Portal vein thrombosis: When to treat and how?

Management of Nonmalignant Portal Vein Thrombosis in Cirrhosis

Nonmalignant portal vein thrombosis (PVT) is a common complication of cirrhosis especially at the stage of decompensations. The diagnosis of PVT in cirrhosis is often incidental and it may be detected during routine semestral abdominal ultrasound with Doppler during screening for hepatocellular carcinoma or during hospitalization for decompensated cirrhosis. After detection of PVT on abdominal ultrasound, it is important to evaluate patients with cross-sectional imaging to determine the age of thrombus, whether acute or chronic, the extent and degree of luminal occlusion of the portal vein, and to rule out hepatocellular carcinoma or other underlying malignancy. Factors influencing management include the degree and extent of luminal occlusion of PVT, potential listing for liver transplantation, and portal hypertension (PHT) complications such as variceal hemorrhage and refractory ascites, severity of thrombocytopenia, and other comorbidities including chronic kidney disease. Anticoagulation is the most common therapeutic option and it is specially indicated in patients who are candidates for liver transplantation. Interventional procedures including transjugular intrahepatic portosystemic shunt (TIPS) placement and mechanical thrombectomy may be used on a case-by-case basis in patients with contraindications or adverse events related to anticoagulation, who develop worsening PVT while on anticoagulant therapy, or have chronic PVT and PHT complications that are not manageable medically or endoscopically.

Portal vein thrombosis in a 10-month-old infant as a complication of neonatal umbilical catheterization: a case report

Introduction

Esophageal varices bleeding after portal hypertension is a rare condition in children but is associated with significant morbidity and mortality. Neonatal umbilical catheterization is one of the risk factors for the development of portal vein thrombosis (PVT) and portal hypertension.

Case presentation

Neonatal umbilical catheterization was used here to provide appropriate treatment for postpartum sepsis. Color Doppler revealed an approximate total obstruction of the portal vein, and endoscopy showed esophageal varices. The patient was sequentially managed with endoscopic sclerotherapy.

Discussion

The manifestations associated with PVT (like splenomegaly and bleeding esophageal varices) have been detected in a 10-month-old, which is considered a relatively young age according to the medical literature review.

Conclusion

Using umbilical vein catheterization in neonates may be associated with several complications, including PVT. This case report describes a rare instance of portal hypertension complicated by bleeding esophageal varices in a 10-month-old infant who had undergone newborn umbilical catheterization.

Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong?

Purpose

This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC).

Materials and Methods

An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out.

Results

The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D.

Conclusion

Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.

Percutaneous radiological interventions of the portal vein: a comprehensive review

The portal vein is the largest vessel supplying the liver. A number of radiological interventions are performed through the portal vein, namely for primary pathologies of the portal vein, for inducing liver hypertrophy or to treat the sequelae of portal hypertension among others. The routes used include direct transhepatic, transjugular, and, uncommonly, trans-splenic and through subcutaneous varices. Portal vein embolization and transjugular intrahepatic portosystemic shunt are among the most common portal vein interventions that are performed to induce hypertrophy of the future liver remnant and to treat complications of portal hypertension, respectively. Other interventions include transhepatic obliteration of varices and shunts, portal vein thrombolysis, portal vein recanalization, pancreatic islet cell transplantation, and embolization of portal vein injuries. We present a detailed illustrative review of the various radiological portal vein interventions.

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

BACKGROUND AND AIMS

The role of thrombolytic therapy in patients with portal venous system thrombosis (PVST) remains ambiguous. This study aimed to systematically collect available evidence and evaluate the efficacy and safety of thrombolysis for PVST.

METHODS

Eligible studies were searched via PubMed, EMBASE, and Cochrane Library databases. Among the cohort studies, meta-analyses were performed to assess the outcomes of PVST patients receiving thrombolysis. Pooled proportions were calculated. Among the case reports and case series, logistic regression analyses were performed to identify the risk factors for outcomes of PVST patients receiving thrombolysis. Odds ratios (ORs) were calculated.

