Presence Of Portal Vein Thrombosis Research Articles

Trans-arterial radioembolization in intermediate-advanced hepatocellular carcinoma: systematic review and meta-analyses.

Trans-arterial radioembolization (TARE) is a recognized, although not explicitly recommended, experimental therapy for unresectable hepatocellular carcinoma (HCC).A systematic literature review was performed to identify published studies on the use of TARE in intermediate and advanced stages HCC exploring the efficacy and safety of this innovative treatment.Twenty-one studies reporting data on overall survival (OS) and time to progression (TTP), were included in a meta-analysis. The pooled post-TARE OS was 63% (95% CI: 56-70%) and 27% (95% CI: 21-33%) at 1- and 3-years respectively in intermediate stage HCC, whereas OS was 37% (95% CI: 26-50%) and 13% (95% CI: 9-18%) at the same time intervals in patients with sufficient liver function (Child-Pugh A-B7) but with an advanced HCC because of the presence of portal vein thrombosis. When an intermediate and advanced case-mix was considered, OS was 58% (95% CI: 48-67%) and 17% (95% CI: 12-23%) at 1- and 3-years respectively. As for TTP, only four studies reported data: the observed progression probability was 56% (95% CI: 41-70%) and 73% (95% CI: 56-87%) at 1 and 2 years respectively. The safety analysis, focused on the risk of liver decompensation after TARE, revealed a great variability, from 0-1% to more than 36% events, influenced by the number of procedures, patient Child-Pugh stage and treatment duration.Evidence supporting the use of radioembolization in HCC is mainly based on retrospective and prospective cohort studies. Based on this evidence, until the results of the ongoing randomized trials become available, radioembolization appears to be a viable treatment option for intermediate-advanced stage HCC.

Primary Prophylaxis for Variceal Bleeding and the Improved Survival of Patients with Newly Diagnosed Hepatocellular Carcinoma.

We evaluated the impact of primary variceal bleeding prophylaxis on long-term outcomes of patients newly diagnosed with hepatocellular carcinoma (HCC). A retrospective cohort of 898 patients newly diagnosed with HCC without a history of variceal bleeding [age 57.4±10.4, males 718 (80.0%)] were analyzed for new onset variceal bleeding during follow-up. Variceal bleeding occurred in 72 patients (8.0%) during follow-up. The presence of portal vein thrombosis [hazard ratio (HR) 3.90; 95% confidence interval (CI) 2.09-7.30; p<0.001] and the presence of the red color sign or ≥grade 2 varices at index endoscopy (HR 7.64; 95% CI 4.56-12.80; p<0.001) were independent risk factors for variceal bleeding. The occurrence of variceal bleeding was an independent risk factor for mortality (HR 1.39; 95% CI 1.06-1.82; p=0.015). The cumulative incidence rate of variceal bleeding at 1year was 2.1, 15.3, and 34.2% for those non-indicated for primary prophylaxis (n=760), indicated for primary prophylaxis and received prophylaxis (n=98), and indicated for primary prophylaxis but did not received prophylaxis (n=40) (p<0.001). Primary prophylaxis for variceal bleeding for indicated patients was associated with a reduced risk of mortality in all patients (HR 0.54; 95% CI 0.33-0.88; p=0.014) and in propensity-matched patients (HR, 0.54; 95% CI 0.31-0.95; p=0.033). Variceal bleeding was independent risk factor for survival of newly diagnosed HCC patients. Screening and providing primary prophylaxis for indicated patients should be considered for patients with HCC.

Clinical significance of vascular endothelial growth factor in hepatitis C related hepatocellular carcinoma in Egyptian patients.

