Venous System Thrombosis Research Articles

Hepatobiliary and pancreatic manifestations in inflammatory bowel disease: an umbrella review of meta-analyses.

Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), can affect the hepatobiliary system and pancreas, substantially impacting the life quality of patients. To evaluate the quality of evidence and comprehensively assess the validity of associations of IBD with hepatobiliary and pancreatic diseases. We performed an umbrella review of existing meta-analyses in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) recommendations. We systematically searched PubMed, Embase, and Web of Science from inception to April 2024, to identify and appraise meta-analyses examining IBD and risk of hepatobiliary and pancreatic manifestations. Methodologic quality was assessed with A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) and the strength of evidence was graded according to prespecified criteria. A total of 14 meta-analyses of observational studies were included. The strongest-validity evidence suggested the significant associations between IBD and risk of gallstones (odds ratio (OR) = 1.72; 95% confidence interval (CI) = 1.40-2.12) and acute pancreatitis (OR = 3.11; 95% CI = 2.93-3.30). Highly suggestive evidence indicated a significantly increased risk of hepatobiliary cancer in UC (incidence rate ratio (IRR) = 2.05; 95% CI = 1.52-2.76) and CD (IRR = 2.31; 95% CI = 1.25-4.28). In addition, highly suggestive evidence indicated that IBD was associated with portal venous system thrombosis. Suggestive evidence showed a significantly higher prevalence of primary sclerosing cholangitis, non-alcoholic fatty liver disease, autoimmune hepatitis, and autoimmune pancreatitis in IBD patients than in the general population. The associations between IBD and multiple hepatobiliary and pancreatic disorders showed varying levels of evidence and magnitude of risk. Further high-quality primary studies are needed to identify IBD patients who are more at risk and would benefit the most from screening and prevention programs. CRD42023451461.

Rescue Transsplenic Gastric Varices Embolization in a Patient of Massive Gastric Variceal Bleed Secondary to Complete Splanchnic Portal Venous System Thrombosis

AbstractEndoscopic sclerotherapy is the first-line modality to manage gastric variceal bleeding; however, knowledge of other treatment options is also essential, especially in case of failure of the endoscopic approach. We are reporting a rare case of successful rescue gastric varices embolization through the transsplenic route in a gastric varices bleeding patient who presented with massive hematemesis and blood from the ileostomy drain site secondary to complete splanchnic portal venous system thrombosis when all other treatment options were not feasible or unsafe. Proper cross-sectional imaging evaluation, knowledge of treatment options, and understanding of intraprocedural challenges are essential for managing gastric varices.

Systemic Thrombolysis of Acute Portal Venous System Thrombosis in Patients with Liver Cirrhosis: A Pilot Study

Background The prevalence of Portal Vein Thrombosis (PVT) is highly variable at different stages of liver disease: in compensated patients 10%, in decompensated patients 17%, in acute decompensated cirrhosis 9%, and in post-liver transplantation patients 2-26%. Aim The aim of the study was to assess the efficacy and safety of systemic thrombolysis in acute portal vein thrombosis in patients with liver cirrhosis. Methods A total of 10 compensated cirrhotic patients with acute portal vein thrombosis were examined by abdominal ultrasonography with color Doppler and Contrast-enhanced computerized tomography. Continuous intravenous infusion of recombinant tissue plasminogen activator(r-tPA.) and Low molecular weight heparin (LMWH) was used to treat all patients for a maximum of 7 days. Patients were followed up for improvement of clinical symptoms and radiological by abdominal ultrasound with color Doppler and contrast-enhanced computerized tomography. Results The regimen of therapy was found to be well-tolerated by all the patients. At the end of the seven days, six patients (60%) had full recanalization of the portal vein, while three had partial recanalization (30%) and no recanalization in only one patient (10%). Conclusion The preliminary data indicate that systemic thrombolytic therapy combined with low molecular weight heparin for the treatment of PVT appears to be safe and effective over a few days with no clinically significant side effects.