RESULTS

Among the 2134 papers initially identified, 29 cohort studies and 131 case reports or case series were included. Based on the cohort studies, the pooled rates of overall response to thrombolytic therapy, complete recanalization of PVST, bleeding events during thrombolysis, further bowel resection, thrombosis recurrence, and 30-day mortality were 93%, 58%, 18%, 3%, 1%, and 4%, respectively. Based on the case reports and case series, acute pancreatitis (OR = 0.084), history of liver transplantation (OR = 13.346), and interval between onset of symptoms and initiation of thrombolysis ≤14 days (OR = 3.105) were significantly associated with complete recanalization of PVST; acute pancreatitis (OR = 6.556) was significantly associated with further bowel resection; but no factors associated with the overall response to thrombolytic therapy, bleeding events during thrombolysis, thrombosis recurrence, and 30-day mortality were identified or could be calculated.

CONCLUSION

Early initiation of thrombolysis should be effective for the treatment of PVST. But its benefits for PVST secondary to acute pancreatitis are weakened.

A novel potential mechanism for the development of portal vein thrombosis in cirrhosis based on portal hemodynamics

BACKGROUND

Marked changes in hemodynamics have been suggested to be a potential contributing factor to portal vein thrombosis (PVT) development. This study investigated the effect of portal hemodynamics based on the anatomical structure of the portal venous system on PVT development.

METHODS

The morphological features of portal venous system in patients with PVT and those without PVT subgroups were compared. In addition, idealized PV models were established to numerically evaluate the effect of the variation in the angulation of superior mesenteric vein (SMV) and splenic vein (SV) on the hemodynamics of portal venous system.

RESULTS

The angle α (angulation of SMV and SV) in patients with PVT was lower than that in patients without PVT (p < 0.0001), which was the only independent risk factor (odds ratio (OR), 0.90 (95% CI 0.84-0.95); p < 0.0001) for the presence of PVT. With the change in angle α, the flow pattern of blood flow changed greatly, especially the helical flow. When α = 80°, helical flow only appeared at the local PV near the intersection of SMV and SV. When α = 120°, most regions were occupied by the helical flow. In addition, the h₂ gradually increased with increasing α, when α = 80°, h₂ = 12.6 m/s²; when α = 120°, h₂ = 29.3 m/s².

CONCLUSIONS

The angulation of SV and SMV was closely associated with PVT development. Helical flow changed following the varying angulation of SV and SMV. Therefore, angulation of SV and SMV may help to identify high-risk cohorts for future PVT development earlier.

Clinical and imaging predictors of the natural course of bland portal vein thrombus in cirrhotic patients

BACKGROUND

Portal vein thrombus (PVT) in cirrhotic patients is associated with worsening portal hypertension, leads to increased complexity of necessary interventions such as transjugular liver portosystemic shunt or liver transplantation, and is associated with worse outcomes after liver transplantation. Additionally, there are no established consensus guidelines for management of bland PVT in cirrhotic patients, which currently exists on a spectrum and is patient and provider dependent.

PURPOSE

The aim of this study was to determine whether there are associations between key clinical and imaging variables and bland PVT burden over time.

MATERIAL AND METHODS

This exploratory, retrospective, single-center study included patients who underwent two or more multiphase CT or MRI examinations between 1/1/2013 and 12/31/2019 and had a diagnosis of PVT. Three readers independently evaluated all index and follow-up examinations for PVT burden using a proposed 8-point scale and the established Yerdel score. Key clinical factors were collected from the electronic medical record. The PVT burden over time and the association of this burden with key clinical and imaging variables were assessed using logistic regression models.

RESULTS

138 patients with cirrhosis and bland PVT were included in the analyses. Median age was 60 years (interquartile range 55-67; 90 men) and median follow-up time was 19.6 months. At baseline, the mean score was 2.31 (± 1.44) and at the final follow-up examination, the mean score was 2.52 (± 1.99). Baseline occlusion level was the only statistically significant association with worsening PVT burden in all four vascular territories (p-value < 0.0001). Anticoagulation status did not have a statistically significant association with change in thrombus burden in any vascular territory or cumulative thrombus burden across all territories (p-value 0.11-0.43).

CONCLUSION

In conclusion, our study shows that in cirrhotic patients with bland PVT, the thrombus burden did not change significantly over time and baseline thrombus burden is the only clinical factor significantly associated with increasing burden over time.

Expanding Indications of TIPS in the Management of Portal Hypertension Complications

Transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.

Transileocolic endovascular treatment by a hybrid approach for severe acute portal vein thrombosis with bowel necrosis: Two case reports

BACKGROUND

Acute portal vein thrombosis (PVT) with bowel necrosis is a fatal condition with a 50%-75% mortality rate. This report describes the successful endovascular treatment (EVT) of two patients with severe PVT.

