Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis

The risk factors of liver cirrhosis complicated with portal vein thrombosis and the efficacy and safety of anticoagulant therapy: a meta analysis

OBJECTIVE

To evaluate the risk factors of liver cirrhosis complicated with portal vein thrombosis and the efficacy and safety of anticoagulant therapy.

METHODS

Relevant literature was searched through PubMed, Cochrane library, Embase, Web of Science, Wanfang Medical Network and CNKI databases, and eligible literature was included. QUADS scale was used to evaluate the quality of the included literatures, and Stata15.1 software was used for meta-analysis and statistical processing.

RESULTS

For risk factors analysis for cirrhosis with Portal vein thrombosis, 19 literatures were included, including 1563 patients with cirrhosis with portal vein thrombosis and 2579 patients with cirrhosis without portal vein thrombosis, all of which were not treated with anticoagulation. The results of meta-analysis showed that compared with the PVT group, there was no significant difference in creatinine(Scr,MD = 0.09,95%CI: -0.03-0.22,P = 0.132)and total bilirubin(TBIL,MD = -0.00, 95%CI: -0.10 ~ 0.09,P = 0.948).There was significant difference in albumin(ALB,MD = -0.32, 95%CI:-0.43-0.21,P = 0.000)and PLT(PLT, MD = 0.15, 95%CI: 0.05-0.26, P = 0.004).And there was also no difference in hypertension history (OR = 0.78,95%CI:0.59 ~ 1.03,P = 0.079). In the study on the anticoagulant effect and safety of liver cirrhosis complicated with portal vein thrombosis, a total of 9 literatures were included. Among them,497 patients with liver cirrhosis complicated by portal vein thrombosis are treated with Anticoagulation treatment, and 633 patients with cirrhosis complicated by portal vein thrombosis without anticoagulation treatment. The analysis results showed that the thrombus recanalization situation of liver cirrhosis complicated with portal vein thrombosis after anticoagulation treatment was better than that of patients without anticoagulation (OR = 4.052,95%CI: 2.737-6.000,P = 0.000),and there was no significant difference in the occurrence of bleeding events between patients with anticoagulation and those without anticoagulation (OR = 1.017, 95%CI:0.735-1.407,P = 0.920). The Stata15.1Egger test showed no significant publication bias for all the results(P > 0.05).

CONCLUSIONS

Patients with liver cirrhosis complicated with low platelet and low albumin are more likely to develop PVT. Anticoagulation is helpful and safe for thrombolysis in patients with liver cirrhosis complicated with PVT.

Advancements of direct oral anticoagulants in cirrhotic individuals with portal vein thrombosis

Individuals with cirrhosis maintain a delicate balance between pro- and anticoagulation, which can lead to a state of hypercoagulability. This hypercoagulable condition not only exacerbates liver fibrosis but also increases the risk of venous thrombosis, particularly portal vein thrombosis (PVT). PVT has detrimental effects on liver function, complicates the success of liver transplantation, and negatively impacts the survival rate of patients with cirrhosis. Currently, multiple studies have confirmed that individuals with cirrhosis responded well to treatment with novel direct oral anticoagulants (DOACs), showing both safety and efficacy. Furthermore, the use of DOACs as a preventive measure in patients with cirrhosis following surgery has been shown to lower the occurrence of portal vein thrombosis and postpone the progression of liver fibrosis.

Safety and Efficacy of Portal Vein Recanalization with Creation of Intrahepatic Portosystemic Shunt (PVR-TIPS) to Treat Chronic Portal Vein Thrombosis in Non-cirrhotic Patients

PURPOSE

This study assesses the efficacy and safety of Portal Vein Recanalization with Intrahepatic Portosystemic Shunt (PVR-TIPS) in non-cirrhotic patients with chronic portal vein occlusion (CPVO), cavernomatous transformation, and symptomatic portal hypertension (PH) and/or portal vein thrombotic progression.

MATERIAL AND METHODS

Medical records of 21 non-cirrhotic patients with CPVO and portal cavernoma undergoing PVR-TIPS were analyzed. Hemodynamic (intraprocedural reduction in portosystemic pressure gradient), clinical (data on gastrointestinal bleeding, abdominal pain, ascites, and presence of esophageal varices from imaging exams) and technical success (PVR-TIPS) assessed efficacy. Safety was determined through complications classified according to the CIRSE Classification System.

RESULTS

PVR-TIPS was successfully performed in all patients, resulting in a significant reduction in portal pressure gradient by 10 mmHg (21.475 ± 9.7 mmHg - 11.454 ± 5,4 mmHg, p < 0.001), alleviating portal hypertension symptoms without thrombotic progression. Clinical success included resolution or reduction of ascites (p = 0.016), gastroesophageal varices (p = 0.004), abdominal pain (p = 0.0021), and cessation of gastrointestinal bleeding (p = 0.021). Complications occurred in 33% of patients, including six grade III events (1 perioperative liver bleeding, 5 delayed stent occlusions) and one grade VI event resulting in death (4.8%). Primary patency rate was 76% (21.3 months, range:0.2-82), secondary patency 100% (4 months, range:3.8-40.8). Survival at follow-up was 90.4%, with one unrelated death. One patient underwent liver transplantation, three became eligible post-recanalization.

CONCLUSION

PVR-TIPS proves effective and safe in reducing portal pressure gradient, thereby alleviating PH symptoms without evidence of portal thrombosis progression in non-cirrhotic patients with CPVO and portal cavernoma. It expands therapeutic options, including liver transplantation.

