Portal vein thrombosis: Prevalence, patient characteristics and lifetime risk: A population study based on 23 796 consecutive autopsies

Rates, Reasons, and Independent Predictors of Readmissions in Portal Venous Thrombosis Hospitalizations in the USA

BACKGROUND

Portal vein thrombosis (PVT), generally considered rare, is becoming increasingly recognized with advanced imaging. Limited data exist regarding readmissions in PVT and its burden on the overall healthcare cost. This study aimed to outline the burden of PVT readmissions and identify the modifiable predictors of readmissions.

METHODS

The National Readmission Database (NRD) was used to identify PVT admissions from 2016 to 2019. Using the patient demographic and hospital-specific variables within the NRD, we grouped patient encounters into two cohorts, 30- and 90-day readmission cohorts. We assessed comorbidities using the validated Elixhauser comorbidity index. We obtained inpatient mortality rates, mean length of hospital stay (LOS), total hospital cost (THC), and causes of readmissions in both 30- and 90-day readmission cohorts. Using a multivariate Cox regression analysis, we identified the independent predictors of 30-day readmissions.

RESULTS

We identified 17,971 unique index hospitalizations, of which 2,971 (16.5%) were readmitted within 30 days. The top five causes of readmissions in both 30-day and 90-day readmission cohorts were PVT, sepsis, hepatocellular cancer, liver failure, and alcoholic liver cirrhosis. The following independent predictors of 30-day readmission were identified: discharge against medical advice (AMA) (adjusted hazard ratio (aHR) 1.86; P = 0.002); renal failure (aHR 1.44, P = 0.014), metastatic cancer (aHR 1.31, P = 0.016), fluid and electrolyte disorders (aHR 1.20, P = 0.004), diabetes mellitus (aHR 1.31, P = 0.001) and alcohol abuse (aHR 1.31, P ≤ 0.001).

CONCLUSION

The readmission rate identified in this study was higher than the national average and targeted interventions addressing these factors may help reduce the overall health care costs.

Epidemiology of portal vein thrombosis in liver cirrhosis: A systematic review and meta-analysis

BACKGROUND

Portal vein thrombosis (PVT) may be associated with negative outcomes in patients with liver cirrhosis. However, the prevalence and incidence of PVT in liver cirrhosis are heterogeneous among studies and have not been sufficiently determined yet.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched. Eligible studies would explore the prevalence and/or incidence of PVT in liver cirrhosis without hepatocellular carcinoma or abdominal surgery. Pooled proportion with 95% confidence interval (CI) was calculated using a random-effect model. Factors associated with the presence/occurrence of PVT were also extracted.

RESULTS

Among the 8549 papers initially identified, 74 were included. Fifty-four studies explored the prevalence of PVT in liver cirrhosis with a pooled prevalence of 13.92% (95%CI=11.18-16.91%). Based on cross-sectional data, Child-Pugh class B/C, higher D-dimer, ascites, and use of non-selective beta-blockers (NSBBs) were associated with the presence of PVT in liver cirrhosis. Twenty-three studies explored the incidence of PVT in liver cirrhosis with a pooled incidence of 10.42% (95%CI=8.16-12.92%). Based on cohort data, Child-Pugh class B/C, higher model of end-stage liver disease score, higher D-dimer, lower platelets count, decreased portal flow velocity, ascites, use of NSBBs, and moderate or high-risk esophageal varices could predict the occurrence of PVT in liver cirrhosis.

CONCLUSION

Approximately one seventh of cirrhotic patients have PVT, and one tenth will develop PVT. Progression of liver cirrhosis and portal hypertension seems to be in parallel with the risk of PVT. Prospective studies with detailed information about classification and extension of PVT in liver cirrhosis are needed.

Portal Interventions in the Setting of Venous Thrombosis or Occlusion

Portal vein thrombosis most commonly occurs as a complication of liver cirrhosis and can result in worsening symptoms of portal hypertension, which often can be challenging to treat with conventional decompression therapies. In addition, because complete portal vein thrombosis is associated with higher posttransplant morbidity and mortality, it is regarded as a relative contraindication to liver transplant. Often, the diagnosis of portal vein thrombosis is incidental; hence, imaging remains the mainstay for diagnosing this complication and is used to guide subsequent treatment. Although anticoagulation is the initial approach used to treat acute portal vein thrombosis, endovascular and/or surgical interventions may be necessary when there is concern for impending bowel ischemia. Treatment of chronic portal vein thrombosis is primarily aimed at alleviating the symptoms of portal hypertension and improving the chance of candidacy for liver transplant. Awareness of the portal venous anatomy to differentiate it from the periportal collaterals is key during recanalization of a chronically occluded portal vein. The authors provide an overview of the pathophysiology, acute and chronic imaging findings, and management of portal vein thrombosis, with a specific focus on endovascular management, as well as a summary of the current related literature. An invited commentary by Lopera and Yamaguchi is available online. ©RSNA, 2022.

Catheter-Directed Thrombolysis in the treatment of acute Portomesenteric Vein Thrombosis after Laparoscopic Sleeve Gastrectomy

Background

Portomesenteric Vein Thrombosis (PMVT) following Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon but potentially debilitating complication. Catheter-Directed Thrombolysis (CDT) has an evolving role in recanalizing the venous flow and preventing thrombus propagation. Therefore, it can be used as an alternative or in combination with systemic anticoagulants in selected patients. We report two trans-hepatic and trans-splenic CDT. The patient’s clinical details, radiological findings, safety, and efficacy are reported.

Cases presentation

Two patients presented to the Emergency Department (ED) within 14 days of surgery. The presenting complaints were generally nonspecific. The diagnosis of PMVT was established in both patients based on abdominal Contrast-Enhanced Computed Tomography (CECT). The two patients received a combined therapy of subcutaneous (SC) heparinization and CDT using a trans-hepatic approach in case 1 and a trans-splenic approach in case 2. Subsequent post-procedure venograms and CECT were performed and showed significant thrombus resolution. Both patients received oral anticoagulant therapy upon discharge with a successful overall recovery.