CASE SUMMARY

The first patient was a 22-year-old man who presented with abdominal pain lasting 3 d. The second patient was a 48-year-old man who presented with acute abdominal pain. Following contrast-enhanced computed tomography, both patients were diagnosed with massive PVT extending to the splenic and superior mesenteric veins. Hybrid treatment (simultaneous necrotic bowel resection and EVT) was performed in a hybrid operating room (OR). EVTs, including aspiration thrombectomy, catheter-directed thrombolysis (CDT), and continuous CDT, were performed via the ileocolic vein under laparotomy. The portal veins were patent 4 and 6 mo posttreatment in the 22-year-old and 48-year-old patients, respectively.

CONCLUSION

Hybrid necrotic bowel resection and transileocolic EVT performed in a hybrid OR is effective and safe.

Liver Growth and Portal Hypertension Improvement After Percutaneous Recanalization of Chronic Portal Vein Thrombosis in Non-Cirrhotic Participants

PURPOSE

To evaluate liver function improvement and volume gain after percutaneous recanalization of chronic portal vein thrombosis (PVT) in non-cirrhotic patients.

MATERIALS AND METHODS

In this retrospective study, five non-cirrhotic participants between 21 and 67 years old with secondary chronic PVT (4-21 years from diagnose) were submitted to percutaneous portal vein recanalization, followed by varices and shunts embolization.

RESULTS

After a mean of 12.6 months, all portal veins remained patent and there was complete resolution of portal hypertension (PH) symptoms in all participants. There was a significant increase in liver volume of 39.8 ± 19.0% (p = 0.042), platelets count of 53120 ± 20188/μl (p = 0.042), and a significant decrease in total bilirubin levels from 1.04 ± 0.23 mg/dL to 0.51 ± 0.09 mg/dL (p = 0.043). We also found a non-significant increase in albumin levels from 3.88 ± 0.39 g/dL to 4.38 ± 0.27 g/dL (p = 0.078) and decrease in spleen diameter from 16.88 ± 4.03 cm to 14.15 ± 2.72 cm (p = 0.068).

DISCUSSION

In this retrospective study, even with a small number of participants, we were capable of showing a median of 39.8% increase in liver volume, laboratorial liver function improvement, platelets count and resolution of PH symptoms, including gastroesophageal varices disappearance after portal vein recanalization followed by shunt embolization.

CONCLUSION

In this small series of cases, recanalization of chronic PVT in non-cirrhotic participants was feasible, successful and safe despite the prolonged time of occlusion. This is a new and promising approaching to an old and still challenging disease.

Acute Portal and Superior Mesenteric Vein Thrombosis with Topical Testosterone Therapy: An Adverse Drug Event Case Report

This is a case report of a 55-year-old Caucasian male prescribed topical testosterone therapy for 12 months prior to admission, when he was diagnosed with acute thrombosis in the portal vein (PVT) and superior mesenteric vein (SMV). The patient had a negative thrombophilia workup, including Factor V Leiden, Prothrombin G20210A, and JAK2 V617F mutations. There were no other pertinent laboratory markers that raised concern for the cause of thrombus. No strong familial history of venous thromboembolism (VTE) was reported during the patient's initial workup. With this in mind, the patient's use of topical testosterone therapy was considered the most likely risk factor for the PVT and SMV thrombus. During hospitalization, the patient was initiated on therapeutic anticoagulation with a heparin drip and discharged to home on apixaban for 3 months with extended therapy to be determined by outpatient hematologist. With no other identified VTE risk factors, probability that this patient's VTE was attributed to testosterone was evaluated using the Naranjo scale with a calculated score of 6, which classifies the adverse reaction as "likely." Clinicians should be aware of the possibility that topical testosterone therapy may be a risk factor for venous thrombosis in unusual sites.

Trombose de veia porta não associada à cirrose – desafio terapêutico

Portal vein thrombosis (PVT) is a disease in which thrombosis occurs from the intrahepatic branches of the portal vein, and may extend to the splenic vein and/or superior mesenteric vein. It is most often associated with liver cirrhosis. PVT not associated with cirrhosis is rare. The aim of this article is to report two cases of PVT in which it was not associated with cirrhosis. Both were treated with anticoagulation and clinical progress afterwards was good.