Splanchnic vein thrombosis: management for the thrombosis specialist

Splanchnic vein thrombosis (SpVT) is an uncommon site of venous thrombosis that is associated with complications including portal hypertension and hepatic dysfunction. The evaluation and management of this patient population has evolved in recent years, but there are limited data from clinical trials to guide management. Given the various acquired and biologic risk factors leading to the development of SpVT and the potential complications that can arise from it, input from a multidisciplinary team can be valuable in managing such patients, including thrombosis specialists or hematologists, gastroenterologists or hepatologists, interventional radiologists, and surgeons. In this article, we present 4 cases that highlight important issues and considerations in the evaluation of SpVT, including initial diagnostic approach in a patient with a new diagnosis of SpVT, considerations for anticoagulant therapy, management of SpVT in patients with myeloproliferative neoplasms, and the role of interventional vascular procedures in the management of SpVT. By reviewing the current literature, we address clinically relevant questions that are posed to clinicians managing patients with SpVT; we also point out gaps in our current knowledge that merit future investigation.

AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review

DESCRIPTION

Portal vein thromboses (PVTs) are common in patients with cirrhosis and are associated with advanced portal hypertension and mortality. The treatment of PVTs remains a clinical challenge due to limited evidence and competing risks of PVT-associated complications vs bleeding risk of anticoagulation. Significant heterogeneity in PVT phenotype based on anatomic, host, and disease characteristics, and an emerging spectrum of therapeutic options further complicate PVT management. This Clinical Practice Update (CPU) aims to provide best practice advice for the evaluation and management of PVT in cirrhosis, including the role of direct oral anticoagulants and endovascular interventions.

METHODS

This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Asymptomatic patients with compensated cirrhosis do not require routine screening for PVT. BEST PRACTICE ADVICE 2: Patients with cirrhosis with PVTs identified on Doppler ultrasound should undergo cross-sectional imaging with computed tomography or magnetic resonance imaging to confirm the diagnosis, evaluate for malignancy, and document the degree of lumen occlusion, clot extent, and chronicity. BEST PRACTICE ADVICE 3: Patients with cirrhosis and PVT do not require a hypercoagulable workup in the absence of additional thromboemboli or laboratory abnormalities or family history suggestive of thrombophilia. BEST PRACTICE ADVICE 4: Patients with cirrhosis and PVT with evidence of intestinal ischemia require urgent anticoagulation to minimize ischemic injury. If available, these patients should be managed by a multidisciplinary team, including gastroenterology and hepatology, interventional radiology, hematology, and surgery. BEST PRACTICE ADVICE 5: Consider observation, with repeat imaging every 3 months until clot regression, in patients with cirrhosis without intestinal ischemia and recent (<6 months) thrombosis involving the intrahepatic portal vein branches or when there is <50% occlusion of the main portal vein, splenic vein, or mesenteric veins. BEST PRACTICE ADVICE 6: Anticoagulation should be considered in patients with cirrhosis without intestinal ischemia who develop recent (<6 months) PVT that is >50% occlusive or involves the main portal vein or mesenteric vessels. Patients who have increased benefit of recanalization include those with involvement of more than 1 vascular bed, those with thrombus progression, potential liver transplantation candidates, and those with inherited thrombophilia. BEST PRACTICE ADVICE 7: Anticoagulation is not advised for patients with cirrhosis with chronic (>6 months) PVT with complete occlusion with collateralization (cavernous transformation). BEST PRACTICE ADVICE 8: Patients with cirrhosis and PVT warrant endoscopic variceal screening if they are not already on nonselective beta-blocker therapy for bleeding prophylaxis. Avoid delays in the initiation of anticoagulation for PVT, as this decreases the odds of portal vein recanalization. BEST PRACTICE ADVICE 9: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants are all reasonable anticoagulant options for patients with cirrhosis and PVT. Decision making should be individualized and informed by patient preference and Child-Turcotte-Pugh class. Direct oral anticoagulants may be considered in patients with compensated Child-Turcotte-Pugh class A and Child-Turcotte-Pugh class B cirrhosis and offer convenience as their dosages are independent of international normalized ratio monitoring. BEST PRACTICE ADVICE 10: Patients with cirrhosis on anticoagulation for PVT should have cross-sectional imaging every 3 months to assess response to treatment. If clot regresses, anticoagulation should be continued until transplantation or at least clot resolution in nontransplantation patients. BEST PRACTICE ADVICE 11: Portal vein revascularization with transjugular intrahepatic portosystemic shunting may be considered for selected patients with cirrhosis and PVT who have additional indications for transjugular intrahepatic portosystemic shunting, such as those with refractory ascites or variceal bleeding. Portal vein revascularization with transjugular intrahepatic portosystemic shunting may also be considered for transplantation candidates if recanalization can facilitate the technical feasibility of transplantation.

Efficacy and safety of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis: a systematic review and meta-analysis

BACKGROUND

The role of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis (PVT) remains unclear. This study aims to evaluate the efficacy and safety of anticoagulation in this patient population.

METHODS

We systematically searched PubMed, Web of Science, Cochrane Library, and Embase up to August 2024. The primary outcomes analyzed were PVT recanalization, progression of PVT, bleeding events, and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for dichotomous variables.