Background and aimsSeveral angiogenic factors are involved in the development and progression of hepatocellular carcinoma (HCC), a hypervascular tumor. Vascular endothelial growth factor (VEGF) is a primary driving force for angiogenesis, and its overexpression has been reported in HCC. However, the significance of plasma and tissue VEGF levels in HCC in Egyptian patients with chronic hepatitis C (CHC) infection is understudied. The aim of this study was to evaluate the role of VEGF (measured in plasma and liver tissue) in patients with hepatitis C virus-related HCC and to assess its significance in the diagnosis and prognosis of HCC.Materials and methodsA total of 90 subjects were studied. Among 90 subjects, 60 with CHC were examined and were subdivided into two groups: 30 patients with CHC-related HCC (HCC group) and 30 patients with CHC without HCC (non-HCC group). Thirty apparently healthy subjects served as the control group. VEGF was estimated in plasma by enzyme-linked immunosorbent assay and its expression in liver tissue was evaluated by real-time polymerase chain reaction. VEGF expression level and its relationship to tumor parameters, patients’ liver function profile, and patients’ clinical parameters were also investigated.ResultsPlasma VEGF levels in the HCC group were significantly higher than those of the non-HCC group, and both groups had significantly higher plasma VEGF levels than did the control group. Liver tissue VEGF expression was significantly higher in the HCC group than in the non-HCC group and positively correlated with plasma VEGF in the HCC group. The plasma VEGF levels were positively correlated with patients’ age, aspartate aminotransferase levels, serum alpha-fetoprotein levels, the presence of portal vein thrombosis, and the number of hepatic focal lesions in the HCC group. However, plasma VEGF levels were not significantly correlated with the Child-Pugh score, alanine aminotransferase levels, the size of focal lesions, and Okuda stage. Using both the VEGF and alpha-fetoprotein levels to detect HCC maximizes the sensitivity and specificity.ConclusionPlasma levels of VEGF may be a useful diagnostic and prognostic marker for HCC in patients who have been diagnosed with CHC.

Presence of portal vein thrombosis in liver cirrhosis is strongly associated with low levels of ADAMTS-13: a pilot study.

Portal vein thrombosis (PVT) dramatically changes the prognosis of cirrhotic patients, especially those waiting for liver transplantation. However, the possible contribution to PVT of von Willebrand factor (VWF) and ADAMTS-13 is poorly documented. The aim of our study was to assess the presence of alterations of VWF and ADAMTS-13 serum levels in cirrhotic patients with PVT. Twenty-four patients with PVT (group PVT) and 60 without PVT (group without PVT) were enrolled. A comprehensive analysis of biochemical and hemostatic parameters was performed. ADAMTS-13 activity was significantly lower in group A (median 16.8 vs. 69.1%, p=0.0047). Group PVT, compared to group without PVT, showed a significantly higher VWF:act, (median 308.4 vs 203.3%, p=0.032), whereas no difference was observed for VWF:Ag, FVIII level and the presence of risk factors for venous thromboembolism. No correlation was found between the Child-Pugh score and ADAMTS-13 activity. In multivariable logistic regression analysis performed on data concerning both group PVT and without PVT, only the ADAMTS-13 activity (p=0.007) was independently and inversely associated with PVT. In conclusion, ADAMTS-13 activity is independently associated with PVT in cirrhotic patients.

Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Technical Considerations

Portal vein thrombosis (PVT) is common in cirrhotic patients and presents a challenge at the time of transplant. Owing to the increased posttransplant morbidity and mortality associated with complete PVT, the presence of PVT is a relative contraindication to liver transplantation at many centers. Our group began performing portal vein (PV) recanalization and transjugular intrahepatic portostystemic shunt placement (PVR-TIPS) several years ago to optimize the transplant candidacy of patients with PVT. The procedure has evolved to include transsplenic access to assist with recanalization, which is now our preferred method due to its technical success without significant added morbidity. Here, we describe in detail our approach to PVR-TIPS with a focus on the transsplenic method. The procedure was attempted in 61 patients and was technically successful in 60 patients (98%). After transitioning to transsplenic access to assist with recanalization, the technical success rate has improved to 100%. The recanalized portal vein and TIPS have maintained patency during follow-up, or to the time of transplant, in 55 patients (92%) with a mean follow-up of 16.7 months. In total, 23 patients (38%) have undergone transplant, all of whom received a physiologic anastomosis (end-to-end anastomosis in 22 of 23 patients, 96%). PVR-TIPS placement should be considered as an option for patients with chronic PVT in need of transplantation. Transsplenic access makes the procedure technically straightforward and should be considered as the primary method for recanalization.

Prevalence and outcome of portal thrombosis in a cohort of cirrhotic patients undergoing liver transplantation.