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.

Hemorheological Alteration in Patients with Cirrhosis Clinically Diagnosed with Portal Vein System Thrombosis After Splenectomy

Background

Portal vein system thrombosis (PVST) is a common and serious complication after splenectomy. Key factors, including wider diameters of the portal vein, decreased liver function, and high flow volume of portosystemic collateral vessel, are recognized PVST risks. Relationships between PVST and altered hemorheology, including increased plasma viscosity, remain unclear. We investigated hemorheological alterations and explored risk factors of PVST in patients with cirrhosis after splenectomy.

Material/Methods

Data on patients with cirrhosis who underwent splenectomy were collected retrospectively from January 2018 to June 2020. Color Doppler ultrasonography was performed after splenectomy. Hemorheological indexes were compared between groups. Receiver operating characteristic (ROC) analysis was conducted to analyze risk factor cutoff values. Univariate and multivariate analyses were conducted to explore risk factors of PVST.

Results

A total of 50 patients were divided into a PVST group (n=30) and control group (n=20). Hemorheological indexes of activated partial thromboplastin time, fibrinogen degradation products (FDP), D-dimer, middle shear rates 50 and 30, low shear rates 5 and 1, and hematocrit in the PVST group were significantly higher than those of the control group (P<0.05). FDP and low shear rate 1 were found to be risk factors of PVST after splenectomy by multivariate analysis. ROC analysis showed that the cutoff points for FDP and low shear rate 1 were ≥38.6 ug/mL and ≥16.855 mPa.s, respectively.

Conclusions

PVST after splenectomy is closely related to hemorheological alteration. FDP and low shear rate 1 may be valuable markers of PVST.

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.

COVID-19 With Preexisting Hypercoagulability Digestive Disease

The outbreak of coronavirus disease of 2019 (COVID-19) has become a global public health and economic crisis. The advent of hypercoagulability and thrombotic complications can substantially influence the prognosis of COVID-19 patients. In this review, we elaborate on the clinical findings, potential underlying pathogenesis, and therapeutic strategy of hypercoagulability and thromboembolism in COVID-19, particularly focusing on the COVID-19 patients with preexisting digestive hypercoagulability disease.

Janus Kinase-2 Mutation Associated Portal Vein Thrombosis Complicating Liver Cirrhosis and Hepatocellular Carcinoma

Background:

Portal vein thrombosis (PVT) might be a catastrophic event complicating liver cirrhosis and hepatocellular carcinoma (HCC).

Aim:

role of JAK2 RS V617F mutation as a risk factor for PVT development in liver cirrhosis and HCC.

Methods:

A case control study conducted on 100 PVT patients (76 HCC and 24 liver cirrhosis) additionally, 100 healthy individuals used as a control group. PVT was diagnosed incidentally by Doppler ultrasound during routine follow-up HCC screening. ProthrombinG20210A mutation, MTHFR mutation, Factor V Leiden mutation (VFL), antithrombin III (ATIII), protein C, S, and antiphospholipid antibodies, along with JAK2 RS V617F mutation by real-time polymerase chain reaction all were analyzed.

Results:

Patients with PVT were significantly older (p<0.001), thrombocytopenic (p<0.001), with high alkaline phosphatase (p<0.001). JAK2 RS V617F mutation was found in 28/100 (28%) in idiopathic PVT complicating liver cirrhosis and hepatocellular carcinoma. Cases with positive JAK2 rs V617F mutation were significantly accompanied by protein S deficiency (P 0.03), LA absence (p 0.06), and high frequency of ascites (P 0.03). While, the MTHFR heterozygous mutation (p0.001), ATIII (P 0.02), and VFL (P 0.01) were more frequent with negative JAK2 rs V617F mutation. The comparison between demographic data and thrombophilic parameters in PVT cases revealed that no significant differences were recorded except for male gender, Diabetes Mellitus, splenomegaly significantly increased among HCC cases (p<0.05).

Conclusions:

JAK2 rs V617F mutation must be considered in any case of PVT with liver cirrhosis and hepatocellular carcinoma without identified thrombophilic risk factors, with potential considerations of evolving myeloproliferative disorders. New diagnostic and therapeutic implications are still awaited.