RESULTS

Seventeen studies, including randomized controlled trials (RCTs) and observational studies, were included in the analysis. Compared to no intervention, anticoagulation significantly increased the PVT recanalization rate (OR = 3.89, p < .001) and decreased the PVT progression rate (OR = 0.28, p < .001) as well as overall mortality (OR = 0.66, p = .008). Importantly, anticoagulation did not significantly increase the bleeding rate (OR = 1.21, p = .41). Subgroup analysis revealed a greater benefit in PVT recanalization within the short-term treatment subgroup (≤ 6 months) compared to long-term treatment subgroup (> 6 months), and in the Asian subgroup compared to the European or United States of America (USA) subgroup. In the Warfarin subgroup, while the total bleeding rate increased significantly, there was no significant rise in major bleeding events. Additionally, a downward trend in variceal bleeding was observed in the Asian subgroup (OR = 0.44; 95% CI: 0.19-1.04; p = .06).

CONCLUSION

Anticoagulation is both safe and effective for asymptomatic cirrhotic patients with PVT. It not only treats PVT and reduces all-cause mortality, but also does so without significantly increasing the risk of bleeding events.

Administration of anticoagulation strategies for portal vein thrombosis in cirrhosis: network meta-analysis

Objectives

Evidences for anticoagulation strategies in cirrhotic with portal vein thrombosis (PVT) are still insufficient. This study aims to comprehensively compare the therapeutic effects of different therapeutic therapeutic measures in individuals suffering from cirrhosis with PVT, with the ultimate goal of providing evidence-based recommendations for thrombolytic therapy in this population.

Methods

Starting from 20 October 2023, a comprehensive search about therapeutic strategies for portal vein thrombosis in cirrhosis was conducted on PubMed, EMBASE, and Cochrane Library.

Results

19 studies were eventually incorporated into this study. Comparison with control in network meta-analysis, direct oral anticoagulants (DOACs) (RR = 2.15, 95%CI: 1.33, 3.48), LMWH (RR = 1.41, 95%CI: 1.01, 1.99), TIPS (RR = 5.68, 95%CI: 2.63, 12.24), warfarin (RR = 2.16, 95%CI: 1.46, 3.21), EBL plus propranolol (RR = 2.80, 95%CI: 1.18, 6.60), LMWH-DOACs sequential (RR = 7.92, 95%CI: 2.85, 21.99) and LMWH-warfarin sequential (RR = 2.26, 95%CI: 1.16, 4.42) significantly improved the incidence of complete recanalization. The anticoagulation drugs were ranked based on their SUCRA values, with the LMWH-DOACs sequential (92.7%), TIPS plus warfarin (91.3%), and TIPS (80.3%) emerging as the top three effective treatments.

Conclusion

In this study, active anticoagulants were recommended for cirrhosis with PVT. The TIPS plus warfarin, LMWH-DOACs sequential, and TIPS improved the complete recanalization rate most effectively, and the EBL plus propranolol, heparin plus DOACs plus warfarin, and DOACs were highly recommended for increasing the incidence of partial recanalization. Warfarin and TIPS were recommended for reducing the frequency of bleeding events, while LMWH plus warfarin and DOACs proved to be most effective in decreasing the rate of major bleeding events. Warfarin, heparin plus DOACs plus warfarin, and DOACs demonstrated the most significant reduction in mortality rates, highlighting its potential as an effective intervention. TIPS plus warfarin, LMWH-DOACs sequential, and TIPS were recommended for reducing the occurrence of PVT expansion. Heparin plus DOACs plus warfarin was recommended for reducing the occurrence of hepatic encephalopathy, and protocols that involve TIPS were generally associated with a higher risk of hepatic encephalopathy. However, a longer follow-up period is necessary to comprehensively evaluate the efficacy of active anticoagulants therapy in patients with PVT in cirrhosis.

Porto-sinusoidal vascular liver disorder with portal hypertension: Natural history and long-term outcome

BACKGROUND & AIMS

Current knowledge of the natural history of patients with porto-sinusoidal vascular disorder (PSVD) is derived from small studies. The aim of the present study was to determine the natural history of PSVD and prognostic factors in a large multicenter cohort of patients.

METHODS

We performed a retrospective study on patients with PSVD and signs of portal hypertension (PH) prospectively registered in 27 centers.

RESULTS

A total of 587 patients were included, median age of 47 years and 38% were women. Four-hundred and one patients had an associated condition, which was graded as severe in 157. Median follow-up was 68 months. At diagnosis, 64% of patients were asymptomatic while 36% had a PH-related complication: PH-related bleeding in 112 patients, ascites in 117, and hepatic encephalopathy in 11. In those not presenting with bleeding, the incidence of first bleeding was 15% at 5 years, with a 5-year rebleeding rate of 18%. The 5-year cumulative incidence of new or worsening ascites was 18% and of developing portal vein thrombosis was 16%. Fifty (8.5%) patients received a liver transplantation and 109 (19%) died, including 55 non-liver-related deaths. Transplant-free survival was 97% and 83% at 1 and 5 years, respectively. Variables independently associated with transplant-free survival were age, ascites, serum bilirubin, albumin and creatinine levels at diagnosis and severe associated conditions. This allowed for the creation of a nomogram that accurately predicted prognosis.

CONCLUSIONS

The prognosis of PSVD is strongly determined by the severity of the associated underlying conditions and parameters of liver and renal function.

