|
1
|
Porada M, Bułdak Ł. From Pathophysiology to Practice: Evolving Pharmacological Therapies, Clinical Complications, and Pharmacogenetic Considerations in Portal Hypertension. Metabolites 2025; 15:72. [PMID: 39997697 PMCID: PMC11857179 DOI: 10.3390/metabo15020072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 01/07/2025] [Accepted: 01/18/2025] [Indexed: 02/26/2025] Open
Abstract
Background: Portal hypertension is a major complication of chronic liver diseases, leading to serious issues such as esophageal variceal bleeding. The increase in portal vein pressure is driven by both an organic component and a functional component, including tonic contraction of hepatic stellate cells. These processes result in a pathological rise in intrahepatic vascular resistance, stemming from partial impairment of hepatic microcirculation, which is further exacerbated by abnormalities in extrahepatic vessels, including increased portal blood flow. Objectives: This review aims to provide a comprehensive overview of the evolving pharmacological therapies for portal hypertension, with consideration and discussion of pathophysiological mechanisms, clinical complications, and pharmacogenetic considerations, highlighting potential directions for future research. Methods: A review of recent literature was performed to evaluate current knowledge and potential therapeutic strategies in portal hypertension. Results: For over 35 years, non-selective beta-blockers have been the cornerstone therapy for portal hypertension by reducing portal vein inflow as an extrahepatic target, effectively preventing decompensation and variceal hemorrhages. However, since not all patients exhibit an adequate response to non-selective beta-blockers (NSBBs), and some may not tolerate NSBBs, alternative or adjunctive therapies that enhance the effects of NSBBs on portal pressure are being investigated in preclinical and early clinical studies. Conclusions: A better understanding of pharmacogenetic factors and pathophysiological mechanisms could lead to more individualized and effective treatments for portal hypertension. These insights highlight potential directions for future research.
Collapse
Affiliation(s)
- Michał Porada
- Students’ Scientific Society, Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland;
| | - Łukasz Bułdak
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| |
Collapse
|
|
2
|
Yu A, Knight GM, Boike J, Thornburg B, Salem R. Portal Vein Recanalization Transjugular Intrahepatic Portosystemic Shunt for Noncirrhotic Chronic Portal Vein Thrombosis Leading to Successful Pregnancy: Case Report. GASTRO HEP ADVANCES 2024; 4:100546. [PMID: 39790239 PMCID: PMC11713488 DOI: 10.1016/j.gastha.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 09/04/2024] [Indexed: 01/12/2025]
Abstract
Portal vein recanalization transjugular intrahepatic portosystemic shunt (PVR-TIPS) is a safe and effective procedure for decompression of portal hypertension (PH). In this short case series, 2 women with chronic noncirrhotic portal vein thrombosis were treated with PVR-TIPS. Both patients hoped to conceive. Without treatment for their PH, their pregnancies posed a significant risk of life-threatening variceal bleeding. Both patients tolerated the procedure well and delivered without complications of PH. In future cases of noncirrhotic portal vein thrombosis in patients hoping to conceive, PVR-TIPS should be considered for definitive treatment of PH.
Collapse
Affiliation(s)
- Andy Yu
- Section of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Gabriel M. Knight
- Section of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Justin Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Section of Vascular and Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| |
Collapse
|
|
3
|
Elkrief L, Hernandez-Gea V, Senzolo M, Albillos A, Baiges A, Berzigotti A, Bureau C, Murad SD, De Gottardi A, Durand F, Garcia-Pagan JC, Lisman T, Mandorfer M, McLin V, Moga L, Nery F, Northup P, Nuzzo A, Paradis V, Patch D, Payancé A, Plaforet V, Plessier A, Poisson J, Roberts L, Salem R, Sarin S, Shukla A, Toso C, Tripathi D, Valla D, Ronot M, Rautou PE. Portal vein thrombosis: diagnosis, management, and endpoints for future clinical studies. Lancet Gastroenterol Hepatol 2024; 9:859-883. [PMID: 38996577 DOI: 10.1016/s2468-1253(24)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/27/2024] [Accepted: 05/08/2024] [Indexed: 07/14/2024]
Abstract
Portal vein thrombosis (PVT) refers to the development of a non-malignant obstruction of the portal vein, its branches, its radicles, or a combination. This Review first provides a comprehensive overview of all aspects of PVT, namely the specifics of the portal venous system, the risk factors for PVT, the pathophysiology of portal hypertension in PVT, the interest in non-invasive tests, as well as therapeutic approaches including the effect of treating risk factors for PVT or cause of cirrhosis, anticoagulation, portal vein recanalisation by interventional radiology, and prevention and management of variceal bleeding in patients with PVT. Specific issues are also addressed including portal cholangiopathy, mesenteric ischaemia and intestinal necrosis, quality of life, fertility, contraception and pregnancy, and PVT in children. This Review will then present endpoints for future clinical studies in PVT, both in patients with and without cirrhosis, agreed by a large panel of experts through a Delphi consensus process. These endpoints include classification of portal vein thrombus extension, classification of PVT evolution, timing of assessment of PVT, and global endpoints for studies on PVT including clinical outcomes. These endpoints will help homogenise studies on PVT and thus facilitate reporting, comparison between studies, and validation of future studies and trials on PVT.
Collapse
Affiliation(s)
- Laure Elkrief
- Faculté de médecine de Tours, et service d'hépato-gastroentérologie, Le Centre Hospitalier Régional Universitaire de Tours, Tours, France; Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Agustin Albillos
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departamento de Gastroenterología y Hepatología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christophe Bureau
- Service d'Hépatologie Hôpital Rangueil, Université Paul Sabatier, Toulouse, France
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Andrea De Gottardi
- Gastroenterology and Hepatology Department, Ente Ospedaliero Cantonale Faculty of Biomedical Sciences of Università della Svizzera Italiana, Lugano, Switzerland
| | - François Durand
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Juan-Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Institut de Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Ton Lisman
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valérie McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Lucile Moga
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Filipe Nery
- Immuno-Physiology and Pharmacology Department, School of Medicine and Biomedical Sciences, University of Porto, Portugal
| | - Patrick Northup
- Transplant Institute and Division of Gastroenterology, NYU Langone, New York, NY, USA
| | - Alexandre Nuzzo
- Intestinal Stroke Center, Department of Gastroenterology, IBD and Intestinal Failure, AP-HP Hôpital Beaujon, Clichy, France; Laboratory for Vascular and Translational Science, INSERM UMR 1148, Paris, France
| | - Valérie Paradis
- Department of Pathology, AP-HP Hôpital Beaujon, Clichy, France
| | - David Patch
- Department of Hepatology and Liver Transplantation, Royal Free Hospital, London, UK
| | - Audrey Payancé
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | | | - Aurélie Plessier
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Johanne Poisson
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Gériatrie, Hôpital Corentin Celton (AP-HP), Paris, France
| | - Lara Roberts
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Riad Salem
- Northwestern Memorial Hospital, Northwestern University, Chicago, IL, USA
| | - Shiv Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Christian Toso
- Service de Chirurgie Viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Dhiraj Tripathi
- Department of Liver and Hepato-Pancreato-Biliary Unit, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Dominique Valla
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Maxime Ronot
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service de Radiologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Pierre-Emmanuel Rautou
- Centre de recherche sur l'inflammation, Université Paris-Cité, Paris, France; Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France.
| |
Collapse
|
|
4
|
Zhang J, Dang X, Zhang L, Li W. A pilot study of safety and efficacy comparison of low molecular heparin calcium sequential oral anticoagulants in the treatment of cirrhotic portal vein thrombosis. Eur J Gastroenterol Hepatol 2024; 36:1119-1125. [PMID: 39101441 DOI: 10.1097/meg.0000000000002787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
BACKGROUND The objective of this study is to compare and assess the efficacy and safety of low-molecular-weight heparin calcium (LMWH-Ca), followed by either warfarin or rivaroxaban, as treatment options for portal vein thrombosis (PVT) in patients with cirrhosis. METHODS In this pilot study, cirrhotic (with liver function score of Child-Pugh A) patients diagnosed with PVT who were not on anticoagulant therapy received 2 weeks of subcutaneous injections of LMWH-Ca. They were then randomized to either warfarin (a full course of oral warfarin for 6 months) or rivaroxaban (a full course of oral rivaroxaban for 2 months), with 30 cases in each group. After a treatment period of up to 6 months, a comparative analysis was performed to assess the efficacy and safety of both groups. Volumetric changes in PVT were monitored dynamically using enhanced computed tomography scans before treatment at week 2 and month 6. RESULTS There were no statistically significant differences in the clinical characteristics of the patients between the two groups. Rivaroxaban treatment reduced PVT median volume from 1.83 cm3 at week 2 to 0.0 cm3 at month 6 and prevented the worsening of PVT after 6 months of treatment with LMWH-Ca (P < 0.001). On the other hand, warfarin treatment increased PVT median volume from 1.95 cm3 at week 2 to 3.78 cm3 at month 6 (P = 0.002). None of the 30 patients in the rivaroxaban group had clinically significant gastrointestinal bleeding, while 2 of the 30 patients (7%) in the warfarin group had gastrointestinal bleeding (P = 0.317). CONCLUSION Rivaroxaban followed by LMWH-Ca is an effective anticoagulant treatment strategy for PVT in cirrhosis.