Conclusion

PMVT is an infrequent and severe post LSG complication. Various approaches for re-establishing the portal venous flow have been described according to the severity of venous thrombosis. This article describes CDT therapy as a safe and effective option for treating PMVT in symptomatic patients.

Thrombus Trifecta: A Laparoscopic Sleeve Gastrectomy Complication

We describe a case of generalized, extreme, colicky abdominal pain status post laparoscopic sleeve gastrectomy where the patient formed thromboses in the portal vein, superior mesenteric vein, and splenic vein, which were visualized with computed tomography (CT) imaging. The case was managed using the standard of care, which is anticoagulation and/or surgical intervention, both of which were used in this case.

Splanchnic venous thrombosis: aetiologies and a review of the literature

BACKGROUND

Splanchnic vein thrombosis (SVT) is an uncommon yet potentially life-threatening manifestation of venous thromboembolism. The aim of this study was to present a retrospective analysis of a cohort of Western Australian patients diagnosed with SVT on imaging study, and a review of the literature surrounding the aetiology, location, anticoagulation treatment and outcomes of SVT.

METHODS

All patients diagnosed with SVT over a five-year period from 2015 to 2020 in three tertiary hospitals in Western Australia were identified by using an electronic search engine of imaging reports. Collected data included patient demographics and co-morbidity, presentation data, location of thrombus, aetiology of thrombus, treatment with anti-coagulation, length of stay and outcome data including mortality.

RESULTS

A total of 164 patients met inclusion criteria. The 90-day mortality was 20.1%; 64% of whom were those with portal vein thrombosis. Aetiology was grouped into haematological conditions (4 patients), non-haematological conditions (130 patients), a combination of factors (17 patients) and idiopathic (13 patients). The majority of deaths were due to malignancy, severe pancreatitis or decompensated liver cirrhosis.

CONCLUSION

Whilst the prevalence of SVT is rising with the increase in accessibility to radiological studies, it remains a diagnostic and therapeutic challenge for clinicians. With no consensus guidelines available to direct treatment, the management of patients with SVT should be individualized and considered carefully. The potential complications of venous thrombosis, SVT recurrence or extension and the risk of bleeding need to be evaluated before the commencement of anticoagulation therapy.

Immunotherapy for advanced hepatocellular carcinoma: From clinical trials to real-world data and future advances

Hepatocellular carcinoma (HCC) is a leading cause of cancer-associated mortality worldwide. HCC is an inflammation-associated immunogenic cancer that frequently arises in chronically inflamed livers. Advanced HCC is managed with systemic therapies; the tyrosine kinase inhibitor (TKI) sorafenib has been used in 1st-line setting since 2007. Immunotherapies have emerged as promising treatments across solid tumors including HCC for which immune checkpoint inhibitors (ICIs) are licensed in 1st- and 2nd-line treatment setting. The treatment field of advanced HCC is continuously evolving. Several clinical trials are investigating novel ICI candidates as well as new ICI regimens in combination with other therapeutic modalities including systemic agents, such as other ICIs, TKIs, and anti-angiogenics. Novel immunotherapies including adoptive cell transfer, vaccine-based approaches, and virotherapy are also being brought to the fore. Yet, despite advances, several challenges persist. Lack of real-world data on the use of immunotherapy for advanced HCC in patients outside of clinical trials constitutes a main limitation hindering the breadth of application and generalizability of data to this larger and more diverse patient cohort. Consequently, issues encountered in real-world practice include patient ineligibly for immunotherapy because of contraindications, comorbidities, or poor performance status; lack of response, efficacy, and safety data; and cost-effectiveness. Further real-world data from high-quality large prospective cohort studies of immunotherapy in patients with advanced HCC is mandated to aid evidence-based clinical decision-making. This review provides a critical and comprehensive overview of clinical trials and real-world data of immunotherapy for HCC, with a focus on ICIs, as well as novel immunotherapy strategies underway.

Small Bowel Perforation Secondary to Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a heterogeneous entity often described as either an acute or chronic occlusion of the portal vein or its tributaries. The clinical presentation is highly variable, and it often mimics other more common causes of abdominal pain. In most patients, imaging studies such as doppler ultrasound, computed tomography, or magnetic resonance imaging are adequate for diagnosis. Occasionally imaging studies may be inadequate, and the diagnosis may not be made until complications such as bowel necrosis and perforation have occurred. We present a case of a morbidly obese 45-year-old female who was initially treated for suspected small bowel enteritis and discharged home on several occasions after nonspecific findings on abdominal imaging were seen and interval improvement in symptoms occurred with intravenous fluids and antibiotics. She then presented with worsening symptoms and was found on abdominal imaging to have a large fluid collection in the peritoneal cavity requiring exploratory laparotomy with peritoneal washout and partial small bowel resection due to perforation. She was diagnosed with PVT with mesenteric extension after samples of the resected mesentery were evaluated in the pathology laboratory. Her treatment included a prolonged course of antibiotics, total parenteral nutrition, and anticoagulation.

Usefulness of Imaging and Biological Tools for the Characterization of Portal Vein Thrombosis in Hepatocellular Carcinoma

This study aims to evaluate the performance of contrast-enhanced ultrasound (CEUS) and biological tests to characterize portal vein thrombosis (PVT). We retrospectively analyzed 101 patients with PVT, liver cirrhosis, and hepatocellular carcinoma (HCC). In all patients, demographic, biologic, imaging, and endoscopic data were collected. All patients underwent CEUS and a second line imaging technique (CE-CT/MRI) to characterize PVT. Of the 101 cirrhotic subjects, 77 (76.2%) had HCC. CEUS had 98.6% sensitivity (Se) and 89.3% specificity (Sp) for the characterization of PVT type. A significant correlation was found between alpha-fetoprotein (AFP) levels and the PVT characterization at CEUS (r = 0.28, p = 0.0098) and CT/MRI (r = 0.3, p = 0.0057). Using the AFP rule-out cutoff values for HCC (AFP < 20 ng/dL), 78% of the subjects were correctly classified as having benign PVT, while 100% of the subjects were correctly classified as tumor-in-vein (TIV) when the rule-in cutoff value was used (AFP ≥ 200 ng/dL). Using multiple regression analysis, we obtained a score for classifying PVT. The PVT score performed better than CEUS (AUC—0.99 vs. AUC—0.93, p = 0.025) or AFP serum levels (AUC—0.99 vs. AUC—0.96, p = 0.047) for characterizing PVT. In conclusion, CEUS is a sensitive method for the characterization of PVT. The PVT score had the highest performance for PVT characterization.