IMPACT AND IMPLICATIONS

Porto-sinusoidal vascular liver disorder (PSVD) is a rare entity that usually affects young people, frequently causes severe complications of portal hypertension, and may reduce life expectancy. To date, there is scarce information regarding its clinical manifestations, natural history and prognostic factors. The present study, including the largest number of patients with PSVD reported so far, shows that overall, when managed at centers of expertise, the prognosis of patients with PSVD is good, with LT-free survival rates of 83% and 72% at 5 and 10 years, respectively. Presence and severity of an underlying associated condition, presence of ascites, age and bilirubin, albumin and creatinine levels were associated with poor prognosis. These results are important to know for hepatologists. A final model combining these parameters enabled development of a nomogram that predicts prognosis with good discrimination and calibration capacity and can be easily applied in clinical practice.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Management of Portal vein Thrombosis in Cirrhosis

Portal vein thrombosis (PVT) is one of the common complications of cirrhosis. The incidence of PVT correlates with liver disease severity-higher incidence in patients with Child-Turcotte-Pugh (CTP) C, large spontaneous portosystemic shunts, hepatofugal portal flow, and in the presence of hepatocellular carcinoma. PVT may worsen ascites, increase the risk and poor control of variceal bleeding. The occurrence of PVT may increase morbidity and lower survival after a liver transplant. Using statins prevents the occurrence of PVT, whereas beta-blockers may aggravate its occurrence. Cross-sectional imaging is mandatory for the precise diagnosis and classification of PVT. Symptomatic, occlusive PVT and candidacy for liver transplantation are the main indications for anticoagulation. Vitamin K antagonists, low-molecular-weight heparin, and newer anticoagulants are effective and safe in cirrhosis. Direct-acting oral anticoagulants are agents of choice in early cirrhosis (CTP A, B). The duration of anticoagulant therapy, predictors of response, and management of complications of cirrhosis while on therapy require in-depth knowledge and individualized treatment. Transjugular intrahepatic porto-systemic shunt can be considered in nonresponsive cases or when anticoagulants are contraindicated. This manuscript reviews the latest updated knowledge about managing PVT in cirrhosis.

Portal vein thrombosis: diagnosis, management, and endpoints for future clinical studies

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.

Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH

While advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism (VTE) including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology, and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard-dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for stroke prevention in AF. In patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA) in Child-Pugh A or B cirrhosis and LMWH alone (or as a bridge to VKA in patients with a normal baseline international normalized ratio) in Child-Pugh C cirrhosis. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.

Portal Vein Thrombosis in Liver Cirrhosis. Part 2: Treatment, Primary and Secondary Prevention

In most cases, portal vein thrombosis progresses without treatment; spontaneous recanalization of portal vein develops in 42 % of patients with liver cirrhosis. Effective treatment strategies include administration of anticoagulants, interventional procedures such as transjugular intrahepatic porto-systemic shunt or endovascular fibrinolysis. Anticoagulant therapy has certain difficulties in patients with liver cirrhosis due to the complex profile of hemostasis, a tendency to both hemorrhages and hypercoagulation. In addition to traditional anticoagulants (heparin preparations, fondaparinux, vitamin K antagonists), direct oral anticoagulants have been widely used in recent years for portal vein thrombosis. Previously, portal vein thrombosis was considered a contraindication to performing transjugular intrahepatic porto-systemic shunt, currently the method is often used to restore portal blood flow through the shunt and prevent repeated thrombosis. Endovascular fibrinolysis is still an option for specialized centers for «difficult» patients. In cases of increased risk of venous thromboembolism, patients with liver cirrhosis are recommended to be prevented with low-molecular-weight heparin or direct oral anticoagulants, but further studies should clarify their effectiveness in this aspect. The review highlights data on the features of therapy, primary and secondary prevention of portal vein thrombosis in patients with liver cirrhosis. Despite the existing clinical recommendations for management of patients with cirrhotic portal vein thrombosis, the choice of a particular strategy primarily depends on an individualized assessment of risks and benefits of each treatment method.

Classification and Management of Portal Vein Thrombosis in Cirrhotic Patients: A Narrative Review

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.

Variations in Practice Among Cirrhotic Patients With Portal Vein Thrombosis and Esophageal Varices: A North American Survey Study

INTRODUCTION

There exists variation regarding the approach to anticoagulation and variceal hemorrhage (VH) prophylaxis among patients with cirrhosis and portal vein thrombosis (PVT).

METHODS

A survey was distributed to gastroenterology and hepatology providers to assess the approach to anticoagulation and VH prophylaxis among patients with PVT in cirrhotic patients.

RESULTS

Providers were more likely to start anticoagulation if the patient was listed for liver transplantation, was symptomatic, or had superior mesenteric vein thrombosis. For prevention of first VH, many providers opt for combination therapy with both nonselective beta blockers and variceal ligation.

DISCUSSION

Although providers agree on the clinical scenarios that merit initiation of anticoagulation, practice variation was identified in the means of preventing first VH.

Preventing variceal rebleeding in cirrhotic patients with portal vein thrombosis: A systematic review and meta-analysis

BACKGROUND AND AIM

Preventing rebleeding is crucial, but the best prevention technique for patients with cirrhosis and portal vein thrombosis (PVT) remains debatable. Therefore, this systematic review and meta-analysis compared a transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy (ET) plus nonselective beta-blockers (NSBBs) for preventing variceal rebleeding in this patient population.

