center, followed by VTE, stroke, and PVT. Among them, patients with VTE and CIT have a significantly longer OS than those with PVT and stroke. HCT-CI ≥ 3 and GVHD were significant risk factors for thrombosis occurrence in HSCT recipients. DisclosuresNo relevant conflicts of interest to declare.

Early Effects of Laparoscopic Sleeve Gastrectomy and Laparoscopic One-Anastomosis Gastric Bypass on Portal Venous Flow: a Prospective Cohort Study.

Portal vein thrombosis (PVT) is an infrequent, yet potentially lethal, complication of bariatric surgery. The aim of this prospective, non-randomized, cohort study is to compare between laparoscopic sleeve gastrectomy (LSG) and laparoscopic one-anastomosis gastric bypass (LOAGB) in terms of their early postoperative effects on portal venous flow and patency. Forty-nine morbidly obese patients were allocated to one of 2 groups (A or B). Group A patients underwent LSG, whereas group B patients underwent LOAGB. Portal venous Doppler ultrasound scanning was performed preoperatively and 2 weeks postoperatively in all cases, in order to assess the portal venous flow (PVF) in terms of flow direction and peak systolic velocity (PSV); as well as to assess the portal venous patency and exclude PVT. The mean change in PSV (ΔPSV) and the mean percentage change in PSV (%ΔPSV) were determined in both groups. In all cases (group A (n = 26); group B (n = 23)), the direction of PVF was "hepatopetal" both preoperatively and 2 weeks postoperatively. The mean ΔPSV and the mean %ΔPSV were higher in LSG patients "group A" (- 0.84 cm/s and 3.25% respectively) compared with LOAGB patients "group B"(- 0.06 cm/s and 0.27% respectively); P = 0.038 and 0.039 respectively. The mean change in PSV was in the negative direction in both groups, i.e., "deceleration." No cases of PVT were reported in the study. Laparoscopic sleeve gastrectomy is associated with greater reduction in portal venous peak systolic flow velocity in the early postoperative period, compared with laparoscopic one-anastomosis gastric bypass.

Hypothermic oxygenated perfusion - initial experience

Purpose: In liver transplantation, the need for extended criteria donors may reduce graft and patient survival related to early and late complications.The last decade saw a renewed interest in organ preservation with perfusion strategies. Hypothermic Oxygenated Perfusion (HOPE) has been thoroughly investigated showing promising results regarding lower early complication rate, improvement of overall transplantation results and suggesting better survival for HCC patients. This work reports preliminary results with HOPE experience in our Unit, the first and only Portuguese Liver Transplant Centre to use machine perfusion. Method: There was a broad indication for HOPE use, for procedure training.Over a 5-month period, HOPE was used efficiently in 8 cases. We analyzed donor, receptor, graft, as well perioperative period data. Results: Donors: median age was 67 years, average BMI of 26,2 kg/m2, high risk scores (average DRI 1,693 and half the patients with D-MELD above 1600).Patients: average MELD-Na was 23; risk factors: 3 cases of ACLF, 4 cases of portal vein thrombosis, 1 re-transplant; 5 patients with urgent liver request. There was no post-reperfusion syndrome nor PNF cases; there was a death duo to graft loss (vascular complications) and sepsis (excluded). Average peak ALT/AST were 623/783 U/L; average bilirubin and INR on the 7 th day were 2,9 mg/dL and 1,28.There was a CIT increase (60-70’); however, 120’ of CIT was attributable to “oxygenated ischemia”. There is yet no time span for delayed complications evaluation. Conclusion: From the initial experience we highlight ease of technique implementation and good immediate graft function on severely ill patients.We await series enlargement as well as future studies that allow confirmation of the multiple advantages described in the literature.

Janus Kinase-2 Mutation Associated Portal Vein Thrombosis Complicating Liver Cirrhosis and Hepatocellular Carcinoma

Background:Portal vein thrombosis (PVT) might be a catastrophic event complicating liver cirrhosis and hepatocellular carcinoma (HCC). Aim:role of JAK2 RS V617F mutation as a risk factor for PVT development in liver cirrhosis and HCC. Methods:A case control study conducted on 100 PVT patients (76 HCC and 24 liver cirrhosis) additionally, 100 healthy individuals used as a control group. PVT was diagnosed incidentally by Doppler ultrasound during routine follow-up HCC screening. Prothrombin G20210A mutation, MTHFR mutation, Factor V Leiden mutation (VFL), antithrombin III (ATIII), protein C, S, and antiphospholipid antibodies, along with JAK2 RS V617F mutation by real-time polymerase chain reaction all were analyzed.Results:Patients with PVT were significantly older (p<0.001), thrombocytopenic (p<0.001), with high alkaline phosphatase (p<0.001). JAK2 RS V617F mutation was found in 28/100 (28%) in idiopathic PVT complicating liver cirrhosis and hepatocellular carcinoma. Cases with positive JAK2 rs V617F mutation were significantly accompanied by protein S deficiency (P 0.03), LA absence (p 0.06), and high frequency of ascites (P 0.03). While, the MTHFR heterozygous mutation (p0.001), ATIII (P 0.02), and VFL (P 0.01) were more frequent with negative JAK2 rs V617F mutation. The comparison between demographic data and thrombophilic parameters in PVT cases revealed that no significant differences were recorded except for male gender, Diabetes Mellitus, splenomegaly significantly increased among HCC cases (p<0.05). Conclusions: JAK2 rs V617F mutation must be considered in any case of PVT with liver cirrhosis and hepatocellular carcinoma without identified thrombophilic risk factors, with potential considerations of evolving myeloproliferative disorders. New diagnostic and therapeutic implications are still awaited.