403 Malignant Cerebral Venous Infarction: Decompressive Craniectomy Versus Medical Treatment

INTRODUCTION: Cerebral venous thrombosis (CVT) is a common stroke in young adults and is associated with 8% mortality. High intracranial pressure (ICP) and brain herniation are these patients' most common causes of death. METHODS: In this retrospective study, Patients with the following inclusion criteria have entered the study: 1) CVT proven by contrast-enhanced magnetic resonance venogram and/or computed tomography venogram, 2) malignant CVT (impending brain herniation according to imaging and clinical finding), and 3) age between 16 and 80 years. Patients with deep venous system thrombosis, Glasgow Coma Scale (GCS) score of 3, and bilateral nonreactive mid-position pupils or mydriasis on admission were excluded. Patients were classified into 2 groups: surgical group (DC group) including patients who received medical treatment and DC and medical group (MG) including patients who received only medical treatment. Outcomes and complications were assessed and compared between the 2 groups. RESULTS: Of 357 patients with CVT hospitalized in our center, 48 patients entered the study. 23 patients were managed medically, and 25 patients were managed surgically. There was no significant difference between the groups concerning age, sex, presenting symptoms, transient and permanent risk factors of CVT, GCS score on admission, and pupils’ reactivity on admission. All patients in the MG died during hospitalization in comparison with 8 patients in the DC group (100% vs. 32%, P < 0.001). A favorable outcome (modified Rankin scale score 0e2) was achieved in 52% of the DC group and 0% of the MG group (P < 0.001). CONCLUSIONS: Our study confirmed that in contrast with DC, medical treatment could not prevent transtentorial herniation. DC is not only lifesaving for patients with CVT with impending brain herniation but also results in favorable outcomes in most patients.

A computational model-based study on the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics.

For portal hypertensive patients with splenomegaly and hypersplenism, splenectomy is an effective surgery to relieve the complications. However, patients who have undergone splenectomy often suffer from portal venous system thrombosis, a sequela that requires prophylaxis and timely treatment to avoid deterioration and death. The aim of this study is to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics based on computational models. First, 15 portal hypertensive patients who had undergone splenectomy were enrolled, and their preoperative clinical data and postoperative follow-up results were collected. Next, computational models of the portal venous system were constructed based on the preoperative computed tomography angiography images and ultrasound-measured flow velocities. On this basis, splenectomy was mimicked and the postoperative area of low wall shear stress (ALWSS) was simulated for each patient-specific model. Finally, model-simulated ALWSS was statistically compared with the patient follow-up results to investigate the feasibility of predicting post-splenectomy thrombosis using hemodynamic metrics. Results showed that ALWSS could predict the occurrence of post-splenectomy thrombosis with the area under the receiver operating characteristic curve (AUC) equal to 0.75. Moreover, statistical analysis implied that the diameter of the splenic vein is positively correlated with ALWSS (r = 0.883, p < 0.0001), and the anatomical structures of the portal venous system also influence the ALWSS. These findings demonstrated that the computational model-based hemodynamic metric ALWSS, which is associated with the anatomorphological features of the portal venous system, is capable of predicting the occurrence of post-splenectomy thrombosis, promoting better prophylaxis and postoperative management for portal hypertensive patients receiving splenectomy.

Association of C-type lectin-like receptor 2 and galectin-1 with portal vein system thrombosis in HBV-related liver cirrhosis.