Portal Vein Thrombosis in Cirrhosis

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.

Coexisting Portal Vein Thrombosis and Aortic Thrombosis in a Patient with COVID-19: A Case Report and Literature Review

The Coronavirus Disease 2019 (COVID-19) pandemic has rapidly progressed, resulting in significant global morbidity and mortality. Predominantly affecting the respiratory tract, it has been found to be associated with extrapulmonary manifestations such as coagulopathies. We hereby report a case of an elderly man with no predisposing risk factors or history of hypercoagulable disorder who presented with acute onset abdominal pain and was diagnosed with portal vein thrombosis and splenic infarct two weeks following mild COVID-19. Incidentally, the patient was also noted to have aortic thrombosis. The patient was treated with therapeutic anticoagulation with complete resolution in his symptoms. Our case highlights a high risk of coagulopathy following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Large-Bore Mechanical Thrombectomy for Subacute Portal Vein Thrombosis in Patient With Acute Bleeding

Portal vein thrombosis remains a clinical challenge with limited treatment options. A patient was admitted with decompensated nonalcoholic steatohepatitis and a history of recurrent esophageal and gastric variceal hemorrhages. Contrast-enhanced computed tomography revealed hepatic cirrhosis with concomitant and extensive thrombosis of the portal, splenic, and superior mesenteric veins. The patient was treated with transjugular intrahepatic portosystemic shunt and mechanical thrombectomy with the FlowTriever System (Inari Medical, Irvine, CA). Post-thrombectomy venography and follow-up computed tomography demonstrated patency and brisk flow. This case report shows that mechanical thrombectomy with the FlowTriever System is promising for treating extensive and subacute portal vein thrombosis.

Point-of-Care Ultrasound Identification of Portal Vein Thrombosis in a Pediatric Patient

ABSTRACT

Abdominal pain is one of the most common presenting complaints encountered in the pediatric emergency department. The use of point-of-care ultrasonography by emergency physicians has been shown to expedite the diagnosis of a large variety of conditions and can be used to accurately identify intra-abdominal pathology in children. We describe the case of a pediatric patient who presented to the pediatric emergency department with acute abdominal pain, in whom point-of-care ultrasonography helped expedite the diagnosis of acute portal vein thrombosis and liver abscess.

COVID-19 in Cirrhotic Patients: Is Portal Vein Thrombosis a Potential Complication?

INTRODUCTION

Several studies have demonstrated that thromboembolic events increased in patients with coronavirus infection, usually occurring in elderly patients with severe illness, associated with comorbid diseases such as diabetes and hypertension. Portal vein thrombosis (PVT) is a rare venous thromboembolic disease occurring typically in patients with an underlying disease such as decompensated cirrhosis with or without hepatocellular carcinoma (HCC).

AIM

To evaluate incidence of occurrence of acute PVT in cirrhotic patients infected with 2019 coronavirus disease (COVID-19).

METHODS

This cross-sectional, observational study involved 70 patients of the liver cirrhosis: (group A) 28 patients with liver cirrhosis infected with COVID-19, and 42 patients with liver cirrhosis as the control group matched for age and sex (group B). All patients were subjected to thorough medical history, routine investigations (complete blood count, liver, and renal function tests), imaging in the form of abdominal and Doppler ultrasonography to assess the presence of acute PVT, serum ferritin, D-dimer, C-reactive protein, and PCR of COVID-19 for group A only.

RESULTS

There was a significant difference between the two groups regarding Doppler ultrasound findings as 3 of the patients in group A had PVT (10.7%), 2 of them had HCC diagnosed by triphasic CT abdomen, and only 1 patient in group B had PVT (2.3%) (p < 0.05).

CONCLUSION

In cirrhotic patients infected with COVID-19, portal vein thrombosis may be a potential complication even in the absence of hepatocellular carcinoma; further prospective studies with longer follow-up may be needed.

Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein

Cavernous transformation of the portal vein (CTPV) is a sequela of extrahepatic and/or intrahepatic portal vein obstruction caused by a combination of local and risk factors. It was ever taken as a relatively rare disease due to its scant literature, which was mainly based on clinical series and case reports. CTPV often manifests as gastroesophageal variceal bleeding, splenomegaly, and portal biliopathy after the long-term insidious presentation. It is unable for CTPV to be recanalized with anticoagulation because it is a complete obstruction of the mesentericoportal axis. Endoscopic therapy is mainly used for temporary hemostasis in acute variceal bleeding. Meso-Rex shunting characterized by portal-flow-preserving shunts has been widely performed in children with CTPV. The multitude of complications associated with CTPV in adults can be effectively addressed by various interventional vascular therapies. With the ubiquity of radiological examinations, optimal treatment for patients with CTPV becomes important. Multivisceral transplantation, such as liver-small intestinal transplantation, may be lifesaving and should be considered for patients with diffuse mesenteric venous thrombosis.

Acute Portal Vein Thrombosis during COVID-19 Convalescent Phase

Acute portal vein thrombosis represents a less common type of venous thromboembolism, even among the prothrombotic complications of coronavirus disease 2019 (COVID-19). Such complications are primarily reported during the active phase of infection. The case here describes acute portal vein thrombosis following resolution of COVID-19 in a 44-year-old male who presented with abdominal pain. Abdominal imaging identified portal and other splanchnic vein thromboses. Studies for hypercoagulable conditions were negative. Polymerase chain reaction was negative for severe acute respiratory syndrome coronavirus-2; however, IgG serology was positive. The case highlights the importance of considering thrombotic complications, particularly splanchnic vein thromboses, in patients with recent COVID-19.