The prevalence of portal vein thrombosis (PVT) in patients that have undergone liver transplantation (LT) is 9.7% (SD 4.5). The aim of our study was to determine the prevalence, assess the factors that are associated with PVT and clarify their association with prognosis in patients with liver cirrhosis (LC) and LT. From 2005 to 2014, laboratory, radiological and surgical data were collected from patients with LC in our center who had undergone LT for the first time. One hundred and ninety-one patients were included. The mean age was 55 (SD 9), 75.4% of patients were male and 48.7% had HCV. The Child-Pugh scores were A/B/C 41.9%/35.9%/25.5% and the MELD score was 15 (SD 6). Previous decompensations were: ascites (61.4%), hepatic encephalopathy (34.4%), variceal bleeding (25.4%), hepatocellular carcinoma (48.9%) and spontaneous bacterial peritonitis (SPB) (14.3%). The mean post-transplant follow-up was 42 months (0-113). PVT was diagnosed at LT in 18 patients (9.4%). Six patients were previously diagnosed using imaging tests (33.3%): 2 patients (11.1%) by DU and 4 patients (22.2%) by CT scan. All patients with PVT had DU in a mean time of 6 months before LT (0-44) and 90 patients (47.1%) had a CT scan in a median time of 6 months before LT (0-45). PVT was significantly related to the presence of SBP (33.3% vs 12.6%; p = 0.02) and lower levels of albumin (3.1g/dl vs 3.4g/dl; p = 0.05). MELD was higher in patients with PVT (16.6 vs 14.9; p = 0.3). There were no significant differences with regard to the need for transfusion of blood components. Moreover, the surgery time was similar in both groups. PVT correlated with a higher mortality in the first 30 days (8.8% vs 16.7%; p = 0.2). Prior history of SBP and lower levels of albumin were identified as factors associated with PVT. The pre-transplant diagnosis rate is very low and the presence of PVT may have implications for short-term mortality.

Predicting Prognosis in Hepatocellular Carcinoma: Comparison of Staging Systems in Pakistani Cohort.

To determine the clinical, biochemical and radiological prognostic indicators and to compare the performance of six staging systems in patients of hepatocellular carcinoma (HCC). Descriptive study. Department of Gastroenterology, Doctors Hospital, Lahore, from October 2007 to December 2013. Patients with HCC were included. Baseline clinical, hematological and radiological variables were noted. Patients were followed for 5 years or till death. Survival predictors were identified using Cox proportional hazard analysis and 6 prognostic staging systems were evaluated by determining homogeneity, discriminatory ability and monotonicity. Of the 228 patients included, male to female ratio was 2.6/1 (165/63) and mean age was 56.5 ±10.4 years. Majority of patients 189 (82.9%) were anti-HCV positive. Solitary HCC lesion was seen in 121 (53.1%) patients, 16 (7%) had 2 lesions while 73 (32%) had 3 or more lesions. Only 36 (15.8%) patients had palliative therapy for HCC. Survival rate was 45.2%, 25%, 12.3%, 7%, 2.2% and 1% for 6 months, 1, 2, 3, 4 and 5 years respectively. Male gender, portal vein thrombosis, serum albumin < 3.5 g/dl, tumor size ≥6 cm and alpha fetoprotein (AFP) ≥147 U/ml were bad prognostic indicators. OKUDA, GRETCH and early stages of CLIP had better homogeneity while CLIP showed superior discriminatory ability and monotonicity for predicting survival. Male gender, presence of portal vein thrombosis, low serum albumin, large tumor size and high AFP level are poor prognostic indicators in patients of HCC. CLIP has better performance in predicting mortality.

Procoagulant imbalance aggravated with falling liver function reserve, but not associated with the presence of portal vein thrombosis in cirrhosis

Hypercoagulability, hemodynamic changes, and endothelial injury are the three major contributors to the development of thrombosis. However, the role of hypercoagulability in portal vein thrombosis (PVT) in liver cirrhosis is still controversial. The aim of this study is to elucidate the relationship between procoagulant imbalance and PVT in patients with liver cirrhosis. This study included 151 patients with cirrhosis with (n=20) or without PVT (n=131). Levels of procoagulant factor (FVIII) and anticoagulants [protein C (PC), protein S (PS), and antithrombin (AT)] were measured. Procoagulant imbalance was also evaluated using a thrombin generation test with/without Protac and the results were expressed as Protac-induced coagulation inhibition percentage (PICI%). The lower the PICI% value, the greater the procoagulant imbalance. The levels of PC (P<0.001), PS (P<0.05), and AT (P<0.001) decreased progressively from Child-Pugh A to C in all patients, whereas the levels of FVIII did not alter with the severity of cirrhosis (P>0.05), which indicated the balance tilting toward procoagulation in liver cirrhosis. Similarly, the PICI% values decreased from Child-Pugh A to C (P<0.001). However, there were no differences in the levels of PC, PS, AT, FVIII or PICI% between patients with and without PVT (P>0.05), even after stratification by Child-Pugh classification (P>0.05). Procoagulant imbalance is not associated with the presence of PVT in patients with cirrhosis, although the imbalance worsens with the severity of cirrhosis.