Hepatitis B virus (HBV) infection is the most common cause of liver cirrhosis. Portal venous system thrombosis (PVST) is a major complication of liver cirrhosis. Recently, it has been shown that C-type lectin-like receptor 2 (CLEC-2) and galectin-1 participate in the activation and aggregation of platelets, thereby promoting the development of thrombosis. This cross-sectional study aims to evaluate the association of serum CLEC-2 and galectin-1 levels with PVST in patients with HBV-related liver cirrhosis. Overall, 65 patients with HBV-related liver cirrhosis were included, of whom 23 had PVST and 42 did not have. Serum CLEC-2 and galectin-1 levels were measured using enzyme-linked immunosorbent assay kits. PVST was assessed by contrast-enhanced computed tomography and/or magnetic resonance imaging scans. Subgroup analyses were conducted according to the degree and location of PVST. Patients with PVST had significantly higher serum CLEC-2 (p = 0.006) and galectin-1 (p = 0.009) levels than those without. Patients with partial/complete PVST or fibrotic cord (p = 0.007; p = 0.002), but not those with mural PVST (p = 0.199; p = 0.797), had significantly higher serum CLEC-2 and galectin-1 levels than those without PVST. Patients with superior mesenteric vein thrombosis had significantly higher serum CLEC-2 (p = 0.013) and galectin-1 (p = 0.025) levels than those without PVST. Patients with main portal vein thrombosis had higher serum CLEC-2 (p = 0.020) and galectin-1 (p = 0.066) levels than those without PVST, but the difference in serum galectin-1 level was not significant between them. Serum CLEC-2 and galectin-1 levels may be associated with the presence of PVST in HBV-related cirrhotic patients, but this association should be dependent upon the degree of PVST.

Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism

To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism. Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS. Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE. The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.

A 0D-3D multi-scale model of the portal venous system coupled with the entire cardiovascular system applied to predict postsplenectomy hemodynamic metrics.

Splenectomy is a common surgery for portal hypertensive patients with splenomegaly. Although splenectomy is able to effectively relieve the complications of portal hypertension, it also increases the risk of portal venous system thrombosis remarkably. Previous studies demonstrated that the hemodynamic metrics of the portal venous system could be employed in predicting the risk of postsplenectomy thrombosis, and 3D models were utilized to simulate the blood flow in the portal venous system. Aiming to reflect the global effect of splenectomy and better simulate the hemodynamic metrics, in this study, a 0D-3D multi-scale model of the portal venous system coupled with the entire cardiovascular system was constructed based on population-averaged data in combination with patient-specific preoperative clinical measurements. The pre- and postoperative global blood flows as well as the variations were calculated successfully, and the flow field and time-averaged wall shear stress of the portal venous system were simulated. The model-simulated spatial distributions of the hemodynamic metrics in the portal venous system were comparable with the regions suffering from thrombosis after splenectomy. These results imply that the present model could reflect the reallocation of the blood flow in the splanchnic circulation after splenectomy and simulate the hemodynamic metrics of the portal venous system, which would promote the more accurate risk stratification of postsplenectomy thrombosis and improve the patient-specific postoperative management.Clinical Relevance- The computational model developed by the present study provides a feasible scheme for simulating postsplenectomy hemodynamic metrics of the portal venous system more accurately, which would benefit the risk prediction and prophylaxis of portal venous system thrombosis for portal hypertensive patients receiving splenectomy.

Nomogram-based prediction of portal vein system thrombosis formation after splenectomy in patients with hepatolenticular degeneration.

Splenectomy is a vital treatment method for hypersplenism with portal hypertension. However, portal venous system thrombosis (PVST) is a serious problem after splenectomy. Therefore, constructing an effective visual risk prediction model is important for preventing, diagnosing, and treating early PVST in hepatolenticular degeneration (HLD) surgical patients. Between January 2016 and December 2021, 309 HLD patients were selected. The data were split into a development set (215 cases from January 2016 to December 2019) and a validation set (94 cases from January 2019 to December 2021). Patients' clinical characteristics and laboratory examinations were obtained from electronic medical record system, and PVST was diagnosed using Doppler ultrasound. Univariate and multivariate logistic regression analyses were used to establish the prediction model by variables filtered by LASSO regression, and a nomogram was drawn. The area under the curve (AUC) of receiver operating characteristic (ROC) curve and Hosmer-Lemeshow goodness-of-fit test were used to evaluate the differentiation and calibration of the model. Clinical net benefit was evaluated by using decision curve analysis (DCA). The 36-month survival of PVST was studied as well. Seven predictive variables were screened out using LASSO regression analysis, including grade, POD14D-dimer (Postoperative day 14 D-dimer), POD7PLT (Postoperative day 7 platelet), PVD (portal vein diameter), PVV (portal vein velocity), PVF (portal vein flow), and SVD (splenic vein diameter). Multivariate logistic regression analysis revealed that all seven predictive variables had predictive values (P < 0.05). According to the prediction variables, the diagnosis model and predictive nomogram of PVST cases were constructed. The AUC under the ROC curve obtained from the prediction model was 0.812 (95% CI: 0.756-0.869) in the development set and 0.839 (95% CI: 0.756-0.921) in the validation set. Hosmer-Lemeshow goodness-of-fit test fitted well (P = 0.858 for development set; P = 0.137 for validation set). The nomogram model was found to be clinically useful by DCA. The 36-month survival rate of three sites of PVST was significantly different from that of one (P = 0.047) and two sites (P = 0.023). The proposed nomogram-based prediction model can predict postoperative PVST. Meanwhile, an earlier intervention should be performed on three sites of PVST.