Collapse
Affiliation(s)
- Jie Zhang
- Department of Hepatology, First Clinical Medical College, Shanxi Medical University, Third People's Hospital of Taiyuan City
| | - Xiaohong Dang
- Department of Gastroenterology, First Clinical Medical College, Shanxi Medical University
| | - Lijuan Zhang
- First Clinical Medical College, Shanxi Medical University, Wanbailin Branch, Imaging Centers, Taiyuan, Shanxi Province, China
| | - Wenhua Li
- Department of Hepatology, First Clinical Medical College, Shanxi Medical University, Third People's Hospital of Taiyuan City
| |
Collapse
|
|
5
|
Cazacu SM, Alexandru DO, Dumitrescu D, Vieru AM, Urhuț MC, Săndulescu LD. Prevalence and Risk Factors for Portal Cavernoma in Adult Patients with Portal Vein Thrombosis. Diagnostics (Basel) 2024; 14:1445. [PMID: 39001335 PMCID: PMC11241764 DOI: 10.3390/diagnostics14131445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
Portal vein thrombosis (PVT) represents a restriction or occlusion of the portal vein by a blood clot, which can appear in liver cirrhosis, inherited or acquired thrombophilia, malignancies, abdominal infection, abdominal inflammation, and injury to the portal vein; it can evolve to local venous extension, recanalization, or portal cavernoma (PC). This research represents an observational study of patients admitted with a diagnosis of PVT between January 2018 and December 2022. We assessed the rate of and risk factors for PC. In total, 189 patients with PVT were included; the rate of PC was 14.8%. In univariate and multivariate analysis, the main risk factors for the presence of PC were etiology (thrombophilia, myeloproliferative disorders, local inflammatory diseases, and idiopathic causes), prior PVT, and complete versus incomplete or single-branch portal obstruction. In patients with superior mesenteric vein (SMV) thrombosis, distal obstruction was more prone to PC than proximal obstruction. The main predictive factors were etiology, prior PVT, complete PVT obstruction, and no prior non-selective beta-blocker (NSBB) use; in patients with SMV thrombosis, the distal extension was more significantly associated with the risk of PC. We propose a composite score for the prediction of PC which includes etiology, prior diagnosis of PVT, prior NSBB use, complete versus incomplete PVT, and distal versus proximal SMV thrombosis, with good accuracy (AUC 0.822) and an estimated sensitivity of 76.92% and specificity of 82.39% at a cut-off value of 4.
Collapse
Affiliation(s)
- Sergiu Marian Cazacu
- Research Center of Gastroenterology and Hepatology, Gastroenterology Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349, Craiova, Romania; (S.M.C.); (L.D.S.)
| | - Dragoș Ovidiu Alexandru
- Biostatistics Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Daniela Dumitrescu
- Imaging Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Alexandru Marian Vieru
- Doctoral School, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Marinela Cristiana Urhuț
- Doctoral School, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349 Craiova, Romania;
| | - Larisa Daniela Săndulescu
- Research Center of Gastroenterology and Hepatology, Gastroenterology Department, University of Medicine and Pharmacy of Craiova, Petru Rares Street no. 2-4, 200349, Craiova, Romania; (S.M.C.); (L.D.S.)
| |
Collapse
|
|
6
|
Alotay AA. Classification and Management of Portal Vein Thrombosis in Cirrhotic Patients: A Narrative Review. Cureus 2024; 16:e65869. [PMID: 39219865 PMCID: PMC11364363 DOI: 10.7759/cureus.65869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/20/2024] [Indexed: 09/04/2024] Open
Abstract
Portal vein thrombosis (PVT) poses significant therapeutic challenges due to its complex pathophysiology and diverse clinical presentations. Recent advancements have spurred the development of new therapeutic approaches to enhance treatment efficacy and safety. This review synthesized emerging therapies for PVT based on a comprehensive literature search across major databases such as PubMed, EMBASE, and Web of Science, among others, focusing on studies published in the last decade. Anticoagulation therapy, particularly with novel oral anticoagulants (NOACs), emerged as beneficial in personalized treatment regimens. Innovative surgical techniques and improved risk stratification methods were identified as crucial in the perioperative management of PVT. Additionally, advances in cell therapy and medical treatments for hepatocellular carcinoma in the context of PVT were explored. Promising outcomes were observed with modalities such as Yttrium 90 and liver transplantation combined with thrombectomy, particularly in complex PVT cases associated with hepatocellular carcinoma, albeit on a limited scale. The reviewed literature indicates a shift towards individualized treatment approaches for PVT, integrating novel anticoagulants, refined risk assessment tools, and tailored interventional strategies. While these emerging therapies show potential for enhanced efficacy and safety, further research is essential to validate findings across broader patient populations and establish standardized treatment protocols.
Collapse
Affiliation(s)
- Abdulwahed A Alotay
- Department of Internal Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, SAU
| |
Collapse
|
|
7
|
Ghazaleh S, Chuang J, Sayeh W, Iqbal A, Beran A, Khader Y, Burmeister C, Aziz M, Assaly R, Nawras A. Comparative Efficacy of Anticoagulant Medications in Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis-A Systematic Review and Network Meta-analysis. Am J Ther 2023; 30:e591-e594. [PMID: 36927678 DOI: 10.1097/mjt.0000000000001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Sami Ghazaleh
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Justin Chuang
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Wasef Sayeh
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Amna Iqbal
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Yasmin Khader
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | | | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH
| |
Collapse
|
|
8
|
García-Villa A, Criado-Álvarez JJ, Carnevali M, Aramberri M, Font C, Díaz-Pedroche C. Cancer-associated splanchnic vein thrombosis: Clinical features upon diagnosis and short-term outcomes. Thromb Res 2023; 231:84-90. [PMID: 37832365 DOI: 10.1016/j.thromres.2023.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION The incidence of splanchnic vein thrombosis (SVT) in cancer patients has increased in recent years and its real clinical significance and management can be challenging. This study aimed to describe the clinical presentation and short-term outcomes of patients with cancer-associated SVT. MATERIAL AND METHODS This was a retrospective observational study of consecutive patients with cancer-associated SVT diagnosed during the period 2015-2020. The primary objective was to describe the clinical presentation of SVT. Patients were clinically classified into two groups based on the presence of symptoms on SVT diagnosis. The main outcomes were overall and SVT-related mortality, major and non-major bleeding rates, and the thrombosis recurrence rate in the first 30 days of follow-up. RESULTS This study enrolled 203 patients. Intra-abdominal tumors (76 %) and metastatic disease (68 %) predominated. A total of 79 (39 %) patients without symptoms were diagnosed with SVT during a scheduled radiological test and were classified as "asymptomatic", while 124 (61 %) patients presented some potential SVT symptoms and were considered as "symptomatic". Although the 30-day outcomes showed no significant differences between the two groups, mortality in the asymptomatic group was slightly lower compared to the symptomatic group (3 % vs. 10 %, p = 0.085). CONCLUSIONS Almost 40 % of cases of cancer-associated SVT are asymptomatic. There were no significant differences in short-term outcomes between the symptomatic and asymptomatic patients. More studies are required to better define long-term management and outcomes in these patients.
Collapse
Affiliation(s)
- Adrián García-Villa
- Department of Internal Medicine, Hospital Virgen del Puerto. Paraje Valcorchero S/N, 10600 Plasencia, Spain.
| | - Juan José Criado-Álvarez
- Department of Medical Sciences, Faculty of Health Sciences, Castilla-La Mancha University. Avenida Real Fábrica de Sedas S/N, 45600 Talavera de la Reina, Spain
| | - María Carnevali
- Department of Internal Medicine, Hospital Universitario 12 de Octubre. Avenida de Córdoba S/N, 28041 Madrid, Spain
| | - Mario Aramberri
- Department of Internal Medicine, Hospital de Galdakao-Usansolo. Labeaga Auzoa, 48960 Galdakao, Spain
| | - Carme Font
- Department of Medical Oncology, Hospital Clinic de Barcelona. Carrer Villarroel, 170, 08036 Barcelona, Spain
| | - Carmen Díaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre. Avenida de Córdoba S/N, 28041 Madrid, Spain
| |
Collapse
|
|
9
|
Georgescu D, Ancusa OE, Azoulay D, Lascu A, Ionita I, Calamar-Popovici D, Ionita M, Rosca CI, Brează GM, Reisz D, Lighezan D. Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong? Int J Gen Med 2023; 16:3889-3906. [PMID: 37662503 PMCID: PMC10473422 DOI: 10.2147/ijgm.s413438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC). Materials and Methods An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out. Results The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D. Conclusion Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.