Clinical significance of hepatosplenic thrombosis in vaccine-induced immune thrombotic thrombocytopenia after ChAdOx1 nCoV-19 vaccination

BACKGROUND

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, serious complication after adenoviral COVID-19 vaccine administration that can involve various organ systems. We aimed to investigate the clinical significance of hepatosplenic thrombosis in patients with VITT.

METHODS

We searched PubMed ePubs, Scopus, Embase, and Web of Science databases for studies published until April 28, 2021 involving patients with VITT after ChAdOx1 nCoV-19 vaccination. Demographic and clinical characteristics including laboratory measurements were collected and compared.

RESULTS

Four case series and three case reports involving 48 cases of VITT were included. Hepatosplenic thrombosis was present in eight cases (17%). Patients with hepatosplenic thrombosis had lower platelet counts (13,000 vs. 29,500/μL, p=0.016) and higher D-dimer levels (140.0 vs. 57.3 times upper limit of normal range, p=0.028). Multiple-site thrombosis was also associated with hepatosplenic thrombosis (88% vs. 15%, p<0.001).

CONCLUSIONS

This is the first study comparing clinical profiles of patients with VITT according to the presence of hepatosplenic thrombosis. Patients with hepatosplenic thrombosis had more severe presentations with lower platelet counts, higher D-dimer levels, and higher rate of multiple-site thromboses. Further studies with larger sample sizes are required to establish definitive evidence regarding the significance of hepatosplenic thrombosis in VITT.

Portomesenteric venous thrombosis in a prophylactically anticoagulated obese patient after laparoscopic sleeve gastrectomy: a case report

Background

Obesity is associated with an increased risk of morbidity and mortality, so weight reduction is important. Bariatric surgery is a well-tolerated approach for reducing body weight, with laparoscopic sleeve gastrectomy commonly performed. An uncommon and potentially fatal sequela of laparoscopic sleeve gastrectomy is portomesenteric vein thrombosis, which may result in severe bowel ischemia.

Case report

A 32-year-old Middle Eastern obese man (body mass index 33) presented to the emergency department with severe, generalized abdominal pain 2 weeks after laparoscopic sleeve gastrectomy. Computed tomography of the abdomen and pelvis revealed extensive acute on chronic portosplenic and superior mesenteric vein thrombosis with associated small bowel ischemia. Laparoscopic exploration was converted to midline laparotomy and an extensive ischemic small bowel resection.

Conclusion

Laparoscopic sleeve gastrectomy carries a risk of both morbidity and mortality. Venous thromboembolism is a well-known risk of bariatric surgery, but portomesenteric vein thrombosis is also a rare but sometimes serious complication. A high index of suspicion for portomesenteric vein thrombosis to prompt early detection is essential in patients who have undergone laparoscopic sleeve gastrectomy to minimize complications and optimize outcomes. Uncertainty still remains around the optimal dose and duration of anticoagulation after laparoscopic sleeve gastrectomy.

Differentiation of malignant from non-malignant portal vein thrombosis in liver cirrhosis: the challenging dilemma

Background

PVT is an ultrasonographic finding in up to 8% of patients with liver cirrhosis. Once hepatocellular carcinoma has occurred as the final station in liver cirrhosis, the risk of PVT rises to 40%. Benign and malignant PVT can occur in patients with liver cirrhosis, and it is important to differentiate the nature of PVT as it has a great impact on patient’s management and outcome.

Diagnosis

Confirming portal vein thrombosis and extension by abdominal ultrasound, contrast-enhanced USG, CT, or MRI. Malignant criteria of PVT are pulsatile pattern in Doppler and heterogeneous contrast enhancement, which are especially seen at the arterial phase, neovascularity within PVT, portal vein thrombus with a diameter of > 23 mm while in benign thrombus, PV diameter does not exceed 20 mm. Visible hypervascular tumor is in close proximity to PVT.

Conclusion

It is not uncommon to find portal vein thrombosis in patients with liver cirrhosis, despite the fact that malignant variant is the most frequent, but efforts should be gathered to exclude benign PVT which may change the management of the patients dramatically.

A rare pediatric case of portal vein aneurysm thrombosis

Portal vein aneurysm (PVA) is rarely encountered, and published papers describing this etiology in adults and children typically include only case reports or small case series. We present a clinical case of PVA in a child associated with severe complications, including diffuse thrombosis of the portal venous system. A 10-year-old boy presented with abdominal pain and vomiting, resulting in an initial diagnosis of pancreatic head tumor based on suspicious images on abdominal grayscale ultrasound. Contrast-enhanced computed tomography confirmed a diagnosis of occlusive PVA thrombosis (36 × 37 × 95 mm). Lacking drastic symptoms, the patient was treated with conservative anticoagulant therapy. On follow-up, the thrombosis appeared to shrink gradually and disappeared at 6 months based on Doppler ultrasound imaging. The PVA was reduced in size, and hepatopetal flow was restored. Surgeons and radiologists should be aware of this rare entity to ensure that a precise diagnosis can be established and to provide suitable treatment.

Splanchnic vein thrombosis-related mortality in the Veneto region (Italy), 2008-2019: Retrospective analysis of epidemiological data

BACKGROUND

Splanchnic vein thrombosis (SVT) is an uncommon manifestation of venous thromboembolism. Epidemiological data on SVT-related mortality rate is not available to date.

METHODS

We investigated time trends in SVT-related mortality rate, 2008-2019, in Veneto, an Italian high-income region of approximatively 5,000,000 inhabitants. SVT-related deaths were identified by the following ICD-10 codes: I81 (portal vein thrombosis), K75.1 (phlebitis of portal vein), K76.3 (liver infarction), K76.5 (hepatic veno-occlusive disease) or I82.0 (Budd-Chiari syndrome).