METHODS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception until May 18, 2023. The studies were screened using predetermined criteria, relevant data were extracted, and pooled analyses were performed using the Reviewer Manager 5.4.1 software.

RESULTS

We retrieved 1032 studies, of which 5 studies comprising a total of 272 patients were included. The postoperative variceal rebleeding rate was significantly lower in the TIPS group than in the ET + NSBBs group (odds ratio [OR] = 0.19, 95% confidence interval [CI] = 0.11-0.35, P < 0.05, I2 = 0%), but the portal vein recanalization rate was higher (OR = 7.92, 95% CI = 3.04-20.67, P < 0.05, I2 = 0%). The rates of hepatic encephalopathy (HE) and mortality did not differ between the groups.

CONCLUSIONS

Our results suggest that TIPS prevents variceal rebleeding without increasing the hepatic encephalopathy risk more effectively than ET plus NSBBs, but this benefit did not translate into improved survival. Thus, it may be preferable to ET plus NSBBs for preventing variceal rebleeding in patients with cirrhosis and PVT. However, more large-scale and multicenter randomized controlled trials involving other patient populations are required to verify the clinical efficacy of both these treatments and ensure generalizability.

Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT).

METHODS

A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival.

RESULTS

A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05).

CONCLUSION

TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.

Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review

It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.

Management of varices but not anticoagulation is associated with improved outcome in patients with HCC and macrovascular tumour invasion

BACKGROUND & AIMS

The value of bleeding prophylaxis and anticoagulation in patients with hepatocellular carcinoma (HCC) and macrovascular tumour invasion (MVI) is unclear. We evaluated the impact of anticoagulation on thrombosis progression, bleeding events, and overall mortality, and assessed the efficacy of adequate management of varices as recommended for patients with cirrhosis.

METHODS

HCC patients with MVI who had Child-Turcotte-Pugh A-B7 were included between Q4/2002 and Q2/2022. Localization of the tumour thrombus and changes at 3-6 months were evaluated by two radiologists. Univariable and multivariable logistic/Cox regression analyses included time-dependent variables (i.e., anticoagulation, systemic therapy, non-selective beta blocker treatment).

RESULTS

Of 124 patients included (male: n = 110, 89%), MVI involved the main portal vein in 47 patients (38%), and 49 individuals (40%) had additional non-tumorous thrombus apposition. Fifty of 80 patients (63%) with available endoscopy had varices. Twenty-four individuals (19%) received therapeutic anticoagulation and 94 patients (76%) were treated with effective systemic therapies. The use of therapeutic anticoagulation did not significantly affect the course of the malignant thrombosis at 3-6 months. Systemic therapy (aHR: 0.26 [95%CI: 0.16-0.40]) but not anticoagulation was independently associated with reduced all-cause mortality. In patients with known variceal status, adequate management of varices was independently associated with reduced risk of variceal bleeding (aHR: 0.12 [95%CI: 0.02-0.71]). In the whole cohort, non-selective beta blockers were independently associated with reduced risk of variceal bleeding or death from any cause (aHR: 0.69 [95%CI: 0.50-0.96]).

CONCLUSION

Adequate bleeding prophylaxis and systemic anti-tumour therapy but not anticoagulation were associated with improved outcomes in patients with HCC and MVI.

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

BACKGROUND AND AIM

Progression of liver disease in cirrhosis is associated with an increased incidence of portal vein thrombosis (PVT) in cirrhosis. However, evidence suggests that spontaneous recanalization of PVT may occur even without anti-thrombotic therapy. Thus, the present meta-analysis was conducted to study the natural history of PVT in cirrhosis, facilitating decisions regarding anticoagulation.

METHODS

Three electronic databases were searched from 2000 to August 2022 for studies reporting the outcome of PVT in cirrhotics without anticoagulation. The pooled proportions with their 95% confidence intervals (CIs) were calculated using a random-effect model.

RESULTS

A total of 26 studies (n = 1441) were included in the final analysis. Progression of PVT on follow-up was seen in 22.2% (95% CI 16.1-28.4), while 77.7% (95% CI 71.6-83.9) remained non-progressive (improved or stable). The most common outcome was a stable PVT with a pooled event rate of 44.6% (95% CI 34.4-54.7). The pooled rates of regression and complete recanalization of PVT in cirrhotics were 29.3% (95% CI 20.9-37.7) and 10.4% (95% CI 5.0-15.8), respectively. On follow-up after improvement, pooled recurrence rate of PVT was 24.0% (95% CI 14.7-33.4). MELD score, and presence of ascites had a negative association, while a longer follow-up duration had positive association with PVT regression.

CONCLUSION

Approximately 25% of the cases of PVT in cirrhosis are progressive, 30% cases improve, and 45% remain stable. Future studies are needed to analyze the predictors of spontaneous regression.

Direct oral anticoagulants for the treatment of splanchnic vein thrombosis: A state of art

Splanchnic vein thrombosis (SVT) is a manifestation of venous thromboembolism in an unusual site. Portal, mesenteric, and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis, although non-cirrhotic patients could be affected as well. Thrombosis of hepatic veins, also known as Budd-Chiari syndrome, is another manifestation of SVT. Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications. Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases. However, recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants (DOACs) in this setting. Available results are mainly based on retrospective studies with small sample size, but first clinical trials have been published in the last years. This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.