Collapse
Affiliation(s)
- Doina Georgescu
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Oana-Elena Ancusa
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Azoulay
- Hepato-Biliary Center, Paul-Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Ana Lascu
- Department of Functional Sciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ioana Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Despina Calamar-Popovici
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mihai Ionita
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ciprian Ilie Rosca
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Gelu-Mihai Brează
- Department IX of Surgery I, Compartment of Hepatic-Biliary-Pancreatic Surgery, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniela Reisz
- Department of Neurosciences, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Daniel Lighezan
- Center of Advanced Researches in Cardiovascular Diseases and Hemostaseology, Department of Internal Medicine I, “V Babes” University of Medicine and Pharmacy, Timisoara, Romania
| |
Collapse
|
|
10
|
Tarar ZI, Farooq U, Kamal F, Nawaz A, Saleem S, Ghous G, Basar O, Chela HK, Tahan V, Daglilar E. Safety of anticoagulation use for treatment of portal vein thrombosis in liver cirrhosis and its effect on hospital-based outcomes: an insight from a US nationwide database. Postgrad Med J 2023; 99:715-723. [PMID: 36008113 DOI: 10.1136/pmj-2022-141915] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/10/2022] [Indexed: 11/04/2022]
Abstract
Abstract
Background and aim
Anticoagulation use for portal vein thrombosis (PVT) in patients with advanced liver disease is controversial. We investigated the effect of anticoagulation on outcomes in patients with PVT with cirrhosis.
Methods
We reviewed National Inpatient Sample data from 2016 to 2018 to identify patients with PVT. Our outcomes were in-hospital mortality, variceal bleeding, hepatic encephalopathy, acute kidney injury (AKI), hepatorenal syndrome (HRS), spontaneous bacterial peritonitis (SBP), sepsis and hospital resource utilisation.
Results
We included 60 505 patients with PVT, out of whom 6.63% (4015) were on anticoagulation. The overall mortality in the anticoagulation group was 2.12% compared with 9.72% in the no anticoagulation group. The adjusted odds of mortality were low in the anticoagulation group (adjusted OR (AOR) 0.27, 95% CI 0.15 to 0.46, p<0.001). Patients on anticoagulation had 29% lower odds of variceal bleeding (AOR 0.71, 95% CI 0.53 to 0.96, p=0.03). Lower odds of HRS (AOR 0.56, 95% CI 0.37 to 0.85, p=0.01) and AKI (AOR 0.57, 95% CI 0.48 to 0.69, p<0.001) were also seen in the anticoagulation group. Patients in the anticoagulation group also showed lower odds of SBP (AOR 0.62, 95% CI 0.43 to 0.89, p=0.01) and sepsis (AOR 0.57, 95% CI 0.35 to 0.93, p=0.03). Anticoagulation use resulted in shorter hospital stay by 1.15 days (adjusted length of stay −1.15, 95% CI −1.51 to –0.79, p<0.001). The mean difference in total hospital charges between the anticoagulation and the no anticoagulation group was −$20 034 (95% CI −$27 077 to −$12 991, p<0.001).
Conclusion
Our analysis found that anticoagulation use is safe and associated with better outcomes in patients with PVT with advanced liver disease.
Collapse
Affiliation(s)
- Zahid Ijaz Tarar
- Internal Medicine , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| | - Umer Farooq
- Internal Medicine , , Berwyn, Illinois , USA
- Loyola Medicine/MacNeal Hospital , , Berwyn, Illinois , USA
| | - Faisal Kamal
- Gastroenterology , , San Francisco, California , USA
- University of California San Francisco , , San Francisco, California , USA
| | - Ahmad Nawaz
- Internal Medicine , , New Haven, Connecticut , USA
- Yale School of Medicine , , New Haven, Connecticut , USA
| | - Saad Saleem
- Internal Medcine , , Las Vegas, Nevada , USA
- Sunrise Hospital and Medical Center , , Las Vegas, Nevada , USA
| | - Ghulam Ghous
- Internal Medicine , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| | - Omer Basar
- Gastroenterology and Hepatology , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| | - Harleen Kaur Chela
- Gastroenterology , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| | - Veysel Tahan
- Gastroenterology and Hepatology , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| | - Ebubekir Daglilar
- Gastroenterology and Hepatology , , Columbia, Missouri , USA
- University of Missouri School of Medicine , , Columbia, Missouri , USA
| |
Collapse
|
|
11
|
Barrera-Lozano LM, Ramírez-Arbeláez JA, Muñoz CL, Becerra JA, Toro LG, Ardila CM. Portal Vein Thrombosis in Liver Transplantation: A Retrospective Cohort Study. J Clin Med 2023; 12:3951. [PMID: 37373645 PMCID: PMC10299236 DOI: 10.3390/jcm12123951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/02/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Portal vein thrombosis was considered a contraindication for liver transplantation. This study analyzes the perioperative complications and survival of liver transplant patients with portal vein thrombosis (PVT). A retrospective observational cohort study of liver transplant patients was conducted. The outcomes were early mortality (30 days) and patient survival. A total of 201 liver transplant patients were identified and 34 (17%) patients with PVT were found. The most frequent extension of thrombosis was Yerdel 1 (58.8%), and a portosystemic shunt was identified in 23 (68%) patients. Eleven patients (33%) presented any early vascular complication, PVT being the most frequent (12%). The multivariate regression analysis showed a statistically significant association between PVT and early complications (OR = 3.3, 95% confidence interval 1.4-7.7; p = 0.006). Moreover, early mortality was observed in eight patients (24%), of which two (5.9%) presented Yerdel 2. For Yerdel 1, patient survival according to the extent of thrombosis was 75% at 1 year and 3 years, while for Yerdel 2, it was 65% at 1 year, and 50% at 3 years (p = 0.04). Portal vein thrombosis significantly influenced early vascular complications. Furthermore, portal vein thrombosis Yerdel 2 or higher impacts the survival of liver grafts in the short and long term.
Collapse
Affiliation(s)
- Luis Manuel Barrera-Lozano
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
- Vascular Medicine Department, Faculty of Medicine, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Jaime Alberto Ramírez-Arbeláez
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | - Cristian Leonardo Muñoz
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | | | - Luis Guillermo Toro
- Transplant Department, Hospital San Vicente Fundación, Rionegro 054047, Colombia; (L.M.B.-L.); (J.A.R.-A.); (C.L.M.); (L.G.T.)
| | - Carlos M. Ardila
- Basic Studies Department, School of Dentistry, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| |
Collapse
|
|
12
|
Mantaka A, Gatselis N, Triantos CK, Thalheimer U, Leandro G, Zachou K, Konstantakis C, Saitis A, Thomopoulos K, Kouroumalis EA, Dalekos GN, Samonakis DN. Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cοhort study. Minerva Gastroenterol (Torino) 2023; 69:107-113. [PMID: 36856274 DOI: 10.23736/s2724-5985.21.02861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a common complication of cirrhosis and can be a cause or consequence of liver disease progression. It is unclear whether PVT treatment is affecting clinical outcomes in cirrhotics. METHODS This is a multicenter study of cirrhotics with PVT, initially retrospectively and thereafter prospectively registered in a data base. We studied the impact of PVT treatment on this population for efficacy, safety and the impact on survival. In survival analysis Mantel-Cox and Wilcoxon-Breslow-Gehan tests were used. A P value of <0.05, was considered significant. For statistical computations the STATA 12.1 was used. RESULTS Seventy-six patients were included (76% decompensated, median MELD score 12 and Child-Pugh score 7), 47% with concomitant HCC. Fifty-one patients with PVT were treated with Vitamin-K antagonists or Low-Molecular-Weight Heparin. Patients were followed up for at least 6 months after PVT diagnosis, or until death or transplantation. PV patency after 6 months was not statistically different between patients receiving or not anticoagulation (complete-partial recanalization 27.4% of treated vs. 20% of untreated, P=0.21). Median survival was statistically worse between patients treated with anticoagulation than those untreated (10 vs. 15 months, P=0.036). Less portal hypertensive bleeding and less decompensation rates were found in treated cirrhotics vs. untreated (45.8% vs. 54.2%, P=0.003 and 78% vs. 80.9%, P=0.78, respectively). Patients with HCC had worse survival when treated vs. untreated (P=0.047). CONCLUSIONS In our cohort of cirrhotics with PVT, treatment was feasible with acceptable side effects, but without meaningful clinical benefits.