Association between portal vein thrombosis and risk of bleeding in liver cirrhosis: A systematic review of the literature

A systematic review of the literature was conducted to explore the association of portal vein thrombosis (PVT) with the risk of bleeding in liver cirrhosis. PubMed, EMBASE, and Cochrane library databases were searched for all relevant papers, which compared the prevalence of bleeding at baseline and/or incidence of bleeding during follow-up between cirrhotic patients with and without PVT. Eighteen papers were eligible for this systematic review. The heterogeneity among studies was marked with regards to the treatment modalities, sources of bleeding, lengths of follow-up, and ways of data expression. But most of their findings were homozygous and suggested that the cirrhotic patients with PVT were more likely to have previous histories of bleeding at their admission and to develop de novo bleeding and/or rebleeding during the short- and long-term follow-up. The association of PVT with the risk of bleeding might be weakened in the multivariate analyses. Additionally, as for the cirrhotic patients with gastric variceal bleeding treated with medical/endoscopic therapy, the association of PVT with the risk of rebleeding remained controversial in 2 studies; as for the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunts for the management of variceal bleeding, a pre-existing PVT was not associated with the risk of rebleeding. Based on a systematic review of the literature, there was a positive association between the presence of PVT and risk of bleeding in liver cirrhosis in most of clinical conditions. However, whether PVT aggravated the development of bleeding during follow-up needed to be further explored.

Outcomes of emergent embolisation of ruptured hepatocellular carcinoma in a western population

To evaluate the authors' experience with interventional radiological management of tumour rupture in hepatocellular carcinoma (HCC) in a Western population. A retrospective review was performed of all consecutive patients treated at a single institution with transcatheter embolisation for ruptured HCC between 2000 and 2013. Patient age, sex, aetiology of liver disease, degree of underlying liver dysfunction, and clinical presentation were assessed. Embolisation was performed in a selective fashion when possible. Success, complications, and survival were assessed. Twenty-three patients were treated with embolisation for ruptured HCC. Of these patients, nine, nine, and five patients were Child-Pugh Class A, B, and C respectively. Embolisation was successful in 22 patients; one patient remained haemodynamically unstable and transfusion dependent despite embolisation. No major complications occurred. Median survival time was 260 days and the 30 day and 1 year survival rates were 83% and 45%, respectively. Child-Pugh class B or C (p = 0.04), Model for End-Stage Liver Disease score greater than 10 (p = 0.04), lobar embolisation (p = 0.04), and presence of portal vein thrombosis (p = 0.01) were significantly associated with worse prognosis. Transcatheter embolisation is effective at controlling haemorrhage in patients with ruptured HCC. Although major procedural complications are low, embolisation should proceed with an understanding of poor prognosis in patients with decompensated liver disease. Superselective embolisation is associated with improved prognosis and should be performed when feasible.

Su1018 The Role of Anticoagulation for Portal Vein Thrombosis Prior to Orthotopic Liver Transplantation