RESULTS

During the study period, a total of 557,932 deaths were recorded. SVT was reported in 823 cases; 776 (94%) consisted of portal vein thrombosis. The age-standardized SVT-related mortality rate varied from 1.47 (year 2008) to 1.52 (year 2019) per 100,000 person-years. An increase in the cause-specific annual mortality rate was observed in women (0.56 in 2008 to 1.04 per 100,000 person-years in 2019; average annual percent change +5.7%, 95%CI +3.1; +8.3%). In men, the cause-specific mortality rate moved from 2.53 in 2008 to 2.03 per 100,000 person-years in 2019 (average annual percent change -1.2%, 95%CI -4.0; +1.6%). After conditioning for age and sex, the odds of having a concomitant liver disease were higher for SVT-related deaths (OR 31.6; 95%CI 17.1-37.0) compared with non-SVT-related deaths. This also applies to gastrointestinal cancers (OR 1.28; 95%CI 1.07-1.55), although to a lesser extent.

CONCLUSIONS

We report first epidemiological estimates of SVT-related mortality in a Western country. These values will serve as a reference to weight novel potential factors associated with SVT-related death and interpret them from an epidemiological perspective.

A Case of Idiopathic Portal Vein Thrombosis in an Immunocompetent Female

Portal vein thrombosis (PVT) is characterized by a complete or partial occlusion of the portal vein by a thrombus. The formation of the thrombus is usually attributed to an underlying condition that is causing a hypercoagulable state, such as malignancy or cirrhosis. When these causes are ruled out, a hypercoagulable workup can reveal other underlying prothrombotic etiologies. Still, some cases of PVT occur without any definitive underlying condition, leading to the diagnosis of idiopathic PVT. This occurred in our patient, a 53-year-old female who presented with PVT but had no clear underlying condition that led to her pathology after an extensive medical investigation.

Idiopathic portal vein thrombosis not related to hepatic disease or malignancy

Acute portal vein thrombosis (PVT) is a rare disorder defined by the sudden occlusion of the portal vein, which could be partial or complete. Prothrombotic states, inherited or acquired, are thought to be the cause in patients without cirrhosis or malignancy. However, the aetiology of some cases remains idiopathic despite a multidisciplinary diagnostic approach. The initial diagnostic modality to confirm PVT is either contrast-enhanced abdominal (CT) or MRI; as it can identify predisposing factors, and detect evidence of complications. Eliciting the underlying aetiology is critical to guide overall management and prevent future recurrence. The purpose of treatment is to stop thrombus extension and achieve portal vein patency by anticoagulation to optimise outcomes. Herein, we present an unusual case of spontaneous PVT in a young woman. We will also discuss the evaluation of patients without obvious aetiology.

Evaluation of Platelet Indices in Patients with Splanchnic Vein Thrombosis

Splanchnic vein thrombosis (SVT) is a rare and lethal form of venous thrombosis. The role of platelet indices (PI's) is not well studied in SVT. The present study was aimed to assess if the PI's have a significant association with SVT. This was a prospective case control study from coagulation laboratory of Hematology department. A total 100 cases of SVT and 80 controls were screened for PI's (MPV, PCT & PDW) and platelet count (PC) along with routine thrombophilic risk factors. The SVT cases were divided into 3 subgroups, that comprised of EHPVO/ PVT (n = 69), BCS (n = 27), and MVT (n = 4). The mean PC and PCT were significantly lower in patients than the controls. The PDW was significantly higher in cases than in the controls and MPV was relatively higher in cases however did not show statistical significance. In addition, 16 patients were found to have deranged thrombophilic risk factors. Among these, 8 cases had inherited risk factors (2: FVL; 5: PC; 1: PS) and 8 cases had acquired risk factors (2: APL; and 5: multiple factors and one case had both FVL mutation and APL positivity). The PDW and PCT together with PC were found to significantly differ in SVT cases than in controls, particularly in idiopathic cases. It may be worthwhile to explore the utility of PI's as a potential risk factor in SVT.

Supplementary Information

The online version contains supplementary material available at (10.1007/s12288-021-01400-5).

Portal Vein Thrombosis in a Patient With Methylenetetrahydrofolate Reductase Gene Mutation and Normal Homocysteine Levels

A 21-year-old male presented with chief complaints of abdominal pain, nausea, and vomiting and was found to have portal vein thrombosis (PVT) on computed tomography (CT) scan of the abdomen, which was redemonstrated on ultrasound. Thrombophilia workup was negative except that patient was heterozygous for methylenetetrahydrofolate reductase (MTHFR) gene mutation. Homocysteine levels were normal. The patient was started on enoxaparin and discharged on apixaban with the plan to continue anticoagulation for at least six months. Follow-up MRI after four months showed interval improvement of the main portal vein thrombus with the use of Eliquis.

TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy

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.

Isolated hepatic tuberculosis associated with portal vein thrombosis and hepatitis B virus coinfection: A case report and review of the literature

BACKGROUND

While tuberculosis (TB) itself is a common disease, isolated TB of the liver is a rare entity. Tubercular involvement of the liver is more commonly a part of a disseminated disease of the hepatic parenchyma. In contrast, isolated hepatic TB spread through the portal vein from the gastrointestinal tract is seldom encountered in clinical practice, with only a few sporadic cases and short series available in the current literature. Vascular complications, such as portal vein thrombosis (PVT), have rarely been reported previously.

CASE SUMMARY

A 22-year-old man was hospitalized with complaints of a 3-mo history of fever and weight loss of approximately 10 kg. He had a 10-year hepatitis B virus (HBV) infection in his medical history. Contrast-enhanced computed tomography (CECT) confirmed hepatosplenomegaly, with hypodensity of the right lobe of the liver and 2.1 cm thrombosis of the right branch of the portal vein. A liver biopsy showed epithelioid granulomas with a background of caseating necrosis. Ziehl-Nelson staining showed acid-fast bacilli within the granulomas. The patient was diagnosed with isolated hepatic TB with PVT. Anti-TB therapy (ATT), including isoniazid, rifapentine, ethambutol, and pyrazinamide, was administered. Along with ATT, the patient was treated with entecavir as an antiviral medication against HBV and dabigatran as an anticoagulant. He remained asymptomatic, and follow-up sonography of the abdomen at 4 mo showed complete resolution of the PVT.