Effects of postoperative use of proton pump inhibitors on gastrointestinal bleeding after endoscopic variceal treatment during hospitalization.

Endoscopic variceal treatment (EVT) is recommended as the mainstay choice for the management of high-risk gastroesophageal varices and acute variceal bleeding in liver cirrhosis. Proton pump inhibitors (PPIs) are widely used for various gastric acid-related diseases. However, the effects of PPIs on the development of post-EVT complications, especially gastrointestinal bleeding (GIB), remain controversial. To evaluate the effects of postoperative use of PPIs on post-EVT complications in patients with liver cirrhosis during hospitalization. Patients with a diagnosis of liver cirrhosis who were admitted to the Department of Gastroenterology of the General Hospital of Northern Theater Command, treated by an attending physician between January 2016 and June 2020 and underwent EVT during their hospitalization were included. Logistic regression analyses were performed to explore the effects of postoperative use of PPIs on the development of post-EVT complications during hospitalization. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. A total of 143 patients were included. The incidence of post-EVT GIB and other post-EVT complications was 4.90% and 46.85%, respectively. In the overall analyses, postoperative use of PPIs did not significantly reduce the risk of post-EVT GIB (OR = 0.525, 95%CI = 0.113-2.438, P = 0.411) or other post-EVT complications (OR = 0.804, 95%CI = 0.413-1.565, P = 0.522). In the subgroup analyses according to the enrollment period, type and route of PPIs after the index EVT, use of PPIs before the index EVT, use of vasoactive drugs after the index EVT, indication of EVT (prophylactic and therapeutic), and presence of portal venous system thrombosis, ascites, and hepatocellular carcinoma, the effects of postoperative use of PPIs on the risk of post-EVT GIB or other post-EVT complications remain not statistically significant. Routine use of PPIs after EVT should not be recommended in patients with liver cirrhosis for the prevention of post-EVT complications during hospitalization.

Early thrombolysis combined with anticoagulation and antibiotics for acute portal venous system thrombosis secondary to intra-abdominal infection

Early thrombolysis combined with anticoagulation and antibiotics for acute portal venous system thrombosis secondary to intra-abdominal infection

Long-Term Outcomes in Patients with Idiopathic Portal Venous System Thrombosis (PVST) in a Limited Resource Setting. Should We Do an Extensive Thrombophilia Work-up?