Portal vein thrombosis (PVT) is common complication in the setting of end stage liver disease. The presence of PVT in the setting of orthotopic liver transplantation (OLT) can be associated with the need for additional anastomoses and potentially reduced survival. The goal of anticoagulation is to achieve partial recanalization to allow end-to-end portal vein anastomosis. Our AIM was to determine the impact of anticoagulation for PVT when indicated on recanalization of the portal vein at the time of OLT and on post OLT outcomes. Methods : This is a single center retrospective study of all patients who underwent OLT who were previously diagnosed with PVT between March 2011 and July 2014. The study included all patients over age 18 with PVT diagnosed by CT or MRI and who subsequently underwent OLT. Data abstracted included demographic data, anatomic extent of PVT, presence/type of anticoagulation, effect on PVT, complications of anticoagulation, and outcomes after transplant including use of jump graft and survival. PVT was classified as occlusive or non-occlusive involving portal vein with or without extension. The decision to anticoagulate was made by a multidisciplinary team at selection conference. Results: 43/333 (13%) patients were diagnosed with PVT before OLT by axial imaging. Median age was 59 years (IQR= 52-63), 27/43 male, median BMI 28 (IQR= 25.7-33), median MELD score 20 (IQR= 17-25). PVT was diagnosed at median of 338 days prior to OLT. In 30/43 patients anticoagulation was initiated (27 warfarin, 3 enoxaparin) prior to OLT for median duration of 9 months (IQR 5 17). The median time to demonstrated improvement or resolution of PVT was 5 months (IQR 37.2). 19/30(63%) of anticoagulated patients achieved partial to full PVT resolution at time of OLT compared to 8/14 patients (57%) in whom no anticoagulation was initiated. 3 patients with partial or full resolution of PVT had recurrent thrombosis post OLT. 3 patients required jump grafts due to thrombosis. In the entire PVT cohort, there were 5 deaths post OLT (2 no anticoagulation, 1 warfarin, 2 enoxaparin). 1 month survival (no anti-coagulation 86% ;warfarin 100%;enoxaparin 67%), 6 month survival (no anti-coagulation 86% ;warfarin 96%%;enoxaparin 33%)and 1 year survival (no anti-coagulation 85% ;warfarin 94%;enoxaparin 0%) were superior in the warfarin treated group compared to enoxaparin or no anticoagulation (p<0.05). Bleeding complications were rare with no difference noted between the anticoagulated and non-anticoagulated groups. Conclusion: Anticoagulation for PVT prior to OLT is safe, and lead to partial or complete resolution in 19/30 patients. Improved survival was noted in the PVT cohort who received anticoagulation with warfarin prior to OLT. Data collection is ongoing to better refine which PVT patients derive benefit with this strategy.

The Presence of Portal Vein Thrombosis Alters the Classic Enhancement Associated with Diagnosis of Hepatocellular Carcinoma.

To determine whether the presence of portal vein thrombosis (PVT) where venous flow within the liver may be altered may delay the diagnosis of HCC and be associated with more advanced disease. We characterized the incidence and imaging characteristics of patients diagnosed with hepatocellular carcinoma in a cohort of patients with PVT compared with those without PVT. This is a single-center retrospective study of a subset of HCC patients who underwent dynamic imaging for HCC screening and were found to have PVT. Data abstracted included demographic data, TNM stage, number/type of scans, AFP level, MELD score, and time to diagnosis. Eighty-two patients newly diagnosed with HCC on screening were reviewed, of which 37 % (30/82) were found to have portal vein thrombosis. Patients with PVT had higher rates of atypical imaging associated with HCC compared with those without PVT (83 vs 56 %, p = 0.01) and had lower rates of portal venous washout (23 % vs 50 %, p = 0.018). Patients with PVT and HCC were also diagnosed at later TNM stage than those without PVT (70 vs 23 %, p < 0.001) and were significantly less likely to receive orthotopic liver transplant (3.6 vs 42 %, p < 0.001). Fourteen patients had preexisting PV clot without HCC; 16 developed PVT during screening or at diagnosis. Those with preexisting PVT were older (63. vs 55 years) and had higher rates of diagnosis of HCC using MRI (79 vs 21 % with CT, p = 0.01), compared with those without preexisting PVT. The presence of PVT found on dynamic imaging was associated with advanced stage of HCC at the time of diagnosis. Clinicians should have a high suspicion for HCC diagnosis in new liver lesions with atypical enhancement in the setting of PVT. In this setting, MRI was more frequently associated with HCC diagnosis.

Transarterial chemoembolization in unresectable hepatocellular carcinoma--assessing the factors affecting the survival: An audit from a tertiary care center in northern India.