CONCLUSION

Upon diagnosis of hepatic TB associated with PVT and HBV coinfection, ATT and anticoagulants should be initiated to prevent subsequent portal hypertension. Antiviral therapy against HBV should also be administered to prevent severe hepatic injury.

Portal Vein Thrombosis In Cirrhosis: Interventional Treatment Options

PURPOSE OF REVIEW

Portal vein thrombosis (PVT) is a frequent consequence of cirrhosis and its management is variable and controversial. Herein we highlight interventional treatment options and outcomes, together with mention of the physiology, presentation and imaging of PVT.

RECENT FINDINGS

Utilization of transjugular intrahepatic portosystemic shunt (TIPS) for acute and chronic PVT is expanding. In acute PVT, TIPS improves hepatopetal flow which promotes thrombus resorption and prevents rethrombosis. The TIPS also functions as a conduit for thrombectomy devices and allows for embolization of variceal shunts. Chronic PVT is a relative contraindication to liver transplant. Portal vein recanalization (PVR) TIPS restores flow in a previously occluded portal vein, allowing for a conventional end-to-end portal vein anastomosis at transplant. PVR TIPS is technically demanding and often requires percutaneous splenic vein access for portal venous recanalization. Selection of endovascular PVT treatment varies with the age (acute or chronic) and the extent of thrombus, along with presenting symptoms and transplant candidacy.

Portal Vein Thrombosis: Diagnosis and Endovascular Management

BACKGROUND

 Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking.

METHODS

 The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted.

RESULTS

 Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization.

CONCLUSION

 Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus.

KEY POINTS

  · This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience..

CITATION FORMAT

· Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1642-0990.

Idiopathic Portal Vein Thrombosis in a Non-cirrhotic Patient: A Discussion of Management and a Review of Literature

Portal vein thrombosis (PVT) is most commonly seen in people with predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal disease, or haematologic disorders. However, the incidence of idiopathic portal vein thrombosis in non-cirrhotic people is low and approximately 25% of existing cases have no identifiable cause. If untreated, complications can include portal hypertension, a cavernous transformation of the portal vein, varices, septic thrombosis, or intestinal ischemia. We report the case of a 27-year-old female who presented to her general practitioner with two weeks of epigastric pain. She was referred for an upper abdominal USG and CT imaging, which identified portal vein thrombosis with a normal appearance of the gallbladder, liver, and spleen. Thrombophilia screen was negative for Factor V Leiden and prothrombin mutations and lupus anticoagulant. The tumour markers alpha-fetoprotein and carcinoembryonic antigen were also within normal limits. The patient was started on rivaroxaban indefinitely following advice from a vascular surgeon and haematologist. Subsequent follow-up imaging also revealed cavernous transformation of the portal vein. We present this case to discuss the diagnosis, management and treatment of this patient and to review the current evidence available in managing idiopathic portal vein thrombosis in non-cirrhotic patients, especially the role of anticoagulation in chronic cases.

Portal Venous Thrombosis in a Special Operations Paratrooper: A Case Report

Portal vein thrombosis is the thrombotic occlusion of the extrahepatic portal system, which can propagate towards the vena caval system. Although rare, it occurs primarily in those with cirrhosis, intra-abdominal infections, malignancy, or hypercoagulable disorders. This report describes the first reported case of a soldier within special operations without identifiable risk factors who was found to have a completely occlusive portal vein thrombosis after approximately 10 days of insidious abdominal pain. This case emphasizes the importance of considering this rare but dangerous pathology among this highly screened and capable special operations population.

Portal vein thrombosis in patients with chronic liver diseases: From conventional to quantitative imaging

Portal vein thrombosis is a pathological condition characterized by the lumen occlusion of the portal vein and its intrahepatic branches, commonly associated to chronic liver diseases. Portal vein thrombosis is often asymptomatic and discovered as an incidental finding in the follow-up of chronic hepatopathy. Imaging plays a pivotal role in the detection and characterization of portal vein thrombosis in patients with hepatocellular carcinoma. Ultrasound and Color-Doppler ultrasound are usually the first-line imaging modalities for its detection, but they have limits related to operator-experience, patient size, meteorism and the restrained field-of view. Unenhanced cross-sectional imaging doesn't provide specific signs of portal vein thrombosis except under certain specific circumstances. Conventional contrast-enhanced imaging can depict portal vein thrombosis as an endoluminal filling defect best detected in venous phase and can differentiate between non-neoplastic and neoplastic thrombus based on the contrast enhanced uptake, but not always rule-out the malignant nature. Functional and quantitative imaging techniques and software seem to be more accurate. The purpose of this work is to provide the reader with an accurate overview focused on the main imaging features of portal vein thrombosis.

When and how to use direct oral anticoagulants in patients with advanced chronic liver disease?

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.

Real-world outcome of immune checkpoint inhibitors for advanced hepatocellular carcinoma with macrovascular tumor thrombosis

Programmed cell death protein-1 (PD-1) inhibitors have shown promising results for treating advanced hepatocellular carcinoma (HCC). However, the clinical utility of such inhibitors in HCC patients with vascular tumor thrombosis remains unclear. This study investigated PD-1 inhibitor efficacy in advanced HCC with macrovascular invasion in a clinical setting. Among the 110 patients with unresectable HCC treated with PD-1 inhibitors, 34 patients with vascular metastases in the portal vein and inferior vena cava were retrospectively compared with 34 patients without tumor thrombi. The vascular response and its effect on survival were assessed. Predictors of survival were identified using multivariate analysis. Among patients achieving objective response, those with and without thrombi exhibited similar response to immunotherapy and comparable survival. Among the 34 patients with tumor thrombi, including 13 receiving PD-1 inhibitors alone and 21 receiving it in combination with tyrosine kinase inhibitors, the median overall survival was 8.9 months (95% confidence interval 3.2-12.6). The objective response rate of vascular metastasis was 52.9%, and vascular responders had a significantly longer survival than did non-responders (11.1 vs 3.9 months). Failure to obtain a vascular response correlated significantly with increased post-treatment Child-Pugh score or class. Multivariate analysis showed that vascular response was a significant positive factor for longer overall survival. Treatment-related grade 3/4 adverse events occurred in 3 (8.8%) of the patients with tumor thrombi. Immunotherapy with PD-1 inhibitors may be a feasible treatment option for HCC with tumor thrombi owing to the high response rate of tumor thrombi and favorable survival outcomes.