Collapse
Affiliation(s)
- Aikaterini Mantaka
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece -
| | - Nikolaos Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Christos K Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras, Greece
| | - Ulrich Thalheimer
- Department of Gastroenterology, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - Gioacchino Leandro
- Department of Gastroenterology, IRCCS Saverio De Bellis Hospital, Castellana Grotte, Bari, Italy
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | | | - Asterios Saitis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | | | - Elias A Kouroumalis
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Dimitrios N Samonakis
- Department of Gastroenterology & Hepatology, University Hospital of Heraklion, Heraklion, Crete, Greece
| |
Collapse
|
|
13
|
Lee S, Saffo S. Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy. World J Gastroenterol 2023; 29:61-74. [PMID: 36683719 PMCID: PMC9850948 DOI: 10.3748/wjg.v29.i1.61] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/22/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023] Open
Abstract
Cirrhosis is a leading cause of morbidity and mortality, impacting more than 120 million people worldwide. Although geographic differences exist, etiologic factors such as alcohol use disorder, chronic viral hepatitis infections, and non-alcoholic fatty liver disease are prevalent in nearly every region. Historically, significant effort has been devoted to modifying these risks to prevent disease progression. Nevertheless, more than 11% of patients with compensated cirrhosis experience hepatic decompensation each year. This transition signifies the most important prognostic factor in the natural history of the disease, corresponding to a decline in median survival to below 2 years. Over the past decade, the need for pharmacotherapies aimed at reducing the risk for hepatic decompensation has been emphasized, and non-selective beta-blockers have emerged as the most effective option to date. However, a critical therapeutic gap still exists, and additional therapies have been proposed, including statins, rifaximin, and sodium-glucose cotransporter-2 inhibitors. Based on the results of innovative retrospective analyses and small-scale prospective trials, these pharmacotherapies represent promising options, but further studies, including randomized controlled trials, are necessary before they can be incorporated into clinical use. This report highlights the potential impact of these agents and others in preventing hepatic decompensation and discusses how this paradigm shift may pave the way for guideline-directed medical therapy in cirrhosis.
Collapse
Affiliation(s)
- Seohyuk Lee
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
| | - Saad Saffo
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
| |
Collapse
|
|
14
|
Luo X, Nicoară-Farcău O, Magaz M, Betancourt F, Soy G, Baiges A, Turon F, Hernández-Gea V, García-Pagán JC. Obstruction of the liver circulation. CARDIO-HEPATOLOGY 2023:65-92. [DOI: 10.1016/b978-0-12-817394-7.00004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
15
|
Lisman T. Bleeding and thrombosis in cirrhosis. CARDIO-HEPATOLOGY 2023:165-202. [DOI: 10.1016/b978-0-12-817394-7.00010-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
16
|
La Mura V, Bitto N, Tripodi A. Rational hemostatic management in cirrhosis: from old paradigms to new clinical challenges. Expert Rev Hematol 2022; 15:1031-1044. [PMID: 36342412 DOI: 10.1080/17474086.2022.2144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with cirrhosis are at risk of both thrombotic and hemorrhagic events. Traditional hemostatic tests are inadequate to assess the complex and fragile balance of hemostasis in this setting, especially in advanced stages of disease such as decompensated cirrhosis or acute on chronic liver failure (ACLF). Furthermore, the indiscriminate use of pro-hemostatic agents for prophylaxis and treatment of bleeding episodes is still debated and often contraindicated. Alongside, splanchnic, and peripheral thrombotic events are frequent in this population and require management that involves a careful balance between risks and benefits of antithrombotic therapy. AREAS COVERED This review aims to address the state of the art on the clinical management of the hemostatic balance of cirrhosis in terms of established knowledge and future challenges. EXPERT OPINION The old paradigm of cirrhosis as a naturally anticoagulated condition has been challenged by more sophisticated global tests of hemostasis. Integrating this information in the clinical decision-making is still challenging for physicians and experts in hemostasis.
Collapse
Affiliation(s)
- Vincenzo La Mura
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli studi di Milano, Milan, Italy
| | - Armando Tripodi
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| |
Collapse
|
|
17
|
Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients. ABDOMINAL RADIOLOGY (NEW YORK) 2022; 47:3724-3732. [PMID: 35943518 DOI: 10.1007/s00261-022-03626-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent. PURPOSE The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time. MATERIAL AND METHODS This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models. RESULTS 138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60 years (interquartile range 55-67; 90 men) and median follow-up time was 19.6 months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43). CONCLUSION In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.
Collapse
|
|
18
|
Odriozola A, Puente Á, Cuadrado A, Rivas C, Anton Á, González FJ, Pellón R, Fábrega E, Crespo J, Fortea JI. Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review. J Clin Med 2022; 11:6435. [PMID: 36362663 PMCID: PMC9655000 DOI: 10.3390/jcm11216435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 08/06/2023] Open
Abstract
Portal vein thrombosis constitutes the most common thrombotic event in patients with cirrhosis, with increased rates in the setting of advanced liver disease. Despite being a well-known complication of cirrhosis, the contribution of portal vein thrombosis to hepatic decompensation and overall mortality is still a matter of debate. The incorporation of direct oral anticoagulants and new radiological techniques for portal vein recanalization have expanded our therapeutic arsenal. However, the lack of large prospective observational studies and randomized trials explain the heterogenous diagnostic and therapeutic recommendations of current guidelines. This article seeks to make a comprehensive review of the pathophysiology, clinical features, diagnosis, and treatment of portal vein thrombosis in patients with cirrhosis.
Collapse
Affiliation(s)
- Aitor Odriozola
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Coral Rivas
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Ángela Anton
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | | | - Raúl Pellón
- Radiology Department, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - José Ignacio Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| |
Collapse
|
|
19
|
DeLeeuw P, Agbim U. Pre-transplant portal vein thrombosis in non-alcoholic fatty liver disease patients-pathogenesis, risk factors, and implications on management. Transl Gastroenterol Hepatol 2022; 7:27. [PMID: 35892050 PMCID: PMC9257532 DOI: 10.21037/tgh-19-361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/20/2020] [Indexed: 02/18/2024] Open
Abstract
Along with the worldwide increase in obesity and metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) and its more severe subset, non-alcoholic steatohepatitis (NASH), are on path to become the leading cause of liver transplantation in the United States. NAFLD, as well as obesity, create an inflammatory milieu via the release of adipocytokines. In turn, the inflammatory environment can trigger an increase in prothrombotic factors. Independent of inflammation, the severity of NASH is associated with a graded increase in hypercoagulability such as an increase in factor VIII, increase in plasminogen activator inhibitor-1, and decrease in protein C. Ultimately, this environment creates an increase in thrombotic risk, leading to higher rates of pre-transplant portal vein thrombosis (PVT) in patients with NASH cirrhosis vesus other causes of cirrhosis. Many studies have shown worse outcomes in liver transplant recipients with PVT as it complicates anastomotic reconstruction which can negatively affect portal blood supply needed for adequate liver functioning. Management and treatment of PVT is not standardized, but from a pharmacologic standpoint, multiple classes of anticoagulants have shown to be successful in recanalization of the portal vein and preventing recurrence of clot with minimal bleeding complications. The increasing prevalence of NASH cirrhosis and subsequent increase in PVT require further research for improved outcomes.
Collapse
Affiliation(s)
- Peter DeLeeuw
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Uchenna Agbim
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
|
20
|
Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol 2022; 76:1291-1305. [PMID: 35589251 DOI: 10.1016/j.jhep.2021.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Patients with cirrhosis frequently acquire complex changes in their haemostatic system including a decreased platelet count and decreased levels of various haemostatic proteins. Although historically patients with cirrhosis were thought to have a haemostasis-related bleeding tendency, it is now widely accepted that the haemostatic system of patients with cirrhosis remains in balance as a result of simultaneous changes in pro- and anti-haemostatic systems. The concept of rebalanced haemostasis has led to changes in clinical management, although firm evidence from well-designed clinical studies is largely lacking. For example, many invasive procedures in patients with cirrhosis and a prolonged prothrombin time are now performed without prophylaxis with fresh frozen plasma. Conversely, clinicians have become more aware of the need for anti-thrombotic therapy, even in those patients with abnormal routine coagulation tests. This paper will outline recent advances in pathogenesis, prevention and treatment of both bleeding and thrombotic complications in patients with cirrhosis. Among other topics, we will discuss the haemostatic status of acutely ill patients with cirrhosis, the various causes of bleeding in patients with cirrhosis, and how best to prevent or treat bleeding. In addition, we will discuss the hypercoagulable features of patients with cirrhosis, new insights into the pathogenesis of portal vein thrombosis, and how best to prevent or treat thromboses.
Collapse
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
| |
Collapse
|
|
21
|
Li Z, Xu WT, Xu XB, Qi XS. Heparins for prevention and treatment of venous thromboembolism in cirrhosis: Research advances. Shijie Huaren Xiaohua Zazhi 2022; 30:381-386. [DOI: 10.11569/wcjd.v30.i9.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Zhe Li
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Wen-Tao Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Xiang-Bo Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| |
Collapse
|
|
22
|
Abstract
Patients with cirrhosis of the liver are at high risk of developing portal vein thrombosis (PVT), which has a complex, multifactorial cause. The condition may present with a myriad of symptoms and can occasionally cause severe complications. Contrast-enhanced computed tomography (CT) is the gold standard for the diagnosis of PVT. There are uncertainties regarding the effect on PVT and its treatment outcome in patients with cirrhosis. The main challenge for managing PVT in cirrhosis is analyzing the risk of hemorrhage compared to the risk of thrombus extension leading to complications. All current knowledge regarding non-tumor PVT in cirrhosis, including epidemiology, risk factors, classification, clinical presentation, diagnosis, impact on natural history, and treatment, is discussed in the present article.