Anticoagulation in patients with advanced liver disease: an open issue

Liver disease has been long considered as a risk factor for bleeding for the presence of prolongation of global tests of clotting activation and low platelet count. For this reason, the use of anticoagulants in patients with liver disease and an indication to anticoagulation, such as atrial fibrillation of venous thrombosis, has been poorly considered. Furthermore, recent studies underscored the fact that patients with chronic liver disease may experience thrombosis in portal as well as systemic circulation and treatment with anticoagulants should be considered. The introduction of direct oral anticoagulants has increased therapeutic options for thromboprophylaxis; however, evidence on their safety and efficacy in specific populations, such as patients with liver disease, is still scarce and needs further investigation. Thus, atrial fibrillation patients with coexistent liver disease have been excluded from clinical trials with direct oral anticoagulants. Here, we provide an overview on mechanisms of thrombosis in patients with advanced chronic liver disease and a summary of evidence on the use of oral anticoagulants in patients with liver disease and portal vein thrombosis or atrial fibrillation.

Acute Pancreatitis: A Rare Complication After Percutaneous Mechanical Thrombectomy of Portal Vein Thrombosis

BACKGROUND

Acute pancreatitis caused by Percutaneous Mechanical Thrombectomy treatment is extremely rare, and so far, no clinical report involving portal veins has been reported. In the article, we summarize this unusual case and share our experience.

METHODS

Percutaneous mechanical thrombectomy was performed for the patient who was diagnosed with portal vein thrombosis. Postoperatively, the patient was complicated by acute pancreatitis and received a series of medical treatments.

RESULTS

During the first month of follow-up, the patient was free of any clinical symptoms or signs.

CONCLUSIONS

When performing percutaneous mechanical thrombectomy therapy, it is crucial to grasp the time limit strictly, strengthen perioperative rehydration and urine alkalinization to prevent massive hemolysis and subsequent complications. Early detection and the early administration of therapy for this potentially severe complication are essential for obtaining a good prognosis.

Portal vein thrombosis — a literature review and our own clinical observations

The portal vein thrombosis (PVT) is a partial or complete occlusion of blood flow through the portal vein that occurs due to the presence of a blood clot in its lumen. Currently, PVT has become more common in the clinic of internal diseases. PVT can be caused by many factors, among which local and systemic. Systemic factors include congenital and acquired thrombophilia. Local factors include inflammatory, infectious, and oncological diseases of the abdominal organs. One of the most likely causes of PVT is currently being considered liver cirrhosis. The article presents the literature data, clinical guidelines for managing patients with PVT in the discussion of three own clinical cases of patients with PVT, which were caused by various diseases.

Escalating interventional recanalization therapy in non-cirrhotic, non-malignant acute portal vein thrombosis

OBJECTIVE

To evaluate the effectiveness of interventional therapy in acute, non-malignant, non-cirrhotic portal vein thrombosis.

METHODS

We present a retrospective study of eight consecutive patients who presented with an acute non-malignant, non-cirrhotic portal vein thrombosis and were treated by mechanical recanalization using an escalating scheme including local aspiration, thrombolysis, rheolysis and the implantation of transjugular intrahepatic portosystemic shunt or other visceral stents.

RESULTS

Recanalization rates applying the escalating scheme were good, with a success rate of 75%. However, major complications occurred in 50% of patients, mostly due to bleeding at the percutaneous access site, and minor complications in 12.5% of patients.

CONCLUSION

Interventional therapy is effective in acute portal vein thrombosis, but should only be performed at specialized centers and based on an individual treatment decision.

Current concepts in portal vein thrombosis: etiology, clinical presentation and management

OBJECTIVE

The aim of this article is to focus on etiology, risk factors, clinical presentation and classification systems of acute and chronic PVT as well as focusing on current diagnostic and therapeutic options for the management of acute and chronic PVT.

RESULTS

PVT represents a serious clinical concern in cirrhotic patients and in those with specific local or systemic risk factors. The rate and extent of thrombus formation can significantly impact patient presentation and the resulting clinical outcomes. The presentation of acute PVT can range from abdominal pain to intestinal ischemia/infarction and even death, while chronic PVT can remain clinically silent. A number of imaging modalities including US, CT and MRI can be used to confirm the diagnosis. In addition to addressing underlying risk factors, AC therapy forms a cornerstone of treatment and has demonstrated efficacy in both acute and chronic settings. Proper caution should be used when initiating AC therapy in cirrhotic patients given their underlying coagulopathic status with attention now being paid to NOACs and LMWH. For patients with bowel ischemia, extensive thrombosis, contraindications or poor response to AC, or for those with co-morbidities that preclude AC, minimally invasive endovascular techniques offer alternative treatment options.