Portal vein thrombosis in hepatitis C virus-related cirrhotic patients: Prevalence and clinical characteristics in an Egyptian cohort

Portal vein thrombosis is a catastrophe not uncommonly complicating hepatitis C virus-related liver cirrhosis. To estimate its prevalence and clinical characteristics, we investigated 1000 cirrhotic patients by abdominal ultrasound or Doppler study at least. Portal vein thrombosis was found in 21.6%, of whom 157 (72.7%) had malignancy. Complete portal vein thrombosis was found in 70.4%. Half of all these patients had at least one episode of portal hypertensive bleeding, a third had abdominal pain and a quarter presented with jaundice. Portal bilopathy was diagnosed in two cases (0.9%). There was significant association between severity of liver disease, ascites, male gender and site of segmental focal lesion and portal vein thrombosis.

Treatment of direct oral anticoagulants in patients with liver cirrhosis and portal vein thrombosis

Although patients with cirrhosis are known to be in a state of “rebalance” in that pro- and anticoagulant factors increase the risk for both bleeding and thrombosis, the prevalence of portal vein thrombosis (PVT) in patients with cirrhosis can be up to 26%. Therefore, physicians should consider anticoagulation for the prevention and management of PVT in patients with cirrhosis who are at high risk of PVT. Vitamin K antagonist or low molecular weight heparin is suggested as the standard treatment for PVT in cirrhosis. With the advent of new direct-acting oral anticoagulants (DOACs), there is a paradigm shift of switching to DOACs for the treatment of PVT in patients with cirrhosis. However, the safety and efficacy of DOACs in the treatment of PVT was not well-known in patients with cirrhosis. Therefore, this review focused on the current knowledge about the efficacy, safety concerns, and hepatic metabolism of DOACs in patients with cirrhosis and PVT.

Primary Thromboprophylaxis in Patients with Malignancies: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO), the Society of Thrombosis and Hemostasis Research (GTH), and the Austrian Society of Hematology and Oncology (ÖGHO)

Patients with cancer, both hematologic and solid malignancies, are at increased risk for thrombosis and thromboembolism. In addition to general risk factors such as immobility and major surgery, shared by non-cancer patients, cancer patients are exposed to specific thrombotic risk factors. These include, among other factors, cancer-induced hypercoagulation, and chemotherapy-mediated endothelial dysfunction as well as tumor-cell-derived microparticles. After an episode of thrombosis in a cancer patient, secondary thromboprophylaxis to prevent recurrent thromboembolism has long been established and is typically continued as long as the cancer is active or actively treated. On the other hand, primary prophylaxis, even though firmly established in hospitalized cancer patients, has only recently been studied in ambulatory patients. This recent change is mostly due to the emergence of direct oral anticoagulants (DOACs). DOACs have a shorter half-life than vitamin K antagonists (VKA), and they overcome the need for parenteral application, the latter of which is associated with low-molecular-weight heparins (LMWH) and can be difficult for the patient to endure in the long term. Here, first, we discuss the clinical trials of primary thromboprophylaxis in the population of cancer patients in general, including the use of VKA, LMWH, and DOACs, and the potential drug interactions with pre-existing medications that need to be taken into account. Second, we focus on special situations in cancer patients where primary prophylactic anticoagulation should be considered, including myeloma, major surgery, indwelling catheters, or immobilization, concomitant diseases such as renal insufficiency, liver disease, or thrombophilia, as well as situations with a high bleeding risk, particularly thrombocytopenia, and specific drugs that may require primary thromboprophylaxis. We provide a novel algorithm intended to aid specialists but also family practitioners and nurses who care for cancer patients in the decision process of primary thromboprophylaxis in the individual patient.

Influence of portal vein occlusion on portal flow and liver elasticity in an animal model

Hepatic fibrosis causes an increase in liver stiffness, a parameter measured by elastography and widely used as a diagnosis method. The concomitant presence of portal vein thrombosis (PVT) implies a change in hepatic portal inflow that could also affect liver elasticity. The main objective of this study is to determine the extent to which the presence of portal occlusion can affect the mechanical properties of the liver and potentially lead to misdiagnosis of fibrosis and hepatic cirrhosis by elastography. Portal vein occlusion was generated by insertion and inflation of a balloon catheter in the portal vein of four swines. The portal flow parameters peak flow (PF) and peak velocity magnitude (PVM) and liver mechanical properties (shear modulus) were then investigated using 4D-flow MRI and MR elastography, respectively, for progressive obstructions of the portal vein. Experimental results indicate that the reduction of the intrahepatic venous blood flow (PF/PVM decreases of 29.3%/8.5%, 51.0%/32.3% and 83.3%/53.6%, respectively) measured with 50%, 80% and 100% obstruction of the portal vein section results in a decrease of liver stiffness by 0.8% ± 0.1%, 7.7% ± 0.4% and 12.3% ± 0.9%, respectively. While this vascular mechanism does not have sufficient influence on the elasticity of the liver to modify the diagnosis of severe fibrosis or cirrhosis (F4 METAVIR grade), it may be sufficient to attenuate the increase in stiffness due to moderate fibrosis (F2-F3 METAVIR grades) and consequently lead to false-negative diagnoses with elastography in the presence of PVT.

Systematic Review of Thrombolysis Therapy in the Management of Non-Cirrhosis-Related Portal Vein Thrombosis

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.

Trends and In-Hospital Outcomes of Splanchnic Vein Thrombosis Associated with Gastrointestinal Malignancies: A Nationwide Analysis

Introduction

Gastrointestinal cancers have a strong association with splanchnic vein thrombosis (SVT), yet the hospitalization data is unknown.