Transjugular intrahepatic collateral-systemic shunt is effective for cavernous transformation of the portal vein with variceal bleeding

BACKGROUND

The transjugular intrahepatic portal collateral-systemic shunt (transcollateral TIPS) is used to treat portal hypertension-related complications in patients with cavernous transformation of the portal vein (CTPV) and whose main portal vein cannot be recanalized. It is still not clear whether transcollateral TIPS can be as effective as portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS). This study aimed to evaluate the efficacy and safety of transcollateral TIPS in the treatment of refractory variceal bleeding with CTPV.

METHODS

Patients with refractory variceal bleeding caused by CTPV were selected from the database of consecutive patients treated with TIPS in Xijing Hospital from January 2015 to March 2022. They were divided into the transcollateral TIPS group and the PVR-TIPS group. The rebleeding rate, overall survival, shunt dysfunction, overt hepatic encephalopathy (OHE) and operation-related complications were analyzed.

RESULTS

A total of 192 patients were enrolled, including 21 patients with transcollateral TIPS and 171 patients with PVR-TIPS. Compared with the patients with PVR-TIPS, the patients with transcollateral TIPS had more noncirrhosis (52.4 vs. 19.9%, p = 0.002), underwent fewer splenectomies (14.3 vs. 40.9%, p = 0.018), and had more extensive thromboses (38.1 vs. 15.2%, p = 0.026). There were no differences in rebleeding, survival, shunt dysfunction, or operation-related complication rates between the transcollateral TIPS and PVR-TIPS groups. However, the OHE rate was significantly lower in the transcollateral TIPS group (9.5 vs. 35.1%, p = 0.018).

CONCLUSION

Transcollateral TIPS is an effective treatment for CTPV with refractory variceal bleeding.

Anticoagulation improves survival in patients with cirrhosis and portal vein thrombosis: The IMPORTAL competing-risk meta-analysis

BACKGROUND & AIMS

Previous meta-analyses demonstrated the safety and efficacy of anticoagulation in the recanalization of portal vein thrombosis in patients with cirrhosis. Whether this benefit translates into improved survival is unknown. We conducted an individual patient data (IPD) meta-analysis to assess the effect of anticoagulation on all-cause mortality in patients with cirrhosis and portal vein thrombosis.

METHODS

In this IPD meta-analysis, we selected studies comparing anticoagulation vs. no treatment in patients with cirrhosis and portal vein thrombosis from PubMed, Embase, and Cochrane databases (until June 2020) (PROSPERO no.: CRD42020140026). IPD were subsequently requested from authors. The primary outcome - the effect of anticoagulation on all-cause mortality - was assessed by a one-step meta-analysis based on a competing-risk model with liver transplantation as the competing event. The model was adjusted for clinically relevant confounders. A multilevel mixed-effects logistic regression model was used to determine the effect of anticoagulation on recanalization.

RESULTS

Individual data on 500 patients from five studies were included; 205 (41%) received anticoagulation and 295 did not. Anticoagulation reduced all-cause mortality (adjusted subdistribution hazard ratio 0.59; 95% CI 0.49-0.70), independently of thrombosis severity and recanalization. The effect of anticoagulation on all-cause mortality was consistent with a reduction in liver-related mortality. The recanalization rate was higher in the anticoagulation arm (adjusted odds ratio 3.45; 95% CI 2.22-5.36). The non-portal-hypertension-related bleeding rate was significantly greater in the anticoagulation group.

CONCLUSIONS

Anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization, but at the expense of increasing non-portal hypertension-related bleeding.

PROSPERO REGISTRATION NUMBER

CRD42020140026.

IMPACT AND IMPLICATIONS

Anticoagulation is effective in promoting recanalization of portal vein thrombosis in patients with cirrhosis, but whether this benefit translates into improved survival is controversial. Our individual patient data meta-analysis based on a competing-risk model with liver transplantation as the competing event shows that anticoagulation reduces all-cause mortality in patients with cirrhosis and portal vein thrombosis independently of recanalization. According to our findings, portal vein thrombosis may identify a group of patients with cirrhosis that benefit from long-term anticoagulation.

Anticoagulation for the Treatment of Portal Vein Thrombosis in Cirrhosis: A Systematic Review and Meta-Analysis of Comparative Studies

Background

Portal vein thrombosis (PVT) leads to significant morbidity and mortality burden in patients with cirrhosis. An improved understanding of the utility of anticoagulation in patients with PVT will aid clinical decision making and inform future research. This meta-analysis aimed to evaluate the association between anticoagulation therapy and clinical outcomes in the context of treatment for PVT in cirrhosis.

Methods

Pubmed, Embase, and Web of Science were searched from inception to February 13, 2022, for studies comparing the use of anticoagulation to other modalities as treatment for PVT in cirrhosis. Pooled odds ratios (OR) were calculated using a random-effects model for PVT improvement, recanalization, progression, bleeding events, and all-cause mortality in treatment studies.

Results

We identified 944 records, of which 16 studies (n = 1126) examining anticoagulation as PVT treatment were included for subsequent analysis. Anticoagulation as PVT treatment was associated with PVT improvement (OR 3.64; 95% CI 2.56-5.17), PVT recanalization (OR 3.73; 95% CI 2.45-5.68), decreased PVT progression (OR 0.38; 95% CI 0.23-0.63), and decreased all-cause mortality (OR 0.47; 95% CI 0.29-0.75). The use of anticoagulation was not associated with bleeding events (OR 0.80; 95% CI 0.39-1.66). All analyses demonstrated low heterogeneity.