Collapse
Key Words
- ACLF, acute-on-chronic liver failure
- BCS, Budd–Chiari syndrome
- DOACs, direct-acting oral anticoagulants
- EASL, European Association for the Study of the Liver
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- INR, international normalized ratio
- JAK2, Janus Kinase 2
- LMWH, low molecular weight heparin
- LT, liver transplant
- MELD, Model for End-Stage Liver Disease
- MTHFR, methyltetrahydrofolate reductase
- NASH, non-alcoholic steatohepatitis
- NO, nitric oxide
- NSBBs, non-selective beta-blockers
- PV, portal vein
- PVT, Portal vein thrombosis
- RCT, randomized controlled trial
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- SVT, splanchnic vein thrombosis
- TIPS, Transjugular intrahepatic portosystemic shunt
- UNOS, United Network for Organ Sharing
- VEGF, vascular endothelial growth factors
- VKAs, vitamin K antagonists
- VKORC1, vitamin K epoxide reductase complex 1
- anticoagulation
- cirrhosis
- eNOS, endothelial nitric oxide synthase
- non-tumoral portal vein thrombosis
- portal hypertension
- rTPA, recombinant tissue plasminogen activator
- transjugular intrahepatic portosystemic shunt
- vWF, von Willebrand factor
Collapse
Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| |
Collapse
|
|
23
|
Villa E, Bianchini M, Blasi A, Denys A, Giannini EG, de Gottardi A, Lisman T, de Raucourt E, Ripoll C, Rautou PE. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 178] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
Collapse
|
|
24
|
Sissingh NJ, Groen JV, Koole D, Klok FA, Boekestijn B, Bollen TL, van Santvoort HC, Verdonk RC, Bonsing BA, van Eijck CHJ, van Hooft JE, Mieog JSD. Therapeutic anticoagulation for splanchnic vein thrombosis in acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:235-243. [PMID: 35012902 DOI: 10.1016/j.pan.2021.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/19/2021] [Accepted: 12/17/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The optimal management of patients with acute pancreatitis (AP) and splanchnic vein thrombosis (SVT) remains unknown. This systematic review and meta-analysis aimed to see if therapeutic anticoagulation (AC) improves outcomes in patients with AP and SVT. METHODS A systematic review was performed according to PRISMA guidelines. Main outcomes were recanalization, recurrent venous thromboembolism, development of varices, collaterals or cavernoma, haemorrhage and mortality. Meta-analysis were performed with the Mantel-Haenszel random effect models. RESULTS Seven retrospective cohort studies (3495 patients) were included. SVT occurred in 233 (7%) patients and involved most frequently the splenic vein (44%). Therapeutic AC was administered to 109 (47%) patients, most frequently to those with triple vessel thrombosis (72%) and least to those with isolated splenic vein (22%) or superior mesenteric vein thrombosis (0%). Most studies administered (low molecular weight) heparin followed by warfarin (duration ranged between 1.5 and 12 months). This meta-analysis showed an absolute risk difference of 9% (95% confidence interval [CI] = -11-28%) for recanalization, -3% (95% CI = -19-12%) for the development of varices, collaterals or cavernoma, 3% (95% CI = -6-12%) for haemorrhage and 2% (95% CI = -8-12%) for mortality. CONCLUSIONS Based on the currently available data, it remains unclear if therapeutic anticoagulation provides benefit to acute pancreatitis patients with splanchnic vein thrombosis. These results are based on low quality data underlining the need for further higher quality studies.
Collapse
Affiliation(s)
- Noor J Sissingh
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands; Department of Research and Development, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Dylan Koole
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bas Boekestijn
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
|
25
|
Gadani S, Partovi S, Levitin A, Zerona N, Sengupta S, D’Amico G, Diago Uso T, Menon KVN, Quintini C. Narrative review of portal vein thrombosis in cirrhosis: pathophysiology, diagnosis, and management from an interventional radiology perspective. Cardiovasc Diagn Ther 2022; 12:135-146. [PMID: 35282661 PMCID: PMC8898691 DOI: 10.21037/cdt-21-98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 10/25/2021] [Indexed: 09/01/2023]
Abstract
OBJECTIVE This paper examines the incidence, clinical presentation, and pathophysiology of portal vein thrombosis (PVT) in cirrhosis. Additionally, we have reviewed the literature regarding the current status of medical and interventional radiology management of PVT and have proposed a novel algorithm for the management given different clinical scenarios. Lastly two representative cases displaying endovascular treatment options are provided. BACKGROUND Portal vein thrombus in the setting of cirrhosis is an increasingly recognized clinical issue with debate on its pathophysiology, natural course, and optimal treatment. Approximately one-third of patients are asymptomatic, and detection of the thrombus is an incidental finding on imaging performed for other reasons. In 30% to 50% of patients, PVT resolves spontaneously. However, there is increased post-transplant mortality in patients with completely occlusive PVT, therefore effective early revascularization strategies are needed for patients with complete PVT who are expected to undergo liver transplant. Additionally, no consensus has been reached regarding PVT treatment in terms of timing and type of interventions as well as type and duration of anticoagulation. METHODS Computerized literature search as well as discussion with experts in the field. CONCLUSIONS Management of PVT is complex, as many variables affect which treatments can be used. Anticoagulation appears to be the optimal first-line treatment in patients with acute PVT but without bleeding varices or mesenteric ischemia. Minimally invasive treatments include various methods of mechanical thrombectomy, chemical thrombolysis, and transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization. Definitive recommendations are difficult due to lack of high quality data and continued research is needed to evaluate the efficacy of different anticoagulants as well as the timing and use of various minimally invasive therapies in specific circumstances.
Collapse
Affiliation(s)
- Sameer Gadani
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sasan Partovi
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Zerona
- Imaging Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shreya Sengupta
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe D’Amico
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K. V. Narayanan Menon
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
|
26
|
Senzolo M, Zanetto A. Anticoagulation in Splanchnic Vein Thrombosis With and Without Underlying Liver Disease. PORTAL HYPERTENSION VII 2022:649-667. [DOI: 10.1007/978-3-031-08552-9_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
27
|
Su F, Northup PG. Anticoagulants and Antiplatelet Agents in Cirrhosis. PHARMACOTHERAPY FOR LIVER CIRRHOSIS AND ITS COMPLICATIONS 2022:23-48. [DOI: 10.1007/978-981-19-2615-0_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
28
|
Vilaseca M, Gracia-Sancho J. Drugs to Modify Liver Fibrosis Progression and Regression. PORTAL HYPERTENSION VII 2022:201-218. [DOI: 10.1007/978-3-031-08552-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
29
|
Knight GM, Clark J, Boike JR, Maddur H, Ganger DR, Talwar A, Riaz A, Desai K, Mouli S, Hohlastos E, Garcia Pagan JC, Gabr A, Stein B, Lewandowski R, Thornburg B, Salem R. TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy. Hepatology 2021; 74:2735-2744. [PMID: 34021505 DOI: 10.1002/hep.31915] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/06/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. APPROACH AND RESULTS Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24 months, and every 6 months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36 months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. CONCLUSIONS TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.