CONCLUSION

Familiarity with the etiology, clinical presentation and classification of PVT optimize early detection and incorporate effective therapeutic options, the management of these complex patients should be undertaken by a multidisciplinary team. Minimally invasive catheter-based therapies and endovascular portosystemic shunt creation demonstrated efficacy in the treatment of AC-resistant patients and for patients with extensive or complicated disease.

Incidence of Splanchnic Vein Thrombosis After Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Abdominal surgery may increase the risk of splanchnic vein thrombosis (SVT). We determined the incidence of SVT after abdominal surgery and identified groups at highest risk.

MATERIALS AND METHODS

MEDLINE and Embase were searched for clinical studies evaluating the incidence of postoperative SVT after abdominopelvic surgery. Study selection, data abstraction, and risk of bias assessment were carried out independently by two reviewers. Clinical heterogeneity was explored by subgroup analyses (i.e., type of intra-abdominal procedure and organ group).

RESULTS

Of 5549 abstracts screened, 48 were analyzed. Pooled incidence of SVT (n = 50,267) was 2.68% [95% confidence interval (CI), 2.24 to 3.11] (1347 events), I² = 96%. Pooled incidence of SVT in high-risk procedures were splenectomy with devascularization (24%), hepatectomy in patients with cirrhosis (9%), and pancreatectomy with venous resection (5%). Pooled incidence of symptomatic and asymptomatic SVT was 1.02% (95% CI: 0.97% to 1.07%) and 0.98% (95% CI 0.88% to 1.07%), respectively. Most common causes of SVT-related mortality were irreversible thrombosis, bowel ischemia, liver failure, and gastrointestinal bleed. Most studies included were at a high risk of bias due to lack of prospective data collection and lack of SVT screening for all participants.

CONCLUSIONS

Incidence of SVT after abdominal surgery is low but remains a relevant complication. Patients undergoing procedures involving surgical manipulation of the venous system and splenectomy are at the highest risk. Given the life-threatening risks associated with SVT, there is a need for larger prospective studies on the incidence and impact of SVT after abdominal surgery.

Acute portal vein thrombosis after liver transplant presenting with subtle ultrasound abnormalities: A case report and literature review

BACKGROUND

Portal vein thrombosis (PVT) after liver transplantation (LT) is an uncommon complication with potential for significant morbidity and mortality that transplant providers should be cognizant of. Recognizing subtle changes in post-operative ultrasounds that could herald but do not definitively diagnose PVT is paramount.

CASE SUMMARY

A 30-year-old female with a history of alcohol-related cirrhosis presented with painless jaundice and received a deceased donor orthotopic liver transplant. On the first two days post-operatively, her liver Doppler ultrasounds showed a patent portal vein, increased hepatic arterial diastolic flows, and reduced hepatic arterial resistive indices. She was asymptomatic with improving labs. On post-operative day three, her resistive indices declined further, and computed tomography of the abdomen revealed a large extra-hepatic PVT. The patient then underwent emergent percutaneous venography with tissue plasminogen activator administration, angioplasty, and stent placement. Aspirin was started to prevent stent thrombosis. Follow-up ultrasounds showed a patent portal vein and improved hepatic arterial resistive indices. Her graft function improved to normal by discharge. Although decreased hepatic artery resistive indices and increased diastolic flows on ultrasound are often associated with hepatic arterial stenosis post-LT, PVT can also cause these findings.

CONCLUSION

Reduced hepatic arterial resistive indices on ultrasound can signify PVT post-LT, and thrombolysis, angioplasty, and stent placement are efficacious treatments.

Pylephlebitis: A Case of Inferior Mesenteric Vein Thrombophlebitis in a Patient with Acute Sigmoid Diverticulitis—A Case Report and Clinical Management Review

Pylephlebitis is a rare complication of intra-abdominal infections and describes thrombosis and infection as two different pathophysiological phenomena in the cause of this disease. The nonspecific presentation of disease makes its diagnosis difficult and thus leads to high mortality. The treatment comprises antibiotics and also includes controversial use of anticoagulation in these patients. Here, we present a patient with past medical history of human immunodeficiency virus and past diverticulitis who presented with fever, chills, diarrhea, neck pain, and photophobia. He was diagnosed with acute sigmoid diverticulitis with associated inferior mesenteric vein thrombophlebitis. He improved after intravenous antibiotics and anticoagulation and was discharged. He underwent sigmoid colectomy 3 months after his initial presentation and was advised to take anticoagulation for a total of 6 months.