Conclusions

These results support the use of anticoagulation in cirrhosis as treatment for PVT. These findings may inform the clinical management of PVT and highlight the need for further studies such as large randomized controlled trials characterizing the safety and efficacy of anticoagulation for PVT in cirrhosis.

Portal vein thrombosis in cirrhosis: A literature review

Portal Vein Thrombosis (PVT), a common complication of advanced liver disease, is defined as an obstruction of the portal vein due to thrombus formation that can extend to the superior mesenteric and splenic veins. It was believed that PVT occurred predominantly due to prothrombotic potential. However, recent studies have shown that decreased blood flow related to portal hypertension appears to increase PVT risk as per Virchow's triad. It is well known that there is a higher incidence of PVTs in cirrhosis with a higher MELD and Child Pugh score. The controversy for management of PVTs in cirrhotics lies in the individualized assessment of risks versus benefits of anticoagulation, since these patients have a complex hemostatic profile with both bleeding and procoagulant propensities. In this review, we will systematically compile the etiology, pathophysiology, clinical features, and management of portal vein thrombosis in cirrhosis.

Treatment of portal vein thrombosis in cirrhosis: a multicenter real life cοhort study

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.

Improving Management of Portal Hypertension: The Potential Benefit of Non-Etiological Therapies in Cirrhosis

Portal hypertension is the consequence of cirrhosis and results from increased sinusoidal vascular resistance and hepatic blood inflow. Etiological therapies represent the first intervention to prevent a significant increase in portal pressure due to chronic liver damage. However, other superimposed pathophysiological drivers may worsen liver disease, including inflammation, bacterial translocation, endothelial dysfunction, and hyperactivation of hemostasis. These mechanisms can be targeted by a specific class of drugs already used in clinical practice. Albumin, rifaximin, statins, aspirin, and anticoagulants have been tested in cirrhosis and were a topic of discussion in the last Baveno consensus as non-etiological therapies. Based on the pathogenesis of portal hypertension in cirrhosis, our review summarizes the main mechanisms targeted by these drugs as well as the clinical evidence that considers them a valid complementary option to manage patients with cirrhosis and portal hypertension.

Development and external validation of prognostic scoring models for portal vein thrombosis: a multicenter retrospective study

BACKGROUND

Portal vein thrombosis is a common complication of liver cirrhosis and hepatocellular carcinoma; however, few studies have reported its long-term clinical prognosis. This study aimed to establish and validate easy-to-use nomograms for predicting gastrointestinal bleeding, portal vein thrombosis resolution, and mortality of patients with portal vein thrombosis.

METHODS

This multicenter retrospective cohort study included 425 patients with portal vein thrombosis who were divided into training (n = 334) and validation (n = 91) sets. Prediction models were developed using multivariate Cox regression analysis and evaluated using the consistency index and calibration plots.

RESULTS

Predictors of gastrointestinal bleeding included a history of gastrointestinal bleeding, superior mesenteric vein thrombosis, red color sign observed during endoscopy, and hepatic encephalopathy. Meanwhile, predictors of resolution of portal vein thrombosis included a history of abdominal infection, C-reactive protein and hemoglobin levels, and intake of thrombolytics. Predictors of death included abdominal infection, abdominal surgery, aspartate aminotransferase level, hepatic encephalopathy, and ascites. All models had good discriminatory power and consistency. Anticoagulation therapy significantly increased the probability of thrombotic resolution without increasing the risk of bleeding or death.

CONCLUSIONS

We successfully developed and validated three prediction models that can aid in the early evaluation and treatment of portal vein thrombosis.

Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy

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.

Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China

Liver diseases are a major cause of illness and death worldwide. In China, liver diseases, primarily viral hepatitis, affect approximately 300 million people, thus having a major impact on the global burden of liver diseases. Portal hypertension is the most severe complication of chronic liver diseases, including ascites, hepatic encephalopathy and bleeding from gastroesophageal varices. Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of these complications. Since its introduction 30 years ago in China, the use of TIPS has evolved and has played an increasingly important role in the management of the complications of portal hypertension. This review will focus on the history, current application and management of complications of TIPS in China.

Portal Vein Thrombosis in the Setting of Cirrhosis: A Comprehensive Review

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.

Clinical predictors for thrombus progression in cirrhotic patients with untreated splanchnic vein thrombosis

INTRODUCTION

Splanchnic vein thrombosis (SVT) occurs in a heterogenous group of patients secondary to a variety of risk factors including liver disease. Minimal data regarding natural history and outcomes of SVT exists to inform management decisions. As such, there is equipoise regarding the utility of anticoagulation in cirrhotic patients with SVT. We sought to identify clinical factors predictive of new or progressive thrombosis in a cohort of patients with untreated SVT.

METHODS

We conducted a retrospective cohort study of cirrhotic patients over 18 years of age diagnosed with SVT at the Oregon Health & Science University from 2015 to 2020, excluding those initially treated with anticoagulation. The primary study endpoint was a composite of the following: imaging-confirmed progression of SVT, development of cavernous transformation, intestinal ischemia, portal cholangiopathy or new venous or arterial thrombosis.

RESULTS

261 patients were included in the analysis (median age 61 years, 68% male, 32% female). Forty percent of all patients experienced the primary composite endpoint. Multivariable logistic regression found that only the presence of pancreatitis or abdominal infection at diagnosis was associated with an increased likelihood of experiencing thrombus progression in patients with untreated SVT (OR 3.61, P = 0.02). There was a statistically significant overall survival difference between patients that did and did not experience the primary composite endpoint after controlling for confounding variables. (p = 0.0068).