Collapse
Affiliation(s)
- Gabriel M Knight
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Jeffrey Clark
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Justin R Boike
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Haripriya Maddur
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Daniel R Ganger
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Abhinav Talwar
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Ahsun Riaz
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Kush Desai
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Samdeep Mouli
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Elias Hohlastos
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan-Carlos Garcia Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica Red de enfermedades hepáticas y digestivas, Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders, Hamburg, Germany
| | - Ahmed Gabr
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Brady Stein
- Department of Medicine, Division of Hematology, Northwestern University, Chicago, IL, USA
| | - Robert Lewandowski
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Bartley Thornburg
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, IL, USA
| |
Collapse
|
|
30
|
Intagliata NM, Davitkov P, Allen AM, Falck-Ytter YT, Stine JG. AGA Technical Review on Coagulation in Cirrhosis. Gastroenterology 2021; 161:1630-1656. [PMID: 34579937 DOI: 10.1053/j.gastro.2021.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Perica Davitkov
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Veterans Affairs Northeast Ohio Health Care System, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan G Stine
- Liver Center, Division of Gastroenterology and Hepatology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
|
31
|
Lopez-Gomez M, Llop E, Puente A, Hernández Conde M, Ruiz P, Alvárez S, Martínez JL, Abad J, Fernández N, Perelló C, Fernández-Carrillo C, Ferre C, Trapero M, Fraga E, Crespo J, Calleja Panero JL. Non-malignant portal vein thrombosis in a cohort of cirrhotic patients: Incidence and risk factors. Hepatol Res 2021; 51:1064-1072. [PMID: 34324766 DOI: 10.1111/hepr.13703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/06/2021] [Accepted: 07/21/2021] [Indexed: 01/04/2023]
Abstract
AIM Non-malignant portal vein thrombosis (PVT) is a complication of liver cirrhosis. The aim of this study was to evaluate the annual incidence of PVT and related risk factors. METHODS We retrospectively reviewed clinical, laboratory, and radiological data collected prospectively from September 2016 to September 2017. A follow-up of 36 months was performed in a subset of patients to determine the cumulative incidence of PVT and related complications. RESULTS The study included 567 patients. The incidence of PVT at 12, 24, and 36 months was 3.7%, 0.8%, and 1.4%, respectively. Patients with PVT were compared with patients without PVT, and showed differences in albumin (p = 0.04), aspartate aminotransferase (p = 0.04), hemoglobin (p = 0.01), and prothrombin activity (p = 0.01). The presence of hydropic decompensation (57.1% vs. 30.1%; p 0.004), gastroesophageal varices (76.2% vs. 39.5%; p = 0.05), variceal bleeding (52.4% vs. 22.7%; p < 0.001), hepatic encephalopathy (38.1% vs. 9.9%; p = 0.01), spontaneous bacterial peritonitis (9.5% vs. 1.7%; p < 0.001), and use of beta-blockers (71.4% vs. 27.7%; p < 0.001) were significantly associated. In the multivariate analysis, use of beta-blockers and hepatic encephalopathy appeared as risk factors, and high albumin levels a protective factor. CONCLUSIONS The incidence of PVT was 3.7%. Beta-blockers and hepatic encephalopathy were risks factors. High albumin levels were a protective factor.
Collapse
Affiliation(s)
- Marta Lopez-Gomez
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Elba Llop
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Angela Puente
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Marta Hernández Conde
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Patricia Ruiz
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Silvia Alvárez
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Jose Luis Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Abad
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Natalia Fernández
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Christie Perelló
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Carlos Fernández-Carrillo
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Carlos Ferre
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Maria Trapero
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Enrique Fraga
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Crespo
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Jose Luis Calleja Panero
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| |
Collapse
|
|
32
|
Xu S, Guo X, Yang B, Romeiro FG, Primignani M, Méndez-Sánchez N, Yoshida EM, Mancuso A, Tacke F, Noronha Ferreira C, De Stefano V, Qi X. Evolution of Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis: A Pictorial Review. Clin Transl Gastroenterol 2021; 12:e00409. [PMID: 34597281 PMCID: PMC8483868 DOI: 10.14309/ctg.0000000000000409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/22/2021] [Indexed: 02/07/2023] Open
Abstract
Portal vein thrombosis (PVT) is a common complication in liver cirrhosis, especially in advanced cirrhosis. It may be related to a higher risk of liver-related events and liver function deterioration. Imaging examinations can not only provide an accurate diagnosis of PVT, such as the extent of thrombus involvement and the degree of lumen occupied, but also identify the nature of thrombus (i.e., benign/malignant and acute/chronic). Evolution of PVT, mainly including development, recanalization, progression, stability, and recurrence, could also be assessed based on the imaging examinations. This article briefly reviews the pathophysiology, diagnosis, classification, and evolution of PVT with an emphasis on their computed tomography imaging features.
Collapse
Affiliation(s)
- Shixue Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
- Graduate School, China Medical University, Shenyang, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
| | - Benqiang Yang
- Department of Radiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Fernando Gomes Romeiro
- Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine. National Autonomous University of Mexico, Mexico City, Mexico
| | - Eric M. Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico, Di Cristina-Benfratelli, Palermo, Italy
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China
| |
Collapse
|
|
33
|
Dong S, Qi H, Li Y, Men P, Alifu M, Zhang Y, Li Y, Zhao R. A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat? Hepatol Int 2021; 15:1356-1375. [PMID: 34487316 DOI: 10.1007/s12072-021-10233-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT. METHODS PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel-Haenszel method. RESULTS A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case-control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01-6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14-0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20-1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02-1.32). CONCLUSIONS In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT.
Collapse
Affiliation(s)
- Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Huihong Qi
- Department of Pharmacy, Tangshan Gongren Hospital, Tangshan, Hebei, China
| | - Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China
| | - Maiwujudan Alifu
- Department of Pharmacy, The Sixth Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1 Dahua Road, Beijing, 100730, China.
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, No.49 Huayuan North Road, Beijing, 100191, China.
| |
Collapse
|
|
34
|
Williams C, Stewart E, Conzen KD, Wolf S, Tran TT. Dabigatran Reversal With Idarucizumab in 2 Patients With Portal Vein Thrombosis Undergoing Orthotopic Liver Transplantation. Semin Cardiothorac Vasc Anesth 2021; 25:200-207. [PMID: 33393437 DOI: 10.1177/1089253220982183] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
There are limited data to guide the use of anticoagulation in cirrhotic patients prior to liver transplantation especially when using direct oral anticoagulants. In this article, we present 2 cases. The first is a 42-year-old male with cirrhosis complicated by portal vein thrombosis (PVT) treated with dabigatran who underwent orthotopic liver transplantation without complication. The second case is a 65-year-old man with alcoholic cirrhosis complicated by PVT treated with dabigatran who underwent orthotopic liver transplantation and required reoperation for surgical bleeding. Both patients were treated with dabigatran's reversal agent idarucizumab prior to incision. In this case series, we discuss the treatment of cirrhotic patients with various anticoagulants, considerations for anticoagulant selection and reversal prior to liver transplant, and questions for future investigation.
Collapse
Affiliation(s)
| | - Erin Stewart
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kendra D Conzen
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Wolf
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy T Tran
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
|
35
|
De Maria C, Galante A, Fasoli A, De Gottardi A. When and how to use direct oral anticoagulants in patients with advanced chronic liver disease? Curr Opin Pharmacol 2021; 60:111-116. [PMID: 34403992 DOI: 10.1016/j.coph.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Direct oral anticoagulants (DOACs) emerged as effective and safe alternatives to traditional anticoagulants for the prevention and treatment of venous thromboembolic disease and the prevention of stroke in non-valvular atrial fibrillation. Patients with advanced chronic liver disease (ACLD) have a higher risk of thromboembolism and bleeding than patients with normal liver function. Therefore, anticoagulation and, in particular, direct oral anticoagulants play a central role. Portal vein thrombosis is a relatively frequent complication in patients with ACLD, but its treatment remains challenging. DOACs have been introduced in clinical practice and demonstrated similar efficacy and safety profiles compared with vitamin K antagonist and heparins. However, further data about the use of DOACs in patients suffering from ACLD are needed. This review summarizes current knowledge in terms of anticoagulation in patients with ACLD and focuses on the available data about the use of DOACs in this population.
Collapse
Affiliation(s)
- Costanza De Maria
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Antonio Galante
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Alberto Fasoli
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Andrea De Gottardi
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland; Facoltà di Scienze Biomediche, Università Della Svizzera Italiana, Lugano, Switzerland.
| |
Collapse
|
|
36
|
Senzolo M, Garcia-Tsao G, García-Pagán JC. Current knowledge and management of portal vein thrombosis in cirrhosis. J Hepatol 2021; 75:442-453. [PMID: 33930474 DOI: 10.1016/j.jhep.2021.04.029] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Abstract
Portal vein thrombosis (PVT) is an increasingly recognised complication of cirrhosis whose incidence increases in parallel with the severity of cirrhosis. Several risk factors have been associated with the occurrence and progression of PVT. Although the negative effect of complete PVT on the surgical outcome of liver transplant recipients is clear, its impact on cirrhosis progression remains uncertain. Treatment options include anticoagulants and interventional thrombolytic therapies, which are chosen almost on a case-by-case basis depending on the characteristics of the patient and the thrombus. In this manuscript, we review current knowledge regarding the epidemiology, risk factors, diagnosis and classification, natural history, clinical consequences and treatment of non-neoplastic PVT in cirrhosis.
Collapse
Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy(†).
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA; Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain; Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain(†)
| |
Collapse
|
|
37
|
Efficacy and Safety of Nadroparin Calcium-Warfarin Sequential Anticoagulation in Portal Vein Thrombosis in Cirrhotic Patients: A Randomized Controlled Trial. Clin Transl Gastroenterol 2021; 11:e00228. [PMID: 32858573 PMCID: PMC7455225 DOI: 10.14309/ctg.0000000000000228] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anticoagulation therapy in portal vein thrombosis (PVT) in patients with cirrhosis is still a matter of debate. Therefore, the aim of this work was to evaluate the efficacy and safety of nadroparin calcium-warfarin sequential (NWS) anticoagulation therapy in cirrhotic patients and to find an optimal anticoagulation strategy.