D-dimer level in liver transplant recipients on the first day after surgery is correlated with postoperative thrombosis recurrence

OBJECTIVE

This study aimed to investigate the relationship between plasma D-dimer level, preoperative complications, and thrombosis in liver transplant recipients.

METHODS

The clinical data of 525 liver transplant recipients with end-stage liver disease (ESLD) in the First Affiliated Hospital of Zhejiang University from October 2012 to December 2015 were retrospectively analyzed. The patients were grouped based on thrombosis before and after surgery to determine the risk factors for postoperative thrombosis recurrence.

RESULTS

Of the preoperative complications assessed, esophageal varices and thrombosis were significantly correlated (P = 0.000); ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy were significantly correlated with preoperative D-dimer level (P < 0.001, P < 0.001, and P = 0.002, respectively); during the first week after surgery, the D-dimer level was significantly and consecutively higher than that before surgery and was significantly higher in the group with both preoperative and postoperative thrombosis than in the other groups on the first day after surgery (P < 0.001); the area under the curve (AUC) for diagnosis of postoperative thrombosis recurrence in the preoperative thrombosis group using plasma D-dimer level on the first day after surgery was 0.698 (P = 0.001); Cox regression analysis showed that D-dimer was an independent risk factor for postoperative thrombosis recurrence (HR = 3.062, P = 0.029).

CONCLUSION

D-dimer level on the first day after liver transplant is related to thrombosis recurrence and is an independent risk factor for postoperative thrombosis recurrence.

Venous invasion by hepatic tumors: imaging appearance and implications for management

Venous invasion by hepatic tumors most commonly occurs with hepatocellular carcinoma and is associated with worse patient prognosis. Imaging plays an important role in the diagnosis of tumor thrombus in the liver. Moreover, differentiating between bland and tumor thrombus in the liver has important diagnostic, staging, therapeutic, and prognostic implications and may require a multimodal imaging approach including ultrasound, computed tomography, and/or magnetic resonance imaging. Treatment of hepatic malignancies with associated tumor thrombus is dependent on tumor type, disease extent within the liver, liver hemodynamics, and underlying liver function. Treatment of such tumors may involve surgical, locoregional and/or systemic therapies. The current review will focus on the imaging characteristics of venous invasion by hepatic tumors. The imaging findings most useful for differentiating hepatic venous tumor thrombus and bland thrombus will be highlighted and demonstrated with imaging examples. Imaging findings with implications for subsequent patient management will be described.

A case of portal vein thrombosis caused by blunt abdominal trauma in a patient with low protein C activity

Portal vein thrombosis (PVT) is caused by several conditions including infection, malignancies, surgery, medications, and coagulation disorders. However, PVT caused by low-energy injury is very rare. A 51-year-old man visited a clinic with a 2-day history of abdominal pain following blunt abdominal trauma. Contrast-enhanced computed tomography (CT) revealed thrombosis in both the portal vein and splenic vein, and he was transferred to our hospital with a diagnosis of PVT. Anticoagulant therapy was initiated using unfractionated heparin. A repeat CT scan revealed enlargement of the thrombus, which occluded the main trunk and first right branch of the portal vein. Laboratory data before heparin administration suggested low protein C activity. Anticoagulation therapy was continued with intermittent assessment of the size of the thrombus and degree of coagulation. On day 23, enhanced CT showed marked shrinkage of the thrombus compared with that on day 8. On day 30, the patient was discharged with a therapeutic prothrombin time-international normalized ratio. Here we present a case of PVT caused by low-energy trauma of the upper abdomen in a patient with a background of low protein C activity that was successfully treated without invasive surgery.