CONCLUSIONS

Overall, only the presence of pancreatitis or intrabdominal infection were found to be significantly associated with thrombotic progression, with varices identified as marginally non-significant risk factor. Notably, thrombotic progression was associated with a significant reduction in overall survival.

Pre-transplant portal vein thrombosis in non-alcoholic fatty liver disease patients-pathogenesis, risk factors, and implications on management

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.

Anticoagulation in Cirrhosis: Evidence for the Treatment of Portal Vein Thrombosis and Applications for Prophylactic Therapy

The clinical utility of anticoagulation for patients with cirrhosis and asymptomatic portal vein thrombosis (PVT) is widely debated. Complex hemostatic derangements in cirrhosis that increase risk of both bleeding and thrombosis, as well as a lack of randomized controlled data, limit conclusive assessments regarding optimal management of anticoagulation in this setting. In this review, we summarize the relevant literature pertaining to PVT in cirrhosis, including the effect of untreated PVT on the natural progression of liver disease and the overall impact of anticoagulation on clot burden and other relevant clinical outcomes. Apart from patients who are symptomatic or listed for liver transplantation, data supporting anticoagulation for the treatment of PVT is limited and without clear consensus guidelines. In patients with cirrhosis without PVT, emerging evidence for the role of prophylactic anticoagulation to mitigate the progression of fibrosis suggests an optimal risk-benefit tradeoff with decreased rates of liver decompensation and mortality, without a heightened risk of bleeding. In summation, as our understanding of the role of both prophylactic and therapeutic anticoagulation in cirrhosis continues to evolve, ongoing risk stratification of patients with asymptomatic PVT demands further attention.

Haemostatic alterations and management of haemostasis in patients with cirrhosis

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.

Anticoagulant therapy for splanchnic vein thrombosis: an individual patient data meta-analysis

Robust evidence on the optimal management of splanchnic vein thrombosis (SVT) is lacking. We conducted an individual patient meta-analysis to evaluate the effectiveness and safety of anticoagulation for splanchnic vein thrombosis (SVT). MEDLINE, EMBASE, and clincaltrials.gov., were searched up to June 2021 for prospective cohorts or randomized clinical trials including patients with SVT. Data from individual datasets were merged, and any discrepancy with published data was resolved by contacting study authors. Three studies for a total of 1635 patients were included. Eighty-five percent of patients received anticoagulation for a median duration of 316 days (range 1 to 730 days). Overall, incidence rates for recurrent VTE, major bleeding, and mortality were 5.3/100 patients-years (p-y) (95% CI, 5.1 to 5.5), 4.4/100 p-y (95% CI, 4.2 to 4.6), and 13.0/100 p-y (95% CI, 12.4 to 13.6), respectively. The incidence rates of all outcomes were lower during anticoagulation and higher after treatment discontinuation or when anticoagulation was not administered. In multivariable analysis, anticoagulant treatment appeared to be associated with a lower risk of recurrent VTE (Hazard Ratio [HR] 0.42; 95% CI, 0.27 to 0.64), major bleeding (HR 0.47; 95% CI, 0.30 to 0.74), and mortality (HR 0.23; 95% CI, 0.17 to 0.31). Results were consistent in patients with cirrhosis, solid cancer, myeloproliferative neoplasms, unprovoked SVT, and SVT associated with transient or persistent non-malignant risk factors. In patients with SVT the risk of recurrent VTE and major bleeding is substantial. Anticoagulant treatment is associated with reduced risk of both outcomes.

EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis

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.

Cirrhosis and Coagulopathy: Mechanisms of Hemostasis Changes in Liver Failure and Their Management

Cirrhosis is an end-stage liver disease that can cause changes in any component of the hemostatic system. The net effects of the complicated hemostatic changes have long been unknown due to concurrent changes in pro-and antihemostatic drivers. Coagulation disorders are caused by various factors, including decreased clotting and inhibitor factor synthesis, reduced clearance of activated factors, quantitative and qualitative platelet defects, hyperfibrinolysis, and increased intravascular coagulation. This review discusses the pathogenesis of coagulopathy and multiple studies related to its clinical presentations. This article also highlights an additional problem in the diagnostic and therapeutic approach to this group of patients: the fact that traditional coagulation tests and transfusional strategies may not be reliable for assessing and managing bleeding or thrombotic risks. Hence, multiple management options have been assessed for bleeding and thrombosis in liver disease.

Nontransplant options for portomesenteric thrombosis

PURPOSE OF REVIEW

Portomesenteric thrombosis (PMT) is a serious condition encountered mainly in cirrhotic patients awaiting liver transplantation. More recently, this potentially fatal complication has been described after bariatric surgery and inflammatory bowel disease. Several consensus guidelines have been published over the past few years and this mini review was conducted to discuss updated nontransplant treatment options based on currently available evidence.

RECENT FINDINGS

Anticoagulation is the mainstay of treatment for PMT involving <50% of the main portal vein. Transjugular intrahepatic portosystemic shunt are usually preserved for patients with more extensive disease or those with clinically significant portal hypertension that are treatment refractory.

SUMMARY

The extent of PMT, response to therapy, and complications related with PMT are the determinants of therapy.