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and third most common cause of cancer-related mortality. According to Barcelona Clinic Liver Cancer (BCLC) staging system, transarterial chemoembolization (TACE) is considered a recommended option for intermediate HCC. The purposes of our study were to evaluate the various factors affecting the outcome of TACE, to study the efficacy of TACE by evaluating the imaging response by European Association for the Study of the Liver (EASL) necrosis criteria, and to study the survival of patients. Fifty-three patients (M = 48, F = 5) with unresectable HCC and treated with TACE were included in our study. Baseline laboratory and imaging characteristics were obtained. Clinical and laboratory toxicities were assessed. EASL necrosis response criteria were used to determine imaging response. Survival from the time of the first chemoembolization treatment was calculated. Univariate, multivariate, and survival analyses were performed using Kaplan-Meier estimations. A total of 53 patients underwent chemoembolization. Median age was 63 years (range 21-81 years). Thirty-one patients (58.4 %) belonged to Child-Pugh class A, while 22 patients belonged to Child-Pugh class B. Thirty-five patients died during the study period. Median study period was 13 months. Overall survival rate at 1 year was 62.26 %. Prognostic factors found to be significant on multivariate analysis were Child-Pugh class, presence of metastasis, and initial tumor size, while on univariate analysis, portal vein thrombosis, EASL response, and baseline AFP levels were also significant. Chemoembolization was an effective and safe treatment in Child A and early Child B patients. Factors that had adverse effect on survival were Child class B, larger tumor size, presence of portal vein thrombosis and metastasis, and high baseline alpha-fetoprotein levels.

Safety and effectiveness of renoportal bypass in patients with complete portal vein thrombosis: an analysis of 10 patients.

The presence of portal vein thrombosis (PVT) is still considered by many transplantation centers to be an absolute contraindication to liver transplantation because of the technical difficulties that it can present and its association with a higher rate of patient morbidity and mortality. Renoportal bypass (RPB) can help to remove these barriers. This study describes our institution's experience with RPB through the description of a new and successful simplified surgical strategy, a patient and graft outcome analysis, intraoperative vascular flow measurements, and the use of splenic artery embolization (SAE) as an effective adjunct for treating sporadic cases of unrelieved portal hypertension. Between January 2004 and January 2013, 10 patients with grade 4 PVT underwent RPB. At the last follow-up (42.2 ± 21.1 months), the patient and graft survival rates were 100%. Five patients (50%) experienced posttransplant ascites, and 2 of those underwent proximal SAE to modulate the liver inflow and overcome the ascites. Three patients (30%) experienced transient kidney injury in the early posttransplant period and were treated efficiently with medical therapy. The renoportal flows were close to the desirable 100 mL/100 g of liver tissue in all cases. The experience and data support RPB as a feasible and easily reproducible technique without the risks and technical challenges associated with the tedious dissection of a cavernous hilum.

A tertiary cancer center experience with yttrium-90 radioembolization in hepatocellular carcinoma.

443 Background: Local-regional radioembolization with Yitrium-90 (Y-90) has become standard practice for patients with hepatocellular carcinoma (HCC) either as a bridge to transplant, or for local disease control. Outcomes data in the United States are limited and here we review our institutional experience with Y-90 radioembolization. Methods: We retrospectively reviewed charts from 70 patients with HCC who were treated with Y-90 from May 2010- January 2014. Clinical variables including Child-Pugh class and CLIP score were extracted from patient records. The Cox proportional hazards model was used to determine prognostic factors, and Kaplan-Meier curves were used to determine PFS and OS. Results: Median age was 61 (range 43-82), 79% Caucasian, 84% male, and 79% Child-Pugh class A. Median progression free survival (PFS) was 8.4 months (95% CI 6-10.7) and overall survival (OS) was 14.2 months (95% CI 9.7-21). Overall survival significantly differed by Child -Pugh score (p= 0.009), CLIP score (p=0.003), and presence of portal vein thrombosis (PVT) (p=0.0384), based on the log-rank test comparing Kaplan-Meier curves. Using univariate Cox proportional hazards models, both elevated baseline AFP, measured on a log scale (HR 1.79, 95% CI 1.32-2.43, p=0.0002) and post Y-90 treatment with sorafenib (HR=2.30, 95% CI 1.07-4.95, p=0.03) were associated with worse mortality. Elevated AFP (HR 2.45, 95% CI 1.73-3.47, p&lt;0.0001) and Child-Pugh score of B (HR 4.83, 95% CI 2.23-10.43, p&lt;0.0001) were associated with worse mortality in a multivariate Cox model adjusting for age and ethnicity. Furthermore, AFP values were significantly higher in the 10 patients who died within 4 months of Y-90 (p=0.001), and significantly lower in 7 patients who eventually received a liver transplant (p=0.0002). Conclusions: In patients undergoing treatment with Y-90 radioembolization, Child-Pugh class, CLIP score, presence of PVT, baseline AFP, and sorafenib post Y-90 were significantly associated with overall survival. Median PFS and OS data in this institutional cohort are encouraging. Further prospective studies on Y-90 treatment for HCC are warranted.