Approach to thrombosis at unusual sites: Splanchnic and cerebral vein thrombosis

Splanchnic vein thrombosis (SVT) and cerebral vein thrombosis (CVT) are two manifestations of unusual site venous thromboembolism (VTE). SVT includes thrombosis in the portal, mesenteric or splenic veins, and the Budd-Chiari syndrome. CVT encompasses thrombosis of the dural venous sinuses and thrombosis of the cerebral veins. Unusual site VTE often represents a diagnostic and therapeutic challenge because of the heterogeneity in clinical presentation, the limited evidence available in the literature on the acute and long-term prognosis of these diseases, and the lack of large randomized controlled trials evaluating different treatment options. This narrative review describes the approach to patients with SVT or CVT by examining the diagnostic process, the assessment of potential risk factors and the appropriate anticoagulant treatment.

Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy

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Portal vein thrombosis due to constriction of hepaticojejunostomy is rarely occured, in which increased biliary pressure by obstructive jaundice decreased portal flow.

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Re-anastomosis and postoperative thromolytic therapy recovered occluded portal flow.

Introduction

This case report aims to inform pancreatic surgeons about our perioperative management of intrahepatic portal vein thrombosis caused by an obstruction of hepaticojejunostomy (HJ) after pancreaticoduodenectomy (PD).

Case presentation

A 65-year-old woman was diagnosed with pancreas head carcinoma involving the superior mesenteric vein (SMV). Pancreaticoduodenectomy combined with SMV resection was followed by HJ. Twisting or narrowing was not evident during anastomosis. Total bilirubin values progressively increased to 13 mg/dL on day 5. At that time, we suspected anastomotic occlusion and found complete portal thrombosis of the left liver. Therefore, emergency re-anastomosis of the HJ was followed by thrombectomy, which was not completely successful and did not completely recover initial portal flow. Thrombolytic drugs improved obstructive jaundice, eradicated the organized thrombosis and recovered the portal flow by day 30. The post-operative course was uneventful.

Discussion

A thrombosis immediately formed in the portal vein due to biliary obstruction of an anastomotic site. We speculated that biliary dilation and related inflammation caused a relative increase in arterial flow and decreased portal flow at the localized part of the umbilical portion. Although early surgical thrombectomy was attempted soon after the primary operation, the organized thrombosis persisted. However, thrombolytic therapy eradicated the thrombosis.

Conclusion

Careful anastomosis of HJ during PD was necessary to avoid postoperative biliary stricture. This type of complication affects intrahepatic blood flow, particularly via the portal vein. Although immediate re-anastomosis or thrombectomy is applied, organized thrombosis cannot always be surgically removed.

Clinical outcomes of transcatheter selective superior mesenteric artery urokinase infusion therapy vs transjugular intrahepatic portosystemic shunt in patients with cirrhosis and acute portal vein thrombosis

AIM

To compare the outcomes of transcatheter superior mesenteric artery (SMA) urokinase infusion and transjugular intrahepatic portosystemic shunt (TIPS) for acute portal vein thrombosis (PVT) in cirrhosis.

METHODS

From January 2013 to December 2014, patients with liver cirrhosis and acute symptomatic PVT who met the inclusion criteria were randomly assigned to either an SMA group or a TIPS group. The two groups accepted transcatheter selective SMA urokinase infusion therapy and TIPS, respectively. The total follow-up time was 24 mo. The primary outcome measure was the change in portal vein patency status which was evaluated by angio-computed tomography or Doppler ultrasound. Secondary outcomes were rebleeding and hepatic encephalopathy.

RESULTS

A total of 40 patients were enrolled, with 20 assigned to the SMA group and 20 to the TIPS group. The symptoms of all patients in the two groups improved within 48 h. PVT was improved in 17 (85%) patients in the SMA group and 14 (70%) patients in the TIPS group. The main portal vein (MPV) thrombosis was significantly reduced in both groups (P < 0.001), and there was no significant difference between them (P = 0.304). In the SMA group, superior mesenteric vein (SMV) thrombosis and splenic vein (SV) thrombosis were significantly reduced (P = 0.048 and P = 0.02), which did not occur in the TIPS group. At 6-, 12-, and 24-mo follow-up, in the SMA group and the TIPS group, the cumulative rates free of the first episode of rebleeding were 80%, 65%, and 45% vs 90%, 80%, and 60%, respectively (P = 0.320); the cumulative rates free of the first episode of hepatic encephalopathy were 85%, 80%, and 65% vs 50%, 40%, and 35%, respectively (P = 0.022).

CONCLUSION

Transcatheter selective SMA urokinase infusion and TIPS are safe and effective for acute symptomatic PVT in cirrhosis.

Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery

Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.