Collapse
|
|
38
|
Cohen O, Caiano LM, Tufano A, Ageno W. Cancer-Associated Splanchnic Vein Thrombosis. Semin Thromb Hemost 2021; 47:931-941. [PMID: 34116580 DOI: 10.1055/s-0040-1722607] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Splanchnic vein thrombosis (SVT), which includes portal, mesenteric, and splenic vein thrombosis and the Budd-Chiari syndrome, is an infrequent manifestation of venous thromboembolism (VTE). Like typical site VTE, SVT is also frequently associated with cancer, particularly intra-abdominal solid malignancies and myeloproliferative neoplasms (MPNs). The clinical presentation of SVT is nonspecific. Symptoms may be related to the underlying malignancy, and thrombosis is incidentally diagnosed by imaging studies for cancer staging or follow-up in a substantial proportion of cases. The occurrence of SVT predicts worse prognosis in patients with liver or pancreatic cancer and, not uncommonly, SVT may precede the diagnosis of cancer. Therefore, the occurrence of an apparently unprovoked SVT should prompt careful patient evaluation for the presence of an underlying malignancy or MPN. Cancer patients carry a high risk of VTE extension and recurrence and long-term anticoagulant treatment is suggested in the absence of high risk of bleeding. Either LMWH or direct oral anticoagulants (DOACs) are suggested for the treatment of patients with cancer-related SVT, although limited experience is available on the use of DOACs in these settings. Vitamin K antagonists (VKAs) are suggested for the short and long-term treatment of SVT associated with MPN. This review outlines the epidemiological aspects, pathogenesis, risk factors, and diagnosis of cancer-associated SVT, and addresses questions regarding the management of this challenging condition.
Collapse
Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-HaShomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Antonella Tufano
- Regional Reference Centre for Coagulation Disorders, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| |
Collapse
|
|
39
|
Davis KA, Joseph J, Nisly SA. Direct oral anticoagulants and warfarin in patients with cirrhosis: a comparison of outcomes. J Thromb Thrombolysis 2021; 50:457-461. [PMID: 31915998 DOI: 10.1007/s11239-019-02035-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anticoagulation management in patients with cirrhosis presents several challenges as a result of alterations in hemostasis. Historically vitamin k antagonists and low molecular weight heparins have been the agents of choice in this patient population. Direct oral anticoagulants (DOACs) may provide an alternative to traditional anticoagulant therapy. To evaluate the rate of major bleeding among patients receiving DOACs or warfarin with cirrhosis. A retrospective, observational, cohort study of adult patients admitted between January 2012 and July 2018 with diagnosis of cirrhosis receiving anticoagulation with DOAC or warfarin therapy was performed. Patients were stratified based on the receipt of a DOAC or warfarin. The primary endpoint was incidence of major bleeding at 90 days. Secondary endpoints included stroke or embolic event at 90 days as well as rehospitalization and mortality at 1 year. One hundred sixty-seven patients were included for analysis; of which 110 received warfarin and 57 received a DOAC. The most commonly used DOAC was apixaban (52.6%) followed by rivaroxaban (45.6%) and dabigratran (1.8%). The incidence of major bleeding was similar between warfarin and DOAC groups (9.1% vs. 5.2% p = 0.381). No difference in the rate of stroke or recurrent embolic event at 90 days was identified between the two groups (0% vs. 1.58% p = 0.341; 1.8% vs. 1.8% p = 0.731). In conclusion DOACs appear to be a safe alternative to warfarin in patients with mild to moderate cirrhosis. Further studies are warranted to confirm these findings.
Collapse
Affiliation(s)
- Kyle A Davis
- Department of Pharmacy, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston Salem, NC, 27157, USA.
| | - Joel Joseph
- Department of Internal Medicine, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston Salem, NC, 27157, USA
| | - Sarah A Nisly
- Department of Pharmacy, Wake Forest Baptist Health, School of Pharmacy, Wingate University, 515 N. Main St, Wingate, NC, 28174, USA
| |
Collapse
|
|
40
|
Cheng Q, Tree K. Systematic Review of Thrombolysis Therapy in the Management of Non-Cirrhosis-Related Portal Vein Thrombosis. J Gastrointest Surg 2021; 25:1579-1590. [PMID: 33452971 DOI: 10.1007/s11605-020-04624-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To review available evidence to assess the efficacy and safety of thrombolysis therapy for non-cirrhosis-related portal vein thrombosis (PVT) that has not improved with anti-coagulation. METHODS A literature search of databases MEDLINE, EMBASE, PUBMED, Cochrane and World Wide Web identified studies after 2000 utilizing portal vein thrombolysis in non-cirrhotic patients, with a minimum of 5 patients. Nine studies met criteria with 134 patients. The primary outcome evaluated was radiological re-canalization of the portal vein and symptomatic improvement post treatment. Secondary data points obtained included morbidity, mortality, thrombolysis approach and technique. RESULTS The re-canalization rate following thrombolysis was 84% (0.67-1.02 CI 95%) and the symptomatic improvement rate 86% (0.70-1.01 CI 95%). The major complication rate was 7% (0.01-0.14 CI 95%) and the overall complication rate 25% (0.08-0.41 CI 95%). The direct and systemic thrombolysis approach showed no significant re-canalization rates with an odds ratio of 0.78 (0.24-2.55 CI 95%, P = 0.68). Thrombectomy in conjunction with thrombolysis demonstrated no improved patency or symptom relief with an odds ratio of 1 (0.17-6.03 CI 95%, P = 1.00). CONCLUSION Thrombolysis is an effective and safe therapy for portal vein thrombosis in non-cirrhotic patients where systemic anti-coagulation has failed. The heterogenicity of study thrombolysis protocols limits the evaluation of secondary outcomes, and future data should be standardized to determine the role of the thrombolysis access route and thrombectomy.
Collapse
Affiliation(s)
- Qiuye Cheng
- Department of Surgery, Blacktown Hospital, 14 Blacktown Rd, Blacktown, NSW, 2148, Australia. .,Discipline of Surgery, University of Western Sydney, Sydney, Australia.
| | - Kevin Tree
- Department of Surgery, Blacktown Hospital, 14 Blacktown Rd, Blacktown, NSW, 2148, Australia. .,Discipline of Surgery, University of Western Sydney, Sydney, Australia.
| |
Collapse
|
|
41
|
Safety and Efficacy of Anticoagulation in Patients with Cirrhosis: A Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:8859602. [PMID: 34007837 PMCID: PMC8102101 DOI: 10.1155/2021/8859602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/06/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND AIMS Portal vein thrombosis is a serious adverse event that occurs during liver cirrhosis. We performed a meta-analysis to evaluate the safety and efficacy of anticoagulant therapy and prophylactic anticoagulant therapy in cirrhosis patients with (/without) portal vein thrombosis. METHODS Eligible comparative studies were identified by searching the following electronic databases: PubMed, Embase, Cochrane Library, Web of Science, and CNKI. A meta-analysis was performed to calculate odds ratios and 95% confidence intervals using fixed-effects models. Recanalization and thrombus progression were defined as the primary outcomes. Secondary outcomes included adverse events and death mortality. RESULTS A total of 3479 patients were included in this analysis. Compared with the control group, the recanalization rate in the anticoagulant therapy group was increased (P < 0.00001) in patients with cirrhosis and portal vein thrombosis without increasing adverse events. Multiple use of enoxaparin in small doses is safer than single large doses (P=0.004). Direct oral anticoagulants are more effective (P < 0.00001) and safer than traditional anticoagulants. Prophylactic anticoagulant therapy can effectively prevent portal vein thrombosis formation (P < 0.00001). CONCLUSIONS Anticoagulation therapy can treat or prevent portal vein thrombosis in patients with liver cirrhosis and is a relatively safe treatment.
Collapse
|
|
42
|
Caiano LM, Riva N, Carrier M, Gatt A, Ageno W. Treatment of portal vein thrombosis: an updated narrative review. Minerva Med 2021; 112:713-725. [PMID: 33832217 DOI: 10.23736/s0026-4806.21.07526-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Portal vein thrombosis (PVT) is the most frequent among the splanchnic vein thrombosis, accounting for 90% of cases. More than half of PVT are provoked by liver cirrhosis, solid cancer or myeloproliferative neoplasms. The remaining cases are non-malignant non-cirrhotic PVT and include either unprovoked events or thrombosis secondary to other less common risk factors (e.g. abdominal surgery, intrabdominal inflammations/infections, or hormonal stimuli). Anticoagulant therapy in patients with acute symptomatic PVT should be started early after diagnosis, if no active bleeding, to obtain greater vessel recanalization and reduce the occurrence of portal-hypertension related complications. Gastroesophageal varices do not represent a contraindication to anticoagulant treatment, as long as adequate measures have been undertaken for the prophylaxis of gastroesophageal bleeding. Different treatment options (unfractionated or low molecular weight heparin, vitamin K antagonists and direct oral anticoagulants [DOACs]) can be considered. In this narrative review we will discuss the treatment of PVT in the three most common scenarios (cirrhosis-associated, cancer-associated and non-malignant non-cirrhotic PVT). We will also discuss the role of the DOACs and summarise recent guidelines on this topic.