Objective and Methods

We analyzed around 78 million discharges from the 2007-2017 Nationwide Inpatient Sample with an inclusion criterion of adult patients admitted for portal or hepatic vein thrombosis as a primary diagnosis with a gastrointestinal or hepatobiliary malignancy as a secondary diagnosis. The outcomes were in-hospital mortality, complication rates, and resource utilization. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

Results

Out of the total 32,324 hospitalizations for SVT, 3,220 (10%) were associated with a GI malignancy, of which hepatocellular carcinoma (HCC) and pancreatic cancer were the most common. Portal vein thrombosis accounted for 95% of these hospitalizations. Admissions for pancreatic cancer-associated SVT have increased by 7.2 times from 2007 to 2017. Patients with SVT and concomitant GI malignancies were significantly older and had a higher comorbidity score than those with SVT without GI malignancy. Risk of inpatient mortality for SVT patients were significantly higher for patients with gastric cancer (rate: 12.1%, OR 8.6, 95% CI: 1.8-39.7) and HCC (rate: 7.6%, OR 2.77, 95% CI 1.5-4.8) as compared to non-GI malignancy-related SVT. Odds of variceal bleeding were significantly higher for patients with HCC (OR 1.67, 95% CI: 1.2-2.34) than patients without GI malignancy.

Conclusions

Digestive cancer-associated SVTs constitute 10% of all SVT related hospitalizations and are significantly increasing in the past decade. We report the baseline characteristics and predictors of inpatient mortality in this study.

Portal vein thrombosis: A concise review (Review)

Portal vein thrombosis (PVT) is a frequent complication in cirrhotic patients, but it may also exist as a basic vascular condition even without any liver damage. Local and systemic factors play a significant role in the pathogenesis of PVT; yet, in practice, more than one factor may be identified. PVT can be considered a result of liver fibrosis and hepatic insufficiency. The JAK2 mutation has been accepted as a factor producing PVT. In general, the anticoagulants are recommended but this therapy should be used carefully in treating patients that associate coagulopathy or thrombocytopenia and esophageal varices. Acute PVT without bowel infarction has a good prognosis. In liver cirrhosis, the mortality due to hemorrhage is higher than in chronic PVT. Therefore, for the patients with PVT, the survival rate is decreased by 55% in two years, due to hepatic insufficiency. Regarding the treatment, LMWH (low molecular weight heparine) is the most utilized in patients with cirrhosis, non-malignancies, infections, or those who are awaiting a liver transplant. DOACs (direct-acting oral anticoagulants) may be used in the rest of the medical conditions, being safe and equal to LMWH.

De novo Portal Vein Thrombosis in Non-Cirrhotic Non-Alcoholic Fatty Liver Disease: A 9-Year Prospective Cohort Study

Background and Aims: Approximately 30-40% of portal vein thrombosis (PVT) remains of unknown origin. The association between non-alcoholic fatty liver disease (NAFLD) and PVT is a matter of debate. This study aimed to investigate the association between PVT and NAFLD. Methods: We included 94 out of 105 consecutive NAFLD patients in this prospective cohort study in addition to 94 from the healthy control group. We evaluated biochemical, clinical, immunological, and histopathological parameters; waist circumference (WC); leptin; adiponectin; and leptin/adiponectin ratio (LAR) for all participants at baseline and every 3 years thereafter. We described the characteristics of participants at baseline and showed individual WC, LAR, and PVT characteristics. Potential parameters to predict PVT development within 9 years were determined. Results: PVT developed in eight (8.5%) patients, mainly in the portal trunk. Univariate analysis showed three PVT-associated factors: diabetes mellitus (P = 0.013), WC (P < 0.001), and LAR (P = 0.002). After adjusting multiple confounding variables, the multivariate model showed that the only significant variables were WC and LAR. By applying the receiver operating characteristic curve, WC had 98.8% specificity, 87.5% sensitivity, and 0.894 area under the curve (AUC) for prediction of PVT (P < 0.001) at cutoff values of > 105 cm. In comparison, LAR had 60.5% specificity, 87.5% sensitivity, and 0.805 AUC for PVT prediction (P < 0.001) at cutoff values of >7.5. Conclusions: This study suggests that increased central obesity and LAR were independently associated with PVT development in non-cirrhotic NAFLD patients, and they should be considered risk factors that may participate in PVT multifactorial pathogenesis.

Treatment of portal vein thrombosis: an updated narrative review

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.

Portal vein thrombosis: an overview of current treatment options

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.

Metastatic Infiltration of Anaplastic Carcinoma of the Pancreas Into the Portal Venous System: A Masquerading Cause of Expansive Portal Venous Thrombosis

BACKGROUND The portal vein thrombosis caused by a carcinoma of the pancreas or liver could be a diagnostic challenge. There are some cases which could be diagnosed only by observing changes in patients' clinical manifestations or imaging studies over time. CASE REPORT A 63-year-old man experienced exacerbation of chronic low back pain for 1 month, with abdominal distention. He was admitted to our hospital because abdominal ultrasonography and abdominal contrast-enhanced computed tomography performed at another hospital revealed an extensive thrombus in the portal, splenic, and superior mesenteric veins. Anticoagulation therapy with warfarin was started immediately on admission. Although no baseline disease, such as malignancies, coagulopathies, infections, or collagen diseases were revealed during the 12 days of his hospitalization, the thrombus gradually expanded, with the appearance of obstructive jaundice 8 months after admission. He was readmitted at that time for biopsy of intrahepatic tumors detected by abdominal computed tomography, which diagnosed metastasis of a carcinoma of unknown origin. Although chemotherapy was started, he died 11 months after his initial admission to our hospital. Autopsy revealed a tumorous lesion in the pancreatic head with almost complete replacement of the portal venous thrombus with a similar-appearing tumor. We confirmed the diagnosis of portal venous metastatic infiltration by undifferentiated pancreatic carcinoma, using histopathological examinations. CONCLUSIONS It is essential to consider portal venous metastatic infiltration of undiagnosed malignancy inducing local hypercoagulopathy as a possible cause of expansive portal venous thrombosis.