Introduction: Portal venous system thrombosis (PVST) typically occurs in liver cirrhosis, cancer, or intra-abdominal inflammation. Some patients do not present an etiological factor in which thrombophilia must be discarded, but an extensive thrombophilia workup in low and middle-income countries is hardly ever affordable. Therefore, this study aims to assess the long-term outcomes in patients with PVST with or without thrombophilia in a middle-income country. Methods: This is a retrospective cohort study that included all the patients with a PSVT diagnosis from January 2000 to December 2021 in a tertiary care hospital in Mexico City. Patients with cirrhosis, cancer, and intra-abdominal inflammatory conditions were excluded. We included patients without an etiological factor that had a work up of thrombophilia, including antiphospholipid syndrome (APS), JAK2 mutation, prothrombin gene mutation (G20210A), antithrombin III deficiency, paroxysmal nocturnal hemoglobinuria (PNH), protein C and protein S deficiency and Factor V Leiden. Patients were divided into 2 groups, those with thrombophilia and those with a negative thrombophilia workup (idiopathic). We assessed the clinical features and outcomes until the last follow-up in these groups and variables associated with thrombosis and bleeding. Results: A total of 80 patients were included. The median age was 39 years (31-52), and 50% were male. Thrombophilia was documented in 45 (56.2%): APS in 48.8%, JAK2 mutation in 28.8%, protein S deficiency 22%, prothrombin gene mutation (G20210A) 13%, protein C deficiency 11.1%, Factor V Leiden 4.4%, and more than one thrombophilia was found in 4 patients. 35% (28 patients) had experienced previous venous thrombosis. Thrombosis limited to the portal vein was the most frequent in both groups (thrombophilia 48.9%, idiopathic 42.9%, p=0.591), followed by porto-mesenteric involvement (thrombophilia 46.7% vs idiopathic 42.9%, p=0.734). Patients were followed-up for a median of 53.5 months (26.7-96.7). Regarding the duration of treatment 60% of patients with thrombophilia received treatment for >12 months vs. 42.9% in the idiopathic group. There were no differences regarding the type of anticoagulant received (vitamin K antagonist, low-molecular-weight heparin or direct oral anticoagulant) in patients with thrombophilia vs. the idiopathic group (42.2% vs. 36.3%, 4.4% vs. 3.8% and 24.4% vs. 27.5% respectively). The incidence of a new thrombosis was 17.8% in the thrombophilia group and 31.4% in the idiopathic group (p=0.155). Two of these were portal venous thrombosis, 10 were pulmonary embolism, 1 hepatic vein thrombosis, 2 arterial events and 2 isolated deep venous thrombosis. At diagnosis, 66.7% in the thrombophilia group had gastric or esophageal varices and 33.3% in the idiopathic group, and the prevalence at last follow-up was 97.7% in the thrombophilia group and 50.3% in the idiopathic group. A higher probability of recanalization was found in the thrombophilia group [55.3% vs 31.3%, p=0.044, OR 0.36 (0.13-0.98), CI 95%]. There were no statistically significant differences between thrombophilia and idiopathic groups regarding the prevalence of variceal bleeding (33.3% vs. 42.9%, p=0.383), or in the incidence of major bleeding (20% vs. 22.9%, p=0.757), respectively. The mortality at the last follow-up was 6.6% in the thrombophilia group and 2.8% in the idiopathic group. In the multivariate analysis, only the use of a DOAC was associated with an increased risk of thrombosis (HR 4.5 [CI 95%, 1.5-13.6]). Meanwhile, thrombocytopenia at diagnosis was associated with variceal bleeding (HR 3.9 [CI 95%, 1.2-13.0]), and the only factor associated with a decreased risk was the porto-mesenteric extension of the thrombosis (HR 0.3 [CI 95%, 0.9-1.0]). Conclusions: Clinically outcomes among patients with PSVT are not significantly different between patients with or without thrombophilia. The incidence of re-thrombosis is high in both groups; thus, some groups have suggested that long-term anticoagulation treatment will be required even in the absence of thrombophilia. Accordingly, In a limited resource setting, it could be considered to test in a priority orderingfor the antiphospholipid syndrome to determine the best anticoagulation treatment and JAK2 mutation in cases where myeloproliferative neoplasia is suspected. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Efficacy and safety of thrombolytic therapy for portal venous system thrombosis: A systematic review and meta-analysis.