Association between Portal Vein Thrombosis and Survival in Non-Liver-Transplant Patients with Liver Cirrhosis: A Systematic Review of the Literature.

A systematic review of the literature was performed to analyze the association between portal vein thrombosis (PVT) and survival in non-liver-transplant patients with liver cirrhosis. PubMed, EMBASE, and Cochrane Library databases were searched for all relevant papers which evaluated the prognostic value of PVT in predicting the survival of liver cirrhosis. Meta-analyses were not conducted because the ways of data expression and lengths of follow-up were heterogeneous among studies. Overall, 13 papers were included. The 5-day, 6-week, and 1-year mortality were investigated in 1, 3, and 1 studies, respectively; and all of them were not significantly different between cirrhotic patient with and without PVT. By comparison, the 3-year mortality was reported in 1 study; and it was significantly increased by the presence of PVT. The overall mortality was analyzed in 5 studies; and the association with overall mortality and PVT was significant in 4 studies, but not in another one. However, as for the cirrhotic patients undergoing surgical or interventional shunts, the overall mortality was not significantly associated with the presence of PVT in 4 studies. In conclusion, the presence of PVT might be associated with the long-term mortality in non-liver-transplant patients with liver cirrhosis, but not with the short-term mortality.

Portal vein thrombosis.

Portal vein thrombosis (PVT) is the blockage or narrowing of the portal vein by a thrombus. It is relatively rare and has been linked with the presence of an underlying liver disease or prothrombotic disorders. We present a case of a young male who presented with vague abdominal symptoms for approximately one week. Imaging revealed the presence of multiple nonocclusive thrombi involving the right portal vein, the splenic vein, and the left renal vein, as well as complete occlusion of the left portal vein and the superior mesenteric vein. We discuss pathogenesis, clinical presentation, and management of both acute and chronic thrombosis. The presence of PVT should be considered as a clue for prothrombotic disorders, liver disease, and other local and general factors that must be carefully investigated. It is hoped that this case report will help increase awareness of the complexity associated with portal vein thrombosis among the medical community.

PAI-1 4G-4G and MTHFR 677TT in non-hepatitis C virus/hepatitis B virus-related liver cirrhosis.

To evaluate the different roles of thrombophilia in patients with and without viral etiology. The thrombophilic genetic factors (THRGFs), PAI-1 4G-4G, MTHFR 677TT, V Leiden 506Q and prothrombin 20210A, were studied as risk factors in 1079 patients with liver cirrhosis (LC), enrolled from January 2000 to January 2014. All Caucasian LC patients consecutively observed in a fourteen-year period were included; the presence of portal vein thrombosis (PVT) and Budd Chiari syndrome (BCS) was registered. The differences between the proportions of each THRGF with regard to the presence or absence of viral etiology and the frequencies of the THRGF genotypes with those predicted in a population by the Hardy-Weinberg equilibrium were registered. Four hundred and seventeen/one thousand and seventy-six patients (38.6%) showed thrombophilia: 217 PAI-1 4G-4G, 176 MTHFR C677TT, 71 V Leiden factor and 41 prothrombin G20210 A, 84 with more than 1 THRGF; 350 presented with no viral liver cirrhosis (NVLC) and 729 with, called viral liver cirrhosis (VLC), of whom 56 patients were hepatitis C virus + hepatitis B virus. PAI-1 4G-4G, MTHFR C677TT, the presence of at least one TRHGF and the presence of > 1 THRGF, were statistically more frequent in patients with NVLC vs patients with VLC: All χ (2) > 3.85 and P < 0.05. Patients with PVT and/or BCS with at least one TRHGF were 189/352 (53.7%). The Hardy-Weinberg of PAI-1 and MTHFR 677 genotypes deviated from that expected from a population in equilibrium in patients with NVLC (respectively χ (2) = 39.3; P < 0.000 and χ (2) = 27.94; P < 0.05), whereas the equilibrium was respected in VLC. MTHFR 677TT was nearly twofold and PAI-1 4G-4G more than threefold more frequently found in NVLC vs patients with VLC; the Hardy-Weinberg equilibrium of these two polymorphisms confirms this data in NVLC. We suggest that PAI-1 4G-4G and MTHFR 677TT could be considered as factors of fibrosis and thrombosis mechanisms, increasing the inflammation response, and causing the hepatic fibrosis and augmented intrahepatic vascular resistance typical of LC. PAI-1 4G-4G and MTHFR 677TT screening of LC patients could be useful, mainly in those with NVLC, to identify patients in which new drug therapies based on the attenuation of the hepatic stellate cells activation or other mechanisms could be more easily evaluated.