Collapse
Affiliation(s)
- Lucia M Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.,Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta -
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| |
Collapse
|
|
43
|
Abstract
Portal vein thrombosis (PVT) is a splanchnic vascular disorder characterised by a recent or chronic thrombotic occlusion of the portal venous system. Its aetiology is miscellaneous, and its management is demanding since PVT can play a critical role as far as morbidity and mortality are concerned. Indeed, PVT can develop as a complication of portal hypertension (PH), in association or not with advanced chronic liver disease, and aggravate its clinical consequences such as variceal bleeding and ascites. Furthermore, a diagnosis of PVT in a non-cirrhotic context can potentially reveal a previously unknown hypercoagulable condition, requiring further diagnostic steps and specific treatment in addition to anticoagulation. In addition to established therapeutic approaches, new strategies, including newer pharmacological treatments and interdisciplinary invasive procedures, gain more attention and have been increasingly introduced into clinical practice. This review aims at discussing the current knowledge in terms of treatment options for PVT.
Collapse
|
|
44
|
Consensus for management of portal vein thrombosis in liver cirrhosis (2020, Shanghai). J Dig Dis 2021; 22:176-186. [PMID: 33470535 PMCID: PMC8252415 DOI: 10.1111/1751-2980.12970] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/10/2021] [Accepted: 01/17/2021] [Indexed: 12/11/2022]
Abstract
Portal vein thrombosis (PVT) is a common and severe complication of liver cirrhosis. So far, there have been few consensuses or practice guidelines on the management of PVT in liver cirrhosis. In this expert consensus, we systematically review the epidemiology, risk factors, imaging examinations, diagnosis, assessment of disease severity, and treatment strategy of PVT in liver cirrhosis, based on the most recent evidence and expert opinions, to further standardize the diagnosis and treatment of the disease in clinical practice.
Collapse
|
|
45
|
Wang L, Guo X, Xu X, De Stefano V, Plessier A, Noronha Ferreira C, Qi X. Anticoagulation Favors Thrombus Recanalization and Survival in Patients With Liver Cirrhosis and Portal Vein Thrombosis: Results of a Meta-Analysis. Adv Ther 2021; 38:495-520. [PMID: 33155180 PMCID: PMC7854392 DOI: 10.1007/s12325-020-01550-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Benefit and risk of anticoagulation in cirrhotic patients with portal vein thrombosis (PVT) remain controversial, especially in those with asymptomatic PVT and in non-liver transplant candidates. Furthermore, the predictors of portal vein recanalization and bleeding events after anticoagulation are critical for making clinical decisions, but still unclear. We conducted a meta-analysis to investigate the outcomes of anticoagulation for PVT in liver cirrhosis and explore the predictors of portal vein recanalization and bleeding events after anticoagulation. METHODS All studies regarding anticoagulation for PVT in liver cirrhosis were searched via PubMed, EMBASE, and Cochrane Library databases. Thrombotic outcomes, bleeding events, and survival were compared between anticoagulation and non-anticoagulation groups. Predictors of portal vein recanalization and bleeding events were pooled. Risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. RESULTS Thirty-three studies including 1696 cirrhotic patients with PVT were included. Anticoagulation significantly increased portal vein recanalization (RR = 2.61; 95% CI 1.99-3.43; P < 0.00001) and overall survival (RR = 1.11; 95% CI 1.03-1.21; P = 0.01) and decreased thrombus progression (RR = 0.26; 95% CI 0.14-0.49; P < 0.0001). Anticoagulation did not significantly influence overall bleeding (RR = 0.78; 95% CI 0.47-1.30; P = 0.34). Early initiation of anticoagulation (RR = 1.58; 95% CI 1.21-2.07; P = 0.0007) significantly increased portal vein recanalization. Child-Pugh class B and C (RR = 0.77; 95% CI 0.62-0.95; P = 0.02) and higher MELD score (MD = - 1.48; 95% CI - 2.20-0.76; P < 0.0001) were significantly associated with decreased portal vein recanalization. No predictor significantly associated with bleeding events was identified. CONCLUSIONS Early initiation of anticoagulation should be supported in liver cirrhosis with PVT. Predictors of portal vein recanalization should be taken into consideration to identify those who may not benefit from anticoagulation. REGISTRATION The work was registered in PROSPERO with registration no. CRD42020157142.
Collapse
Affiliation(s)
- Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
- Postgraduate College, Dalian Medical University, Dalian, China
| | - Xiaozhong Guo
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China
| | - Valerio De Stefano
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Aurelie Plessier
- Hôpital Beaujon, AP-HP, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence Des Maladies Vasculaires du Foie, Inserm U1149, Centre de Recherche Sur L'Inflammation (CRI), Université Paris 7-Denis-Diderot, ERN Rare Liver Clichy, Paris, France
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia E Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly Called General Hospital of Shenyang Military Area), Shenyang, China.
| |
Collapse
|
|
46
|
Durand F, Dokmak S, Roux O, Francoz C. Liver Transplantation in the Setting of Non-malignant Portal Vein Thrombosis. PORTAL VEIN THROMBOSIS 2021:131-156. [DOI: 10.1007/978-981-33-6538-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
47
|
Northup PG, Garcia-Pagan JC, Garcia-Tsao G, Intagliata NM, Superina RA, Roberts LN, Lisman T, Valla DC. Vascular Liver Disorders, Portal Vein Thrombosis, and Procedural Bleeding in Patients With Liver Disease: 2020 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:366-413. [PMID: 33219529 DOI: 10.1002/hep.31646] [Citation(s) in RCA: 358] [Impact Index Per Article: 89.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi I i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, CT.,Veterans Administration Healthcare System, West Haven, CT
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Center for the Study of Hemostasis in Liver Disease, University of Virginia, Charlottesville, VA
| | - Riccardo A Superina
- Department of Transplant Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Surgical Research Laboratory, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Dominique C Valla
- Hepatology Service, Hospital Beaujon, Clichy, France.,Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver), Barcelona, Spain
| |
Collapse
|
|
48
|
Rugivarodom M, Charatcharoenwitthaya P. Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis. J Clin Transl Hepatol 2020; 8:432-444. [PMID: 33447527 PMCID: PMC7782107 DOI: 10.14218/jcth.2020.00067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/27/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.
Collapse
Affiliation(s)
- Manus Rugivarodom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence to: Phunchai Charatcharoenwitthaya, Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Wang-Lang Road, Bangkoknoi, Bangkok 10700, Thailand. Tel: +662-419-7282, Fax: +662-411-5013, E-mail:
| |
Collapse
|
|
49
|
Ahmed Z, Singal AK, Kamath PS. Anticoagulants and Their Monitoring. Clin Liver Dis (Hoboken) 2020; 16:146-148. [PMID: 33163166 PMCID: PMC7609710 DOI: 10.1002/cld.946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Zunirah Ahmed
- Division of Gastroenterology and HepatologyBaylor College of MedicineHoustonTX
| | - Ashwani K. Singal
- Division of Transplant HepatologyAvera Transplant InstituteUniversity of South Dakota Sanford School of MedicineSioux FallsSD
| | - Patrick S. Kamath
- Division of Gastroenterology and HepatologyMayo Clinic and Mayo Medical SchoolRochesterMN
| |
Collapse
|
|
50
|
Efficacy and safety study of direct-acting oral anticoagulants for the treatment of chronic portal vein thrombosis in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2020; 32:1395-1400. [PMID: 32675774 DOI: 10.1097/meg.0000000000001846] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS This study is designed to investigate the efficacy and safety of direct-acting oral anticoagulants (DOACs) for the treatment of chronic portal vein thrombosis (PVT) in liver cirrhosis patients. MATERIALS AND METHODS In a prospective cohort study, patients were divided into DOACs group (oral rivaroxaban tablets or dabigatran etexilate capsules) and control group (no anticoagulant treatment). Based on propensity score matching method, 40 patients with cirrhosis and chronic PVT in each of the groups were recruited for this study. CT portal venography was used to monitor the portal vein area. Color Doppler ultrasound was used to monitor the portal vein flow rate. Biochemical testing and thromboelastography (TEG) were also used for monitoring the status of PVT. RESULTS After 3 months of DOACs treatment, the complete/partial recanalization rate of DOACs was 12.8% (5/39). After 6 months of DOACs treatment, the PVT complete/partial recanalization rate of DOACs was 28.2% (11/39). The recanalization rate and portal vein flow velocity improvement were higher than those in the control group (P < 0.05). Patients' total bilirubin level and Child-Pugh scores were improved in the DOACs group. The TEG coagulation index was lower in the DOACs group than in the control group (P < 0.05). There was no statistically significant difference between the DOACs group and control group in the cases of bleeding (P > 0.05). CONCLUSION DOACs are effective and safe for chronic PVT in patients with liver cirrhosis. The TEG can predict the risk of bleeding in patients with chronic PVT in cirrhosis, which is more sensitive than conventional coagulation function test.
Collapse
|