The role of thrombolytic therapy in patients with portal venous system thrombosis (PVST) remains ambiguous. This study aimed to systematically collect available evidence and evaluate the efficacy and safety of thrombolysis for PVST. Eligible studies were searched via PubMed, EMBASE, and Cochrane Library databases. Among the cohort studies, meta-analyses were performed to assess the outcomes of PVST patients receiving thrombolysis. Pooled proportions were calculated. Among the case reports and case series, logistic regression analyses were performed to identify the risk factors for outcomes of PVST patients receiving thrombolysis. Odds ratios (ORs) were calculated. Among the 2134 papers initially identified, 29 cohort studies and 131 case reports or case series were included. Based on the cohort studies, the pooled rates of overall response to thrombolytic therapy, complete recanalization of PVST, bleeding events during thrombolysis, further bowel resection, thrombosis recurrence, and 30-day mortality were 93%, 58%, 18%, 3%, 1%, and 4%, respectively. Based on the case reports and case series, acute pancreatitis (OR = 0.084), history of liver transplantation (OR = 13.346), and interval between onset of symptoms and initiation of thrombolysis ≤14 days (OR = 3.105) were significantly associated with complete recanalization of PVST; acute pancreatitis (OR = 6.556) was significantly associated with further bowel resection; but no factors associated with the overall response to thrombolytic therapy, bleeding events during thrombolysis, thrombosis recurrence, and 30-day mortality were identified or could be calculated. Early initiation of thrombolysis should be effective for the treatment of PVST. But its benefits for PVST secondary to acute pancreatitis are weakened.

Impact of Asymptomatic Superior Mesenteric Vein Thrombosis on the Outcomes of Patients with Liver Cirrhosis.

The impact of asymptomatic superior mesenteric vein (SMV) thrombosis on the outcomes of cirrhotic patients remains uncertain. Nonmalignant cirrhotic patients who were consecutively admitted between December 2014 and September 2021 and underwent contrast-enhanced computed tomography/magnetic resonance imaging scans were screened. Portal venous system thrombosis (PVST) was identified. Death and hepatic decompensation were the outcomes of interest. Nelson-Aalen cumulative risk curve analysis and competing risk regression analysis were performed to evaluate the impact of asymptomatic SMV thrombosis and portal vein thrombosis (PVT) on the outcomes. Overall, 475 patients were included, of whom 67 (14.1%) had asymptomatic SMV thrombosis, 95 (20%) had PVT, and 344 (72.4%) did not have any PVST. Nelson-Aalen cumulative risk curve analyses showed that the cumulative incidences of death (p = 0.653) and hepatic decompensation (p = 0.630) were not significantly different between patients with asymptomatic SMV thrombosis and those without PVST, but the cumulative incidences of death (p = 0.021) and hepatic decompensation (p = 0.004) were significantly higher in patients with PVT than those without PVST. Competing risk regression analyses demonstrated that asymptomatic SMV thrombosis was not a significant risk factor for death (subdistribution hazard ratio [sHR] = 0.89, p = 0.65) or hepatic decompensation (sHR = 1.09, p = 0.63), but PVT was a significant risk factor for death (sHR = 1.56, p = 0.02) and hepatic decompensation (sHR = 1.50, p = 0.006). These statistical results remained in competing risk regression analyses after adjusting for age, sex, and Child-Pugh score. Asymptomatic SMV thrombosis may not influence the outcomes of cirrhotic patients. The timing of intervention for asymptomatic SMV thrombosis in liver cirrhosis should be further explored.

Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis.

Acute portal venous system thrombosis (PVST) can cause acute mesenteric ischemia and even intestinal infarction, which are potentially fatal, and requires recanalization in a timely fashion. Herein, we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation. Initially, anticoagulation with enoxaparin sodium for 4 d was ineffective, and then systemic thrombolysis for 7 d was added. After that, his abdominal pain completely disappeared, and portal vein system vessels became gradually patent. Long-term anticoagulation therapy was maintained. In conclusion, 7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.