Méningite néonatale à streptocoque A et thrombose porte : une association fortuite ?

Invasive group A streptococcal infections are potentially serious. The occurrence in the neonatal period and meningeal location are two unusual situations. The complications reported in the literature vary; we add the risk of thromboembolic events. We report the case of a newborn, admitted to our department at 22 days of life for late neonatal group A streptococcal meningitis and diffuse cerebral infarction lesions. Ultrasound and abdominal CT scan objectified the presence of portal vein thrombosis and cavernoma. Echocardiography, electrocardiogram, as well as coagulation and thrombophilia tests were normal. Progression was marked by the installation of cerebral atrophy and ventricular dilation without the appearance of signs of portal hypertension over 18 months. We therefore concluded in neonatal group A streptococcal meningitis complicated by multiple thrombosis that can be explained by the invasive properties and hypercoagulability characterizing group A beta-hemolytic streptococcus. However, the characteristics of the fetal circulation may explain the possibility of paradoxical cerebral embolism from portal thrombosis.

Beneficio sobre la supervivencia con las técnicas intraarteriales en el carcinoma hepatocelular

The two intraarterial techniques used in the treatment of hepatocellular carcinoma (HCC) are the transarterial chemoembolization (TACE) and radioembolization (RE). TACE includes various procedures whose objective is to expose tumor cells to a chemotherapy agent and induce acute ischemia in the tumor. The survival benefit obtained by adding a chemotherapy agent or lipiodol to simple particle embolization has not been demonstrated in 2 meta-analyses, which suggests that the antitumor effect is primarily ischemic. RE is a form of brachytherapy that consists of an intraarterial injection of microspheres loaded with yttrium 90 as the source of radiation, a pure beta emitter with a mean tissue penetration of 2mm. TACE is performed in several sessions every 4–8 weeks, while RE is generally a single procedure. The guidelines adopted by the main research societies support the use of TACE for the palliative treatment of patients with intermediate stage HCC. This is a level 1 recommendation based on the positive results of 2 randomized clinical trials and 3 meta-analyses and on several uncontrolled studies with thousands of patients with unresectable HCC. Survival in clinical practice studies is heterogeneous due to the heterogeneity of the treated population. The survival rate varies from 8% to 26% at 5 years, and the median is 16–40 months in the early stage and 15–27 months in the intermediate stage. TACE with drug-eluting beads (DEB-TACE) has not shown superiority versus conventional TACE in terms of improved survival or tumor response, but it decreases the severe chemotherapy-related adverse events. One of its advantages is the standardization of the procedure, while its primary disadvantage is the onset of biliary complications when used nonselectively. There is level 2 evidence to support the use of RE in HCC, evidence that comes from patient cohorts with consistent results and case-control studies. The treated population includes mainly patients with unresectable tumors, who are considered suboptimal candidates for TACE or are progressing toward this condition, and those for whom TACE was directly contraindicated by the presence of portal vein thrombosis. Consequently, these patients tend to have large or extensively bilobar tumors and other factors for a poor prognosis. The overall survival reported for patients in the intermediate and advanced stages is 16–18 months and 7–17 months, respectively. A number of retrospective studies have reported comparable survival for patients treated with TACE and RE in the same institution; however, these results should be interpreted as a generator of ideas and not as an equivalent efficacy test. Although the combination of systemic agents such as sorafenib with intraarterial techniques is attractive, the results to date are not encouraging. In the only available randomized trial that compared the combination of a continuous regimen of sorafenib started before the first session of DEB-TACE versus DEB-TACE alone, neither the time to progression nor the overall survival were significantly different between the 2 groups. TACE and RE are contraindicated in cases of decompensated cirrhosis. TACE is also contraindicated for patients with considerable tumor burden in whom the procedure cannot be performed selectively and in patients with portal vein invasion.