Predicting the risk of postsplenectomy thrombosis in patients with portal hypertension using computational hemodynamics models: A proof-of-concept study

The high incidence of thrombosis in the portal venous system following splenectomy (a frequently adopted surgery for treating portal hypertension in patients with splenomegaly and hypersplenism) is a critical clinical issue. The aim of this study was to address whether quantification of postsplenectomy hemodynamics has potential value for assessing the risk of postsplenectomy thrombosis. Computational models were constructed for three portal hypertensive patients treated with splenectomy based on their preoperative clinical data to quantify hemodynamics in the portal venous system before and after splenectomy, respectively. Each patient was followed up for three or five months after surgery and examined with CT to screen potential thrombosis. The area ratio of wall regions exposed to low wall shear stress was small before splenectomy in all patients, which increased markedly after splenectomy and exhibited enlarged inter-patient differences. The largest area ratio of low wall shear stress and most severe flow stagnation after splenectomy were predicted for the patient suffering from postsplenectomy thrombosis, with the wall regions exposed to low wall shear stress corresponding well with the CT-detected distribution of thrombus. Further analyses revealed that postoperative hemodynamic characteristics were considerably influenced by the anatomorphological features of the portal venous system. Postoperative hemodynamic conditions in the portal venous system are highly patient-specific and have a potential link to postsplenectomy thrombosis, which indicates that patient-specific hemodynamic studies may serve as a complement to routine clinical assessments for refining risk stratification and postoperative patient management.

Review article: thromboelastography in liver diseases

Patients with liver diseases have complicated haemostatic alternations, resulting in both bleeding and thromboembolic complications, which cannot be sufficiently evaluated by conventional coagulation tests (CCTs), such as platelet count or prothrombin time. Thromboelastography (TEG) is a whole blood viscoelastic test which globally reflects changes in the haemostatic system, and its utility in evaluating patients with liver disease is increasingly recognised. To review the current evidence and clinical significance of TEG in liver diseases. Literature regarding TEG and liver diseases was comprehensively searched. TEG is associated closely with the severity and aetiology of liver disease, the course of infection and the risk of bleeding and death, but not the risk of portal venous system thrombosis. Additionally, TEG-guided transfusion protocols can significantly decrease the requirement for blood products compared to those guided by CCTs. TEG can reflect the haemostatic status of liver diseases more comprehensively than CCTs. It has the potential to assess the severity of liver diseases, predict the risk of bleeding and death in patients with liver disease and guide blood product transfusion. Future studies should standardise the use of TEG for assessing disease severity and development of clinical events and guiding blood product transfusion in patients with liver diseases.

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.

Association of endoscopic variceal treatment with portal venous system thrombosis in liver cirrhosis: a case-control study.

Background:The association of endoscopic variceal treatment (EVT) with portal venous system thrombosis (PVST) in liver cirrhosis is still unclear.Methods:PVST was assessed by contrast-enhanced CT or MRI in 406 cirrhotic patients from our prospective database. Case and control groups, which are defined as patients with and without PVST, respectively, were matched at a ratio of 1:1 according to age, gender, Child-Pugh class, and MELD score. History of EVT was reviewed. Logistic regression analysis was used to identify the risk factors for PVST. Odds ratios (ORs) were calculated. Subgroup analyses were further performed in terms of degree and location of PVST.Results:Overall, 109 patients each were included in case and control groups. The case group had a significantly higher proportion of patients who had undergone EVT than the control group (53.2% versus 18.3%; p < 0.001). In detail, the case group had significantly higher proportions of patients who had undergone EVT for controlling bleeding (45.9% versus 14.7%; p < 0.001), endoscopic variceal ligation (EVL) alone (19.3% versus 9.2%; p = 0.033), and EVL combined with endoscopic cyanoacrylate glue injection (24.8% versus 5.5%; p < 0.001). EVT was independently associated with PVST (OR = 4.258; p < 0.001). In subgroup analyses, EVT remained independently associated with partial PVST (OR = 10.063; p < 0.001), complete PVST/fibrotic cord (OR = 4.889; p = 0.008), thrombosis within main portal vein (OR = 5.985; p < 0.001), and thrombosis within superior mesenteric and splenic veins (OR = 5.747; p < 0.001).Conclusions:EVT may lead to a higher risk of PVST, especially more severe PVST, in liver cirrhosis. Screening for and prophylaxis of PVST after EVT should be further explored.

From the Editor’s Desk...

From the Editor